Issue 9 / 14 March 2016

THE tragic events at Bacchus Marsh Hospital, where seven babies died avoidable deaths in 2013 and 2014, were an unmistakeable wake-up call for the Victorian health system.

Review of the events at Bacchus Marsh has shown that serious safety and quality issues were not identified by the hospital’s management or known to the Department of Health and Human Services until it was far too late. Instead, the hospital was fully accredited and was receiving excellent performance scores under the Department’s performance monitoring framework.

Something was obviously awry.

The Department commissioned an immediate external review of how it handled this issue, which reported late last year. Victorian Health Minister Jillian Hennessy has now also asked the Department to commission another review, looking at the broader issues of how governance of safety and quality of hospital care in Victoria can be improved. I chair that review.

The Bacchus Marsh tragedy calls into question whether existing systems and processes are fit for purpose. As it stands, serious safety and quality issues were not being identified. Hospital performance was opaque to those responsible for monitoring it, and there were clear gaps in accountability.

Reducing the likelihood of another Bacchus Marsh will require much greater oversight of safety and some tightening of accountability arrangements for hospitals.

Other states do hospital quality monitoring quite differently. Queensland uses a statistical process control system to monitor trends in key measures of outcomes of care.

New South Wales has established separate specialist organisations to lift the profile of quality improvement and safety monitoring across the state. South Australia has a state-of-the-art incident monitoring system. All these states provide much greater levels of support for safety improvement than Victoria does.

Other countries also do things differently. In England, patients undergoing some procedures (such as hip replacements) are asked before and after surgery about their level of pain and discomfort – the common reasons for presenting to a surgeon – so that their experience can be tracked using measures which are meaningful to them. Hospitals’ average performance on these measures can also be tracked and is made available publicly. Much more information is also available to the public in the United States about a hospital’s performance on both process and outcomes of care than is available in Australia.

Victoria clearly has room to improve.

Safety and quality is not a problem we can afford to neglect. It costs lives and livelihoods, and it adds hundreds of millions of dollars to the cost of running the hospital system. In a time of budget pressures, we should be pursuing improvement as urgently as ever.

More important than dollars is duty. Victorian legislation charges hospital executives, boards, the Department and its Secretary with responsibility for ensuring hospitals are monitoring and improving the quality of care. People therefore expect to be able to go to hospital knowing that systems are in place to minimise the risk of things going wrong and, if they do, ensure that lessons will be learned so that the same problems don’t occur again. This is something they have legal assurance of, and indeed deserve.

The job of the current review is to set a new path for improvement in quality and safety of care. That path has to start with looking at how to involve clinicians in the process of improving quality and safety. In South Australia and Queensland, “clinical senates” have been established to provide a statewide clinician voice to improve clinical engagement. NSW has more than 1000 clinicians engaged in statewide clinical improvement activities through the work of clinical networks. The Victorian review needs to address how to foster a culture of continuous improvement and clinical excellence in the health sector.

The Bacchus Marsh tragedy shows that early warning signs weren’t picked up and acted upon soon enough. More needs to be done on strengthening oversight of both safety issues and clinical governance by the Department, so that warning signs are detected and acted upon in a timely manner. 

The other side of the safety and quality governance equation also needs to be looked at. Clinical governance of hospitals needs to be improved, so that the public can be confident that all hospitals – big and small, public and private – are delivering safe care.

Finally, we need to improve transparency within the health sector, so that communities can verify that their local hospital is rapidly identifying and rectifying important defects in care when they arise.

These are big challenges. But the public expects to be able to go to hospital knowing that systems are in place to minimise the risk of things going wrong and, if they do, lessons will be learned so that the same problems don’t occur again. It is the job of the review to make recommendations to give the public confidence that this is what happens in Victoria. The review has issued a discussion paper about the review and welcomes input from the public and health care staff about what needs to be done to improve safety and quality of care.

Stephen Duckett is Director of the Health Program at Grattan Institute and chair of the Review panel examining quality and safety in Victorian hospitals.

8 thoughts on “Lessons from Bacchus Marsh

  1. Stephen Stuckey says:

    Given the hierarchical nature of the Victorian public health system do we really believe individuals will come forward and say what they really think to this review?

    Sounds like there is clear intent for further central control and costs (which will be diverted from the coalface).

    I would suggest providing the resources at the coalface so that those providing the service are less tired, looking after a reasonable number of patients (perhaps define what is an unreasonable workload for each group?) and have time to perform quality improvement processes.

  2. Valerie Peers says:

    I have been a part time staff member as a GP Obstetrician at the Bacchus Marsh Hospital for 15 years. I frequently attended the monthly Obsteteric meetings where statistics were presented and discussed from the previous month. The figures and complications appeared to be transparent.

    The medical staff asked many times regarding the State rates for adverse events compared to the local figures and time and again we were told that they were not made available to the Administration.

    However, when the alarm was raised about the numbers of neonatal deaths over a 24 month period 2013-2014, the State figures were quickly found. I am still curious how these figures compare with other regional hospitals in Victoria.

  3. Jenny Haines says:

    Health Departments in each of the States need to get serious about their policies in relation to adverse events, especially when it involves medical practice. In comparison nursing has taken up the modern policies on adverse events relatively well.There is still to much emphasis on covering up poor medical practice rather than open disclosure, evaluation, reflection and learning. We have to move away from the punitiive response to the learning and teaching response to adverse events while respecting those who suffer through these events, both  patients , family and staff.  Staff should not have to be whistleblowers if the system of dealing with advserse events is working properly. A commitment to a high standard of practice should not just be a matter of medical governance. Each professional has a responsiblity too.

  4. Janet Wallace says:

    While ever whistleblowers become lepers and are feared and cast out, people will not dare to come forward. Those that dare to tell are not appreciated. And that is from the top down! Repeatedly.


  5. Leigh Grant says:

    New Zealand has a great system of no-blame reporting, with the government funded ACC (accident compensation corporation) personal accident insurance available to all residents and visitors. Adverse events are covered by the fund, so medical staff no longer fear reprimands.The district health boards also support / back their staff during all complaints processes, with the underlying view that human error is not something to be ashamed of. A much healthier environment to work in, where early warnings are acted on.

  6. Dr Ian Relf says:

    Am 25 year GP in Bacchus Marsh.

    Aftrer asking for more funding for years while the birth rate doubled and staffing levels didnt:

    The staff should get medals rather than bureaucratic derision and sackings- for operating with large staffing shortages – which penalises those trying to do the work and brings about surveillance errors.

    Now that there is a political ‘show’, they have spent money and replaced the ‘previous medical person’ with at least 5 medical staff and increased the important nursing levels.

    The bureaucrats that caused the staff shortages should be asked to apologize publicly.

    All the pontificating political class should try and explain why this is not like a rail crossing that gets replaced after a certain number of deaths- so that the political point can be scored.

    Fix the real problem.


    Bacchus Marsh GP



  7. Maria otten says:

    As an employee of the hospital I would like to make the following comments

    1. This hospital has been in this situation before. Management has been changed before due to poor governance While many of the same staff remain at the coalface there will continue to have issues. We are foolish if we think poor care is only in maternity. It is entrenched throughout the hospital. I note that in the other departments the NUMs and ANUMs remain.   I have no confidence in change occurring

    2. Where is DHS culpability in this. This hospital went through accreditation. The findings were that it this was either the safest hospital in Australia or that they were simply not reporting. The accreditors thought this was a low risk situation so they did nothing. Who are they kidding. If incidents are not reported how do you know what is happening

    3. Again – where is DHS culpability in this – staff through the union wrote to them complaining of the conditions at the hospital. This is clearly a complaint against senior management. DHS simply sent the letter to the people being complained about for review. Who lets the person being complained about manage their own investigation 

    4. Tto the doctor above. If complaints are not filed or their severity altered then you would not be fully aware of the facts. You would be going to meetings and thinking you are operating in a transparent environment. But those of us at the coal face. We knew we werent

    5. I do think the removed doctor has been scapegoated here.  There was simply not enough staff and not enough training. Resources were not supplied. It was these or managements team job to let dHS aware of the stress placed on the hospital and they didn’t

  8. Anonymous says:

    It would be a tragedy if the findings and recommendations coming out of this review were limited to Victoria. Each jurisdiction seems to have its own approach which means there is excellence but also variation across the nation. Alas the national quality framework is really a minimal set of standards and would benefit from a generational uplift.

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