University of Otago Midwinter Dialogue
Christchurch School of Medicine, 13 June 2008

It's an honour to be invited, for the second time, to participate in the University of Otago's Midwinter Dialogues. It's always a pleasure to return to Christchurch. When my appointment as Commissioner was announced in February 2000, some people asked me if that meant a move to Christchurch, assuming that our office was based here! There was clearly a strong link between HDC and Canterbury in the wake of Robyn Stent's 1998 inquiry report.

I'm also pleased to be speaking with George Downward, whose passion for patient safety I greatly admire. Canterbury DHB is very fortunate to have someone of his calibre in role of Medical Director of Patient Safety. A couple of years ago, in speaking to the NZ Medical Students Association, I singled George out as a leader, noting that as President of NZMA, he had challenged the profession to be brave and to tackle healthcare induced harm.

So, what is patient safety? I recall Peter Roberts, who succeeded George as President of NZMA, asking this question in characteristically blunt fashion at a conference on patient safety and the law, in Auckland in 2003. Peter said, "Can someone tell me this abstract thing 'patient safety' looks like?" Well, here's what it looks like. The death of Mervyn McAlpine, an 82-year-old diabetic patient, was hastened after a medication mix-up at Auckland City Hospital in 2004. Three unpaginated pages relating to another patient's medication were affixed in error to Mr McAlpine's one page referral after it was faxed by his GP to the hospital.

91-year-old Eileen Anderson, who in 2002 was referred with a chest infection to Palmerston North Hospital Emergency Department, was given another patient's electronic label in error, and received five doses of morphine sulphate intended for the other patient for four days, with no nurse or doctor detecting the error. Mrs Anderson died two weeks later.

So, why all the fuss about patient safety? I'd like to offer some reflections on the role of HDC in all this, and explain why I've been on a personal crusade to highlight the need to make our hospitals safer, echoing the call of the Canterbury Medical Staff Association for "a health system that is safe for patients and health professionals alike".

It's 20 years this August since Judge Silvia Cartwright delivered her "Report of the Cervical Cancer Inquiry", on events at National Women's Hospital, where women with carcinoma in situ, without their knowledge or consent, had not received standard treatment and not been kept safe. The Cartwright Report was a wake-up for the medical profession, and for the New Zealand public. In calling for a Code of Patients' Rights and an independent Commissioner and patient advocates, Judge Cartwright warned: "Health professionals need to listen to their patients, communicate with them, protect them, offer them the best health care within their resources, and bravely confront colleagues if standards slip. If this does not happen, then the kind of events disclosed during the Inquiry may well occur again."

Back in 1988, I was a lecturer in law at the University of Auckland. The Inquiry prompted me to start teaching a new medico-legal course, and to immerse myself in the area. This in turn led then Director-General of Health Karen Poutasi, and Minister of Health Jenny Shipley, to ask me in 1995 to advise the Government on the final wording of the Code of Consumers' Rights (which it had come to be called, given the expansion to cover disability services). I participated in some fairly intense negotiations with the first Commissioner, and some fascinating debate with Cabinet. But we got there, and the Code was promulgated as regulations in April 2006, and became law on 1 July 2006. Robyn Stent even graciously presented me with a t-shirt (showing the various rights) to mark the occasion!

Of course Commissioner Stent is rightly remembered for her landmark Canterbury Health Inquiry Report, published in 1998. Her inquiry was precipitated by the actions of desperate senior doctors who, on Christmas eve 1996, wrote to the Minister of Health that "Patients are Dying" at Christchurch Hospital. The Stent report was an indictment on the managerially focussed health system of the 1990s, but also on the dysfunction at Christchurch Hospital at the time. Robyn Stent stated the obvious: "A hospital is dependent on the knowledge and influence of senior clinicians" (p 13), and made numerous recommendations for improvement, noting that "It is time for all to work co-operatively in the interests of providing good service to the people of Canterbury" (p 2).

I became Commissioner in March 2000. A few months later, I made my first visit to Canterbury Health and Christchurch Hospital. I recall a tense meeting with senior management. Followed by question and answer session to a packed lecture theatre of senior doctors, chaired by Roy Holmes. It was pretty obvious that I was being closely scrutinised by a sceptical audience. Some of you may have been present. What sticks in my mind was the question someone asked: "So, can your office ever be more than the ambulance at the bottom of the cliff? Do you have to wait til things go wrong?"

I've been determined to answer that challenge. For me the past 8 years have been a quite deliberate effort to transform the role of Commissioner from simply being a complaints handling agency, to a public watchdog speaking out to prevent things going wrong in the first place. Building a fence at the top of the cliff (7).

Along the way, there have been some major influences on public and professional recognition that sometimes health care harms patients. Most significant was the landmark Institute of Medicine report, To Err is Human, in 1999. As significant in this country, but much less publicised, was Peter Davis's 2001 study on "Adverse events in New Zealand public hospitals". Yet somehow the message of the need to make hospitals safer did not galvanise the attention of health professionals, politicians, and the public. The focus was on other things - the new district health boards, the renewed emphasis on medical professionalism (led by ASMS), and the reforms of health professional regulation introduced by the Health Practitioners Competence Assurance Act.

We were busy at HDC too. I faced the challenge of reducing a big backlog of old files, making changes to ensure that complaints and investigations met the requirements of natural justice, and dealing with the inevitable major inquiries that came along. Gisborne Hospital was a case in point, where my investigation team found "a traumatised community within [the] hospital and a worried community beyond … Senior doctors and nurses felt disenfranchised, unable to exercise an effective clinical voice in management decisions. Suspicion and distrust was endemic."

I was pleased when NZMA chair John Adams recognised that in the Gisborne Hospital report, "HDC looked beyond the culpability to individual practitioners to the system." Taking a systems approach has been a hallmark of our work, leading Alan Merry and Mary Seddon in 2006 to commend HDC on "a world-leading focus on addressing aspects of the system which contribute to patient harm, rather than only seeking individual scapegoats when things go wrong".

For me a turning point came when I was asked by Australian federal and state health ministers, to review safety and quality in the Australian health system. Getting away from New Zealand, and meeting clinicians, managers, consumer and professional groups right across Australia, convinced me of the need for national leadership of safety and quality, better co-ordination of quality improvement efforts around the country, and much greater transparency for the public. My 2005 report was accepted by Australian health ministers, and led to the creation of the Australian Commission on Safety and Quality in Health Care.

My work in Australia, and opportunities to learn from leading safety and quality experts like Liam Donaldson in England and Don Berwick in the United States, and to see the extraordinary focus on improving patient safety in those countries, convinced me that we needed to do more in New Zealand. And I continued to see the human tragedies - for patients, their families, and affected staff - in the complaints that came across my desk. I was transfixed by a slide on the programme for a private hospital dinner I attended in Wellington in 2005. I gave a speech on patient safety, but the programme announced that the topic was "Risk Management", and the inside joke seemed to be that the Commissioner was the shark lurking in the water - the risk to be managed by senior doctors and managers in their work. Yet it seemed to me that the real hidden danger was the risk of preventable errors faced by patients entering hospital, reliant on doctors, nurses and complex systems to keep them safe.

In 2006, Alan Merry and Mary Seddon confirmed my view, noting in an NZMJ editorial that "our hospitals are not yet acceptably safe at present". I started to push the message of accountability of our district health boards, and to name boards so that the public would be better informed. In April last year, in a case involving Capital and Coast DHB, I upped the ante. In a widely publicised decision, I reported serious failings in the care of a 50-year-old patient with a chest infection admitted to Wellington Hospital in September 2004, over the 40 hours prior to his death. Individual staff and the hospital system failed to respond to signs of deterioration (and didn't read his chest X-ray until it was too late); and there was a lack of compassion for the dying patient and a lack of candour with his family and the Coroner after his death.

Two features of my handling of the case were radically different. I referred Capital and Coast DHB to the Director of Proceedings for potential prosecution - the case was settled but it was a clear signal to boards of their own accountability. And I required all district health boards to report to HDC on their own systems for keeping patients safe. This was an attempt to shift the focus from an individual system to the entire health system. It led to my publishing Mary Seddon's review, "Safety of Patients in New Zealand Hospitals: A Progress Report", in October 2007, confirming that a lot of excellent work was being undertaken by DHBs around the country - and naming Canterbury DHB as one that "really understood what a safety culture was and demonstrated systems thinking". But I also noted the need for greater coordination of efforts nationally, and for faster progress to reduce avoidable harm to patients.

My comments did not fall on deaf ears. The media started picking up the message of patient records getting lost and exposed to harm in complex hospital systems that don't talk to each other, or to general practice systems. There was an example in the New Zealand Herald last December, involving a patient transferred from Auckland City to Middlemore Hospital, without her known risk of CJD being properly flagged in her records.

The Government was also listening. Former Health Minister Pete Hodgson had beefed up the Quality Improvement Committee (QIC) under chair Pat Snedden, and announced a major medication safety initiative. And new Minister David Cunliffe was quick to heed my call for faster action on QIC's patient safety initiatives.

This year, two events have galvanized action. First, my widely reported comments in February to Health Select Committee, that our hospitals are not yet acceptably safe (which the media rather misleadingly reported as "Hospitals unsafe, says Commissioner), that we need to start publishing some comparative healthcare quality data, and that with 21 district health boards doing different things, we have "an unduly complicated system for 4 million people". Secondly, soon afterwards, the release by QIC and all the district health boards of the sentinel event information (in response to requests made under the Official Information Act, and a ruling in favour of disclosure from the Ombudsman), leading to further wave of media publicity. And to swift action from the Minister, including a commitment to public reporting, a threat of financial penalties for boards that don't prioritise patient safety, and investment in major patient safety initiatives led by QIC (backed by money in the recent budget).

This was "the fuss" that I was thinking of when I suggested the title for today's dialogue. It is not a risk-free strategy, and there are some skeptics and knockers. According to The Press, two local Board members criticized my "damming comment" on the health system and Canterbury hospitals and my "generalized, sweeping statement" that undermined the public's confidence in health services.  Apparently they hadn't read the text of my comments to the Select Committee, and were unaware that I had previously singled out Canterbury DHB for praise.

I do worry about the risk of undermining public confidence and sapping staff morale. That's why, whenever I make public comments about this issue, I remind people that all western health systems are facing these challenges, and that the vast majority of patients in New Zealand hospitals receive very good care most of the time. HDC even advertised in local papers last year, seeking patients' stories of great care, and published a booklet, "The Art of Great Care".

But we are kidding ourselves if we don't see the need for greater coordination of efforts nationally, and for faster progress to reduce avoidable harm to patients. Our patients and our staff deserve no less.

I commend the efforts of George Downward and clinicians and managers to improve safety for patients of Canterbury DHB. Keep up the good work. I will continue to speak out for patient safety. I think it's worth all the fuss!

Ron Paterson
Health and Disability Commissioner