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Strategic Plan 2013–16

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The New Zealand Triple Aim for quality improvement

Health Quality & Safety Commission Strategic Plan 2013–16ii

The Commission’s vision is for New Zealand

to have a sustainable, world-class and

patient-centred health care and disability

support system.

It’s about doing the right thing, and

doing it right, first time.

Published in April 2013 by the Health Quality & Safety CommissionPO Box 25496, Wellington 6146ISBN 978-0-478-38540-3 (print)

ISBN 978-0-478-38536-6 (online)

This document can be downloaded from the Commission’s website at: www.hqsc.govt.nz

The illustrations in this publication were created by a graphic artist at the Asia Pacific Forum on Quality Improvement in Health Care 2012 to capture attendees’ visions of patient safety.

Health Quality & Safety Commission Strategic Plan 2013–16 1

Contents

Introduction ........................................................................................................... 1

Message from the Chair .......................................................................................... 2

Message from the Chief Executive ............................................................................ 3

Commission’s strategy 2013–16 .............................................................................. 4

Our role and purpose ............................................................................................. 6

Strategic priorities .................................................................................................. 7

Our success ......................................................................................................... 20

Building for the future ........................................................................................... 21

References ........................................................................................................... 22

IntroductionWelcome to the Health Quality & Safety Commission’s (the Commission’s) Strategic Plan 2013–16.

As a Crown entity, the Commission accounts for its performance in several documents. This strategic plan outlines our high-level direction and also addresses our immediate three-year programme of activity. It summarises our planning and how the Commission will continue to invigorate change in a health care system focused on doing the right thing, and doing it right, first time.

Further details about the Commission’s activities on an operational level, and our achievements, can be found in our statement of intent and annual report. These are available on the Commission’s website: www.hqsc.govt.nz.

Health Quality & Safety Commission Strategic Plan 2013–162

Message from the ChairThe Commission was established in November 2010 to build a culture of constant examination and improvement in the health and disability sector, and reduce deaths, harm and waste from preventable errors.

New Zealand already has an excellent, cost-effective and patient-centred health care system, but faces many challenges with regard to maintaining quality and safety, particularly in light of the global financial crisis.

The Commission’s vision is for New Zealand to have a sustainable, world-class and patient-centred health care and disability support system. How we will achieve this is encapsulated in the New Zealand Triple Aim of:

• improved quality, safety and experience of care• improved health and equity for all populations• best value for public health system resources.

Over time we must demonstrate the value of our work at both at the programme and system level.

By 2016 we aim to be a hub for clinical and consumer leadership and networks in the sector, and facilitate the sharing of good practice – helping the sector move from ‘islands of excellence’ to an integrated system of excellent health care. We will provide information and analysis across quality and safety issues, and have a broader ‘system view’ of quality across the whole health and disability sector. The sector will have a culture that supports and champions quality and safety, and improved equity between different populations.

With that in mind, our work must be practical, relevant, future-focused and provide value for money, aligning with other work taking place in the sector.

The Commission is a small organisation that does not provide or fund health and disability services directly. Our value comes from using our knowledge of health quality and safety across the system, our analytical capability and our relationships and networks to influence the national quality and safety agenda and to support quality and safety improvement across the country.

Everyone who uses New Zealand’s health services, and every health professional in this country, has a stake in the delivery of better, safer health care. This strategic plan sets out how this will be achieved.

Professor Alan Merry, ONZMChairHealth Quality & Safety Commission


Message from the Chief ExecutiveHealth sector resources are limited, and the Commission is focused on delivering results and value for money. This strategic plan summarises the priorities we have chosen to support in the delivery of better, safer care.

In prioritising our work we consider criteria, such as the potential for improved quality, safety and equity. We also consider the strength of the evidence supporting interventions and whether our investment represents value for money.

A strong focus over the next three years is implementing a national patient safety campaign. The campaign will be led and coordinated nationally by the Commission and implemented and led regionally and locally by the health sector. Clinicians and consumers will be the face of the campaign.

The campaign aims to energise the sector to reduce harm from:• medication• surgery• falls• healthcare associated infections.

Broadening our focusWhen the Commission was established, its initial focus was on district health board (DHB) hospital settings. This focus is now broadening to include other settings, such as primary care, aged residential care, disability services, home and community services, the wider mental health sector, other government agencies, professional bodies, non-government organisations and private providers. These areas will also benefit from quality improvement expertise and advice, and by sharing good practice.

In our individual programme areas we will share expertise and be a catalyst for improvement. We will help programmes to start up, and we will exit once those programmes are self-sustaining and the benefits are evident. Government priorities, our knowledge of the sector’s quality and safety strengths and weaknesses, and what consumers identify for us, will provide the starting point for developing new programmes and work in new areas.

We will use our growing understanding of the nature and extent of disparities to target our programmes and work to improve equity between different populations.

Dr Janice WilsonChief ExecutiveHealth Quality & Safety Commission


Commission’s strategy 2013–16

Our vision

New Zealand will have a sustainable, world-class, patient-centred health care and disability support system, which will attract and retain its workforce through its commitment to continually improve health quality, and deliver equitable and sustainable care.

Our mission

To work with everyone to ensure New Zealand has the highest quality health care. To achieve this mission, we will simultaneously pursue the Triple Aim of:


It’s about doing the right thing, and doing it right, first time.



Our values

Person-centredBy having the patient/consumer at the heart of everything we do, we support individual and family/whanau participation and decision-making about health and disability services at every level.

Evidence-informedBy basing our programmes and initiatives on strong evidence, and evaluating their effectiveness to inform our priorities, we demonstrate the value of quality improvement in reducing harm and costs.

PartnershipBy working alongside stakeholders we improve health quality and safety. We value the views of others and respect diversity of culture and opinion.

Open and transparentWe encourage sharing ideas and knowledge. We communicate in clear language for all to understand. We encourage sharing of information in a just culture, so we can identify best practice, learn from mistakes and make health and disability services better and safer.

LeadershipBy showing strong leadership we set the direction for health quality and safety in New Zealand, and encourage innovation and change to achieve our shared vision.


Our role and purposeThe Commission was established in 2010 to lead and coordinate health quality and safety work across the health and disability sector, in particular to:

• monitor the quality and safety of health and disability services• help providers across the sector to improve the quality and safety of health and disability

services.

The Commission adds value to health quality and safety in New Zealand by identifying what needs to improve and providing expertise and advice to support improvement and spread good practice.

The Commission’s functions include:• leading and coordinating improvements in quality and safety in health care and

disability services• disseminating knowledge on and advocating for quality and safety• identifying quality and safety indicators and datasets to inform and monitor

improvements in quality and safety• reporting publicly on the state of quality and safety, including performance against

national indicators• advising the Minister of Health on: how to improve quality and safety in health and

disability services; health epidemiology and quality assurance; and mortality review• managing the New Zealand Public Health and Disability Act 2000 mortality review

functions.

Shining the light on

variation, and key

areas for improvement

Being an intelligent

commentator and

advocate for change

Lending a hand by

making expert advice,

guidance and tools

available.


Strategic priorities

1. Monitor and report on quality and safety.2. Build sector capability for quality and safety improvement.3. Support clinicians to be leaders of quality and safety improvement and follow best practice.4. Build consumer engagement and partnership.5. Support reporting and management of health care incidents.6. Manage mortality review functions.7. Influence the health quality and safety agenda and be a catalyst for change.8. Ensure success in our programme areas:

• national medication safety programme• reducing perioperative harm programme• reducing harm from falls programme• infection prevention and control programme.

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Improved health and equity

for all populations

Best value for public health system resources

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The New Zealand Triple Aim has been accepted by the Ministry of Health (including the National Health Board, the National Health IT Board, the National Health Committee and Health Workforce New Zealand), DHBs, Health Benefits Ltd and PHARMAC. This common purpose is central to achieving the goal of improving the quality and safety of health and disability services across the whole sector.

All our strategic priorities are underpinned by the New Zealand Triple Aim for quality improvement, which includes:



Priority 1

Monitor and report on quality and safety

Our role is to monitor the value of quality and safety improvement to individuals, families, the community and health services, and to develop a health and disability sector and public that are knowledgeable and informed about quality and safety. We show change over time and assess the impact of quality and safety improvement on people and costs.

By monitoring and reporting on quality and safety, we can identify where problems lie and key opportunities for improvement. We can provide examples of good practice to follow. Avoiding waste related to poor quality care is vital; without good measurement and evaluation we do not know where waste occurs or whether interventions to reduce waste have worked.

By linking ethnicity with quality and safety information we can examine health care disparities, work to understand why those disparities exist and determine which causes of disparity can be tackled successfully.

Focus• Quality and Safety Markers – a set

of related process and outcome measures that concentrate on our four priority programme areas as a way of tracking improvement.

• Quality and Safety Indicators – a small set of indicators to track progress over time in quality and safety in the health system.

• Atlas of Healthcare Variation – a tool to identify and prompt questions and discussion about variation in the provision of health services and health outcomes, and to help reduce variation where it is unwarranted.

• Quality Accounts – a report in which health care providers must account for the quality of their services, just as how financial accounts show how an organisation uses its money.

Outcomes• Evidence of quality and safety

improvement in the sector from measured reduction in harm and evaluation of programmes.

• Evidence of improved equity through reduction in variation.

• Significant reduction in variation over time, through best practice approaches to specific populations.

• Positive engagement by clinicians and consumers, and informed discussions about quality and safety resulting from reporting on indicators and variation.


Priority 2

Build sector capability for quality and safety improvement

Clinicians’ ability to continually measure the effects of the way care is delivered – on both individuals and services – will result in better experience of service, better outcomes for patients and better value for money.

A key element in building a health culture where quality and safety improvement is part of everything we do is the ability of clinicians and other health professionals to use improvement science and skills. Being able to recognise problems and apply improvement tools helps changes to be made and sustained.

FocusThe Commission is developing a comprehensive plan for building sector capability.

• Describing the competencies in health quality improvement science that clinicians need to reduce harm in our four priority programme areas.

• Describing the competencies (knowledge, skills and attitudes) that leaders, managers and those in governance roles need to understand the system or organisational changes required to improve quality and safety.

• Assessing development needs to help plan future education, training or development.

• Supporting education and training in improvement science.

• Promoting the essential elements that will enhance sustainable quality and safety, including clinical leadership, clinical expertise, improvement expertise, a supportive culture and systems thinking.

Outcomes• Frontline health care staff with the

knowledge and skills to initiate and complete quality and safety improvements in the workplace.

• People with the technical and leadership skills and knowledge to facilitate system-wide improvement in the health and disability sector.

• Health care workers working with consumers as partners in measuring effectiveness of services.

• Routine use of measurement as a fundamental tool for improvement in health care.


Priority 3

Support clinicians to be leaders of quality improvement and follow best practice

Great services have strong clinical leadership. Strong leadership can drive quality and safety improvement by clinicians and active patient/consumer engagement, resulting in better outcomes and reduced costs.

The Commission has a role in building clinical networks and clinical expertise and capability for quality and safety improvement.

Focus• Building a cohort of quality

and safety improvement clinical leaders for key Commission programmes.

• Developing networks of clinicians to champion and lead improvement within the sector.

• Leading discussion on unwarranted variation and continued review of indicators and measures.

• Connecting with clinical leadership groups.

Outcomes• Clinicians initiate and lead

quality and safety initiatives in their everyday practice.

• Clinicians proactively use measurement and consider the quality and safety improvement cycle in their everyday practice.

• Clinicians engage with patients/consumers in joint decision-making.

• Clinical leaders in quality and safety improvement are well known regionally and nationally.


Priority 4

Build consumer engagement and partnership

Patient- and family-centred care is a fundamental element of quality in health care. Partnerships between clinicians/providers and consumers/families mean consumers are more informed and have a sense of control over their health and treatment. There is emerging evidence that such partnerships lead to improved health, better experience of care, lower health care costs and increased workforce satisfaction.

Health literacy is also of critical importance – people with good health literacy can make informed and appropriate health decisions, and better manage their own health.

Focus• Implementing the Partners in

Care framework, which supports consumer engagement and participation across the health and disability sector.

• Supporting a ‘co-design’ programme that helps providers, clinicians and consumers work together to improve service design and delivery.

• Carrying out a demonstration project to improve health literacy in community pharmacies.

• Establishing a consumer network and the appointment of consumer representatives in all Commission work programmes.

• Developing a leadership programme for consumers and clinicians.

• Engaging with international experts to develop best practice.

Outcomes• Consumers are represented in all

Commission work programmes and a consumer network supports and guides the Commission’s work.

• The completed co-design initiatives are evaluated, and successful models are used by the sector to inform its work in developing provider/consumer partnerships to improve services.

• A more structured approach to consumer engagement and participation in health care provider organisations.

• Clinicians and providers use proven tools developed through the demonstration projects to improve health literacy.

• Literacy tools help providers engage and communicate effectively with patients/consumers.


Priority 5

Support reporting and management of health care incidents

Incidents that cause patient harm result in increased lengths of stay in hospitals, greater treatment and rehabilitation costs, and significant personal costs – sometimes death.

This work programme recognises that to increase safety there needs to be a system to identify when things go wrong and improve the response – including open disclosure, conducting root-cause analysis and sharing information so other providers can improve systems and prevent similar events from occurring. The information gathered from reporting will also inform the Commission’s other work programmes.

The Commission reports annually on the serious and sentinel events that occur in our hospitals. This focus is broadening to include the whole health and disability sector.

The aim of this programme is to prevent the recurrence of adverse events that result in patient/consumer harm and the consequent costs, both human and financial.

Focus• Reporting on serious and sentinel

events, reviewing outcomes and sharing lessons learnt across the sector.

• Developing whole-of-sector serious and sentinel events reporting.

• Working with our partner central agencies – the Accident Compensation Corporation (ACC), the Health and Disability Commissioner and the Ministry of Health to learn how to improve systems.

• Helping the sector use tools such as the Global Trigger Tool to identify harm.

• Developing appropriate reporting from the mental health sector.

Outcomes• Whole health and disability sector

reporting of serious and sentinel events.

• Reporting systems that share lessons learnt from the review of serious incidents.

• Appropriate training and education systems to support providers, including guidance on open disclosure and root-cause analysis.

• An annual serious and sentinel event report that includes information from a wide range of providers, and maintains an emphasis on quality improvement rather than compliance.

• Greater sharing of information across central agencies.


Priority 6

Manage mortality review functions

Mortality review is an applied research process that is used to identify and address systemic issues relating to any type of death or adverse event with the aim of improving systems and practice within health and disability services.

While one unexpected, preventable death may be seen as a tragedy, deaths occurring in a pattern are usually an indication of larger systems failures.

There are four Mortality Review Committees operating under the umbrella of the Commission:

• Family Violence Death Review Committee• Perioperative Mortality Review Committee• Child and Youth Mortality Review Committee• Perinatal and Maternal Mortality Review Committee.

These committees review particular deaths, or the deaths of particular people, to learn how best to prevent those deaths.

Focus• Reviewing deaths and making

recommendations for preventing deaths and harm.

• Working with stakeholders in health and across other sectors (including Social Development, Transport, Justice, Corrections and Local Government) to assist and encourage change to save lives and prevent illness and injury.

See the Commission’s website for further information about each committee: www.hqsc.govt.nz

OutcomesThe overall aim is to reduce preventable deaths.

• Each Mortality Review Committee will provide at least one report annually with recommendations to improve systems and reduce preventable mortality and morbidity.

• Where the report has recommendations relevant to an organisation, most of those organisations will use recommendations to confirm current practice or make service improvements.

• Improved data management.• Outcomes resulting from national

mortality review are captured and clearly demonstrated.


Priority 7

Influence the health quality and safety agenda and be a catalyst for change

The value of our role and work will be demonstrated by clinicians, providers, funders and policy-makers using our knowledge and information to review continuously the quality and safety of services for individuals and communities, thereby making the best use of funds.

The Commission’s knowledge base helps identify quality and safety priorities. We work with the sector to enable clinicians, consumers and managers to create the changes required over time, and to spread good practice, by building better engagement, partnership and capability.

Focus• Identifying and discussing quality

and safety issues (eg, serious and sentinel events, Atlas of Healthcare Variation, mortality review reports) and creating a ‘tension’ in the system to address those issues.

• Highlighting good practice in the sector and commenting on key issues.

• Providing good evidence to challenge practice – and asking ‘why haven’t you…?’

• Highlighting the importance of ‘doing the right thing, and doing it right, first time’.

Outcomes• There is wide agreement on

the quality and safety agenda throughout the health and disability sector.

• The sector has the knowledge and tools to make changes.

• The sector demonstrates a strong will to improve health quality and safety, evidenced by improvement being at the centre of all practice.


Priority 8

Ensure success in our programme areas

The Commission is leading and coordinating a national patient safety campaign aimed at achieving large-scale change by galvanising people to work towards the same goals. The campaign will focus on reducing harm in our four priority programme areas:

• national medication safety programme• reducing perioperative harm programme• reducing harm from falls programme• infection prevention and control programme.

These programme areas were chosen because of the compelling evidence that improvement would reduce harm to patients, save lives and thus reduce costs both to individuals and to the health system.

The success of the four programmes is underpinned by our other strategies. These strategies identify the challenges that need to be addressed in the longer term, enhance the capability of the health workforce and consumers to improve health quality and safety, and measure and evaluate the impact of interventions.

These strategies are:

• measurement and evaluation• consumer engagement and partnership• building sector capability and clinical leadership• building a culture of quality and safety improvement.


Priority 8

National medication safety programmeMedicines are the most common interventions in the health system and impact on the lives of every New Zealander at some point. The medicines management process is complex and open to medication errors, which can result in adverse drug events. International studies have shown that medication errors and adverse drug reactions are the main causes of adverse drug events, resulting in disability and/or death in about 6.5 percent of hospital admissions (1–6).

Around 60 percent of adverse drug events are thought to be preventable (7–10).

This programme is a partnership between the Commission and the National Health Board/National Health IT Board. Its primary aim is to ensure the right patient gets the right medicine in the right dose at the right time and by the right route.

Focus• Improving prescribing and

administration by supporting the introduction of the national medication chart and medicine reconciliation in DHB hospitals and accelerating electronic medicines management in hospitals.

• Improving the transfer of medicine information at transition points of care.

• Reducing harm from high-risk medicines and situations by providing alerts to the sector.

• Measuring and evaluating reductions in medication harm and contributing errors, and assessing programme effectiveness, by developing a measurement and evaluation framework.

Outcomes• Fewer patients are harmed by

adverse drug events and less resource is wasted through inaccurate, inappropriate and inefficient use of medicines.


Priority 8

Reducing perioperative harm programmeOver 300,000 publicly funded surgical operations are performed in New Zealand each year. Even routine surgery requires the complex coordination of surgeons, anaesthetists, nurses and support staff to provide timely and effective care. Effective teamwork and communication lie at the heart of providing safe surgical care.

Patients undergoing surgical intervention are at increased risk of complications and death. A systematic review of studies suggests that about 1 in 10 hospital patients in developed countries experiences an adverse event and that about 60 percent of these are surgical patients (11). A number of interventions to improve safety practices have been shown to reduce complications significantly, including the use of checklists and improvements to teamwork and communication (12–19).

This programme aims to reduce perioperative harm by encouraging teams to consistently apply evidence-based practices and safety checks to all patients, and by improving teamwork and communication.

Focus• Fostering better communications

and teamwork.• Supporting the effective use of

the World Health Organization Surgical Safety Checklist.

• Supporting the ongoing implementation of the Productive Operating Theatre Programme in operating theatres.

• Developing other evidence-based interventions known to improve outcomes for surgical patients but not currently used consistently in clinical practice.

Outcomes• Preventable complications of

perioperative harm are reduced.• Rates of surgical harm and

mortality are reduced.


Priority 8

Reducing harm from falls programmeFalls are the largest category of serious and sentinel events* reported by hospitals. In the 2011–12 serious and sentinel events report (20), DHBs reported 170 falls that were classified as a serious or sentinel event. ACC claims data from 2010–11 indicates the claim costs from 2,600 in-patient falls per year is around $3 million. A review of a range of data suggests the direct costs of in-patient falls could be about $5 million per year nationwide (21).

Falls also occur in aged residential care facilities and in the community (including homes and other settings). The scale and burden of harm from falls is reported to be five-fold for aged residential care and nearly 20-fold in community settings. Falls that lead to harm impose extra diagnostic, treatment, rehabilitation and care costs on hospitals, aged residential care facilities and other community-based providers (21).

This programme aims to reduce falls and harm from falls in care settings, with a focus on older people.

Focus• Developing and implementing

a programme focused on older people at risk of injury from falling in care settings (hospital in-patients, people in aged residential care, those at home receiving care) and those on a large number of medications or with previous hip fracture.

• Identifying the costs and benefits of proven falls-prevention interventions and the extent to which interventions impact on costs and effectiveness across various settings.

Our work is complementary to the work of ACC, which is mandated by Ministers as the lead agency responsible for the over-arching New Zealand Injury Prevention Strategy.

Outcome• A demonstrated reduction in the

number of falls and the degree of related harm in identified care settings.

* A serious adverse event is one that leads to significant additional treatment but is not life-threatening, and has not resulted in a major loss of function. A sentinel adverse event is life-threatening or has led to an unexpected death or major loss of function.


Priority 8

Infection prevention and control programmeHealthcare associated infections are among the most common adverse events in the health sector. Up to 10 percent of patients admitted to modern hospitals in the developed world acquire one or more infections. These infections cause pain and suffering, prolong hospital admissions and use valuable health care resources.

Coordinated programmes have been shown to reduce infection rates, improve patient outcomes and reduce human and economic costs. Individual cases of hospital-acquired infection can cost an additional NZ$20,000–45,000 depending on the severity of the infection and the treatment required (22). In 2003 it was estimated that the annual cost of treating patients with infections picked up while in hospital was approximately $140 million nationally (23).

This programme aims to reduce the number of healthcare associated infections by building a culture that examines and improves systemic problems and promotes clinically led actions across the whole sector.

Focus• Supporting hand hygiene culture

change among all health care workers.

• Building sector capability and knowledge in relation to healthcare associated infections.

• Establishing targeted national surveillance to monitor healthcare associated infections, to provide timely feedback that will inform clinical practice.

• Leading a focused response to emerging healthcare associated infections.

Outcomes• Compliance in hospitals with the

five moments for hand hygiene programme.

• A 20–50 percent reduction in the rate of hospital-acquired Staphylococcus aureus bacteraemia infection.

• A zero central line associated bacteraemia rate.

• Demonstrated reduction in surgical site infections related to hip and knee joint replacements, coronary artery bypass grafts and Caesarean sections.

• Demonstrated reduction in other infections on which the Commission is focused.


Our successWe will know we are succeeding when we have consumer-driven change, and:

• more effective and timely services• reduced deaths, harm and wastage• reduced unwarranted variation • improved equity• improved efficiency• increased appropriateness of care• financial savings that can be reinvested in the health and disability sector.

We will have a workforce with increased capability and skills to achieve quality and safety.

The Commission will develop and publish measures of the impacts of its programmes, such as how the delivery of health and disability services has changed, and outcomes, such as how harm to patients and associated costs have reduced.

The impact and outcomes of our four priority areas – reducing harm from medication, surgery, falls and healthcare associated infections – are measured in a variety of ways, including:

• uptake of good practice (changed practice)• higher proportion of appropriate treatments (reduced variation)• reduced number of adverse events• reduced mortality and harm• reduced costs of unnecessary hospital stays and treatments• improved patient experience.


Building for the futureOver the next three years we will strengthen the Commission’s ability to manage and interpret a wide range of information to provide a better view of the ‘big picture’, encourage change and innovation, and improve equity for all populations.

1. We will develop a knowledge strategy outlining what needs to be developed by when, including:

• data collection and storage systems• evaluation capability• research and information-gathering on best practice, including international scanning• relationships that support exchange and flow of information.

2. We will prepare for the Commission’s future reports (for example, a consolidated ‘state of the nation’ report on quality and safety in health care), and identify what information and knowledge those reports will draw on and how frequently reports will be developed.

3. We will continue to build clinical and consumer networks, including:

• building a cohort of clinical leaders for specific programmes• developing networks of clinicians to champion and lead quality improvement• connecting with clinical leadership bodies• identifying consumer leaders who can be involved in the Commission’s work• supporting the developing networks of consumers and their partnerships with health and

disability services.

4. We will build our organisational expertise and capability in:

• quality improvement science• improving equity • our access to expert advisors.

5. We will reinforce our approach to creating debate and discussion in the system, as a catalyst for improvement.

The above will work together to build a strong quality and safety culture in our health and disability services.


References1 Bates DW, Cullen DJ, Laird N, et al. 1995. Incidence of adverse drug events and potential adverse drug events:

implications for prevention. Journal of the American Medical Association 274: 29–34.2 Thomas EJ, Studdert DM, Burstin HR. 2000. Incidence and types of adverse events and negligent care in Utah

and Colorado. Medical Care 38: 261–71.3 Brennan TA, Leape LL, Laird N, et al. 1991. Incidence of adverse events and negligence in hospitalized

patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324: 370–75.4 Leape LL, Brennan TA, Laird N, et al. 1991. The nature of adverse events in hospitalized patients. Results of the

Harvard Medical Practice Study II. New England Journal of Medicine 324: 377–84.5 Wilson RM, Runciman WB, Gibberd RW, et al. 1995. The Quality in Australian Health Care Study. Medical

Journal of Australia 163: 458–71.6 Pirmohamed M, James S, Meakin S, et al. 2004. Adverse drug reactions as cause of admission to hospital:

prospective analysis of 18, 820 patients. British Medical Journal 329: 15–19.7 Lisby M, Nielsen LP, Mainz J. 2005. Errors in the medication process: frequency, type, and potential.

International Journal for Quality in Health Care 17(1): 15–22.8 Classen DC, Pestotnik SL, Evans S, et al. 1997. Adverse drug events in hospitalized patients. Journal of the

American Medical Association 277(4): 301–06.9 Kunac DL, Kennedy J, Austin N, et al. 2009. Incidence, preventability and impact of adverse drug events (ADEs)

and potential ADEs in hospitalized children in New Zealand. Pediatric Drugs 11(2): 153–60.10 Bates DW, Leape LL, Petrycki S. 1993. Incidence and preventability of adverse drug events in hospitalized

patients. Journal of General Internal Medicine 8(6): 289–94.11 de Vries EN, et al. 2008. The incidence and nature of in-hospital adverse events: a systematic review. Quality

and Safety in Health Care 17(3): 216–23.12 Haynes AB, et al. 2009. A surgical safety checklist to reduce morbidity and mortality in a global population.

New England Journal of Medicine 360(5): 491–99.13 de Vries EN, et al. 2010. Effect of a comprehensive surgical safety system on patient outcomes. New England

Journal of Medicine 363(20): 1928–37.14 van Klei WA, et al. 2012. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital

mortality: a cohort study. Annals of Surgery 255(1): 44–49.15 Lingard L. 2004. Communication failures in the operating room: an observational classification of recurrent types

and effects. Quality and Safety in Health Care 13(5): 330–34.16 Lingard L, et al. 2005. Getting teams to talk: development and pilot implementation of a checklist to promote

interprofessional communication in the OR. Quality and Safety in Health Care 14(5): p. 340–36.17 Lingard L, et al. 2008. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and

anesthesiologists to reduce failures in communication. Archives of Surgery 143(1): 12–17; discussion 18.18 Neily J, et al. 2010. Association between implementation of a medical team training program and surgical

mortality. Journal of the American Medical Association 304(15): 1693–700.19 Young-Xu Y, et al. 2011. Association between implementation of a medical team training program and surgical

morbidity. Archives of Surgery 146(12): 1368–73.20 Health Quality & Safety Commission. 2012. Making Our Hospitals Safer: Serious and Sentinel Events reported

by District Health Boards in 2011/12. Wellington: Health Quality & Safety Commission. 21 de Raad JP. 2012. Towards a Value Proposition... Scoping the Cost of Falls. NZIER scoping report to Health

Quality and Safety Commission NZ. Wellington: New Zealand Institute of Economic Research.22 Burns A, Bowers L, Pak NT, Roberts SA et al. 2010. The excess cost associated with healthcare-associated

bloodstream infections at Auckland City Hospital. New Zealand Medical Journal. 123(1324): 17–24. URL: http://journal.nzma.org.nz/journal/123-1324/4392/

Upton A, Smith P, Roberts SA. 2005. Excess cost associated with Staphylococcus aureus poststernotomy mediastinitis. New Zealand Medical Journal. 118: 1210(1316). URL: http://www.nzmj.com/journal/118-1210/1316/content.pdf

23 Graves N, Nicholls T, Morris A. 2003. Modelling the costs of hospital-acquired infections in New Zealand. Infection Control Hospital Epidemiology. 24: 214–23.

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