MEDICAL SERVICES

Medical services processes and structures were reviewed from a perspective of effectiveness and appropriateness with regard to key issues of safety and quality.

OBSERVATIONS

No specific serious quality or safety issues were identified during the review process.

That being said, there are many issues outlined below that are patient safety risk factors. The situations are identified below:

• Based on discussions, there appear to be barriers to full disclosure of quality and safety information. The emerging patient safety agenda demands transparency and full disclosure.

• There are numbers of patients transferred between facilities, and problems have occurred. Sometimes case specific collaboration occurs between two facilities, but there is no system established to evaluate quality concerns or risks, especially proactively. There is a Patient Safety Committee, but its focus has been too narrow.

• Many patients do not have progress notes on the chart. As a result, physicians covering for their colleagues don’t have the information they need to approve a patient discharge even though the patient may be ready. Progress notes are critical for team communication – physician to nurse, to other physicians and to other members of the health care team.

• Morbidity and Mortality reviews are not held (very few exceptions were acknowledged).

• Data pertaining to quality is not regularly available to clinicians or quality committees. Data is not circulated, nor is there a system in place for who should receive the data.

• Many expressed concern regarding care for patients with mental health problems, addiction, chronic pain and chronic diseases.

• The quality assurance system is reactive, not proactive.

Shifting focus to medical structures and processes to support a quality environment, the following is noted:

• The Patient Safety Committee is advisory and has focused specifically on disclosure and hand washing. A joint committee (between PCH and QEH) does exist but it has not met for some time.

• Medical Advisory Committees exist in both institutions and are well attended, but some are considered ineffective in addressing issues. Chiefs of staff (department heads) are in place (with some vacancies) but their ability to manage difficult situations is limited by concern that the Medical Advisory Committee may not support them, and by the challenge of holding colleagues accountable.

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• There are some necessary committees in place – such as operating room, pharmacy and therapeutics – but they are not felt to be effective. There is a need to design a system that responds to management of tough situations in small physician groups (which is likely every site in PEI where there are physicians).

• Some structures are missing. Leadership in the intensive care unit, currently done by committee, is often ineffectual when it comes to dealing with problem behavior amongst staff (e.g. accountability for performance in accordance with defined policies and standards).

• There is no formal process to hold MDs accountable for behaviour, practicing evidence-based medicine or meeting national standards for length of stay, and systems to manage this are under-developed.

• The Medical Advisory Committee seems to have an excessive orientation to advocacy, and not quality management. For instance, the Medical Advisory Committee should develop standards and determine if staff are expected to abide by the standards. These policy commitments become the means by which the administrative arm of the institutions (including the department head and medical director) function to address individual concerns.

• The Medical Advisory Committee is currently mainly focused on advocacy whereas it should be quality oriented.

• Relationships between administration and medical leadership seem to be quite good. Respectful interactions can occur even if agreement is not present.

• Management of contracts – as in compensation via service contract or salary – is inadequate. Initial conditions and expectations are not well laid out, deliverables are unclear and ongoing routine evaluation/renegotiation (on an individual basis) is non-existent. Management of contracts is poor and in other provinces in similar situations, the Auditor General’s Office has chastised other Ministries of Health for inadequate fiscal management.

• Bylaws are not standardized across the province. While in and of itself, this is not necessarily bad, it reflects that standards have not been set for clinical expectations allowing for lack of accountability and inappropriate individual discretion.

Simply put, the current system is ineffective from the perspective of supporting principles of patient safety, administering contracts, establishing and defining standards, ensuring accountability and adherence to standards.

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RECOMMENDED STRATEGIC DIRECTIONS – MEDICAL SERVICES

Define strategy to enable quality and utilization management. This would include processes to ensure that issues are identified and tracked and that

improvement/resolution occurs when required. This will demand:

 defined processes for quality review, incident reporting and routine monitoring of quality indicators;

 clear targets for access to address areas where delays could be leading to unsafe or lower quality care (e.g. DI wait times);

 introduction of protocols and pathways for high volume patient populations;

 clear accountabilities for all physicians to participate in processes, with consequences for non-compliance; and

 identification and endorsement of a lead physician(s) to assist in building capacity surrounding quality and safety.

Renew structures and processes. There is a clear need to create the proper

environment and structures for effective medical leadership and involvement in quality management. This should include one set of bylaws and rules for all medical staff,

medical leadership positions with clear roles, responsibilities and reporting relationships that reflect the three main thrusts of medical leadership: advocacy, quality management and medical administration, and one medical director position each for the West and East Island to manage issues, support and mentor department heads and play a

leadership role in quality management. Additionally, a province-wide Medical Advisory Committee (PEIMAC) should be created representing all medical staff in the province irrespective of whether the medical staff is defined provincially or locally.

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