September 2005, six key recommendations have been developed to move forward. These include; increasing public health funding, implementing alternative frameworks to decrease pressure on acute settings and completing a national review (Queensland Parliament, 2005). The main recommendation proposed was to create a national body of registration with the Australian Productivity Commission, which advocated for a nationwide registration and accreditation system (Queensland Parliament, 2005; Walton et al., 2012). This resulted in the formation of the Australian Health Practitioner Regulation Agency in 2010, which is still implemented in contemporary healthcare (Walton et al., 2012).
The Review also suggests the existing organisational structure is not responsive or effective, and proposed the structure to be modified to meet the needs of the community. By collaborating with the patient and community, health professionals can produce clinical decisions, which reflect patient centered care (Queensland Parliament, 2005). The Clinical Services Capability Framework provided a clear outline of the support services needed such as staffing and safety requirements for health settings. It suggests some of the negligence by Patel would have been recognized to be out of the hospitals scope of practice; therefore earlier intervention could have occurred (Queensland Parliament, 2005).
In conclusion due to the lack of checking relevant accreditations and insufficient management of complaints the negligence by Patel was exposed (Daly, Cleary, and McCormack, 2012; Davies, 2005; N.S.W. Nurses’ Association 2006). The need for a clear, well developed clinical governance framework similar to what is used at the Hospital and Health Service would have provided direction and prevented some of the events which occurred. In light of these events through the recommendations provided by the Queensland Health Systems Review, staff, management and Queensland Health have been able make changes to improve patient safety and organisational culture (Queensland Parliament, 2005).
All the recommendations resulting from the plethora of investigations into healthcare governance have merit, but perhaps the six most important are as follows:
A media release from Queensland Government, (2005) stated that:
Each care facility should maintain up to date personnel files, usually with the Human Resources department and it is up to them, with the help of senior management, to ensure that they monitor and document regular ongoing performance and development appraisals of all clinical staff. This providing effective supervision and peer review processes without fear of bullying or reprisals. Similarly, there should be a state wide clinical governance framework in place, which efficiently monitors liability for clinical conduct and is accountable to monitoring for compliance. To ensure that quality care and patient safety is given top priority effective clinical incident and complaints management strategies should be implemented and a single (but multidisciplinary) committee needs to be in place to address issues that arise in a timely manner and then provide feedback to staff. Lastly, district policies surrounding the reporting of incidents should be clearly articulated so that clinicians know their responsibilities and how they may be accountable from Queensland Government, (2005).
Analysis of Hospital managements’ response to safety
No Formal incident reporting or Complaints System
There was no formal incident reporting or complaints system in place at Bundaberg Hospital for employees or patients with hospital management did not seeing it as a complaint unless the incident had been fully investigated by them (Davis, 2005; Dunbar et al, 2011). This made it very difficult to keep track of how many or to what extent the complaints had been happening. Management are not excused but this highlights a need for a robust employee and consumer feedback process (Queensland Health, 2007). In terms of clinical governance, managements role should have been to protect all parties (DDHHS, 2014; O’Hagan &
Analysing managements response to safety was alarming, with personality conflicts labeled as the main issue (Davis, 2005). Many employees gathered evidence including a renal Nurse on behalf of Dr Miach and Ms Hoffman in ICU (Davis, 2005; Dunbar et al, 2011). But like with many of the other complaints raised regarding patient safety management either stated there was insufficient evidence or the evidence had not been received (Davis, 2005; Dunbar et al, 2011). Management frequently stated the complaints were personality conflicts between employees rather than any actual issues with Dr Patel’s performance (Davis, 2005; Dunbar et al, 2011). Dr Keating’s response was that Dr Patel was a very capable surgeon with the ability to complete many surgeries and complaints were because employees did not get along, but as noted previously Dr Patel had not had his practice assessed (Davis, 2005, p. 101-104; Dunbar et al, 2011).
Hospital management had failed to get Dr Patel credentialed and privileged; a process which would have assessed his competence, a process which may have highlighted areas of need (Australian Council for Safety and Quality in Health Care, 2004) When asked during the inquiry managements response for this not happening was the Medical Council did not offer anyone suitable to complete the task (Davis, 2005; Dunbar et al, 2011).
The Otego database, an audit tool used to track incidences in the surgical department was no longer in use, more alarming was that it had not been replaced with another suitable tool (Davis, 2005; Dunbar et al, 2011). This is something that hospital management should have been aware of and should have been asking why and yet it seemed they were not aware or may have chosen to ignore as Dr Patel was after all the Director of Surgery so it was his choice to use it or not (Davis, 2005).
Intensive Care Unit
Managements’ response to many of the Toni Hoffman complaints was that Ms Hoffman and Dr Patel were experiencing a personality clash, which she had admitted (Davis, 2005; Dunbar et al, 2011). In the beginning, Toni Hoffman, did try and resolve any personality issues but found it difficult to talk to Dr Patel stating he was aggressive to colleagues, patients and relatives (Davis, 2005).
Toni Hoffman had raised concerns, regarding ICU capacity to take on complex cases and the extended stays, initially the surgeries continued because Dr Patel had informed management he could perform them, again management had no way of knowing if he could actually safely perform these complex surgeries (Davis, 2005; Dunbar et al, 2011). It was not until the second death from an oesophagostomy did management take some responsibility and say no more, which unfortunately was too little too late for the patient that had died (Davis, 2005).
The work environment at Bundaberg Hospital had begun to drop and morale was at an all time low with many feeling they were not being listened too by management (Dunbar et al, 2011). Nurses were get extremely concerned and had started to consult Queensland Nurses Union (Davis, 2005; Dunbar et al, 2011). Management were not happy about this and did not want the incidents to leak outside of hospital walls but Toni Hoffman took it one step further, having discussed the case with a member of parliament hence the nickname ‘whistle blower’ (Davis, 2005; Dunbar et al, 2011, Habiba, 2014).
Throughout the course of Dr Patel’s employment Toni Hoffman had documented the complaints (Davis, 2005; Dunbar et al, 2011). This documentation and Toni Hoffman as a patient advocate lead to an inquiry which resulted in Dr Patel no longer being able to practice in Australia (AHPRA, 2015; Dunbar et al, 2011). This also lead to the development of the clinical incident management standard including PRIME which is an incident reporting system throughout Queensland Health (Dunbar et al, 2011; Queensland Health, 2007). Also, the employment of patient safety officers being trained and deployed across the state (Queensland Health, 2007).
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