Thank you for the opportunity to speak. I have been looking forward to it. I want to make some general observations on quality improvement and alert you to the Quality Improvement Committee. Then I have a few things to say about patient flow and safety, which I see as a subset of the quality agenda and as a priority within that agenda.

Let me set the scene as I see it. I think we have reached a point in time when the opportunity to focus on, and deliver, quality improvement is the best it has been for many years.

There are two main reasons for this.
The first is that the structural reforms are over. At last. It is difficult to deliver on a quality agenda when the prevailing ideology is that structural reform will solve all problems. We started with Area Health Boards; we finished with District Health Boards which are much the same thing yet we journeyed to hell and back between times, searching for some holy grail that didn’t exist.

But it is over. DHBs are a settled idea. A population based approach to health care is a settled idea. The strategic direction offered by the Health Strategy, the Disability Strategy and all the individual strategies is mostly settled. So now we can get stuck into serious implementation.

The second reason that the time is right is that the quality improvement agenda is maturing. People around the world are researching, campaigning, implementing -and holding conferences.

The agenda is maturing in New Zealand rather quickly. So now not only can we get into serious implementation, we are getting better at understanding how to do so.

My own story is a case in point. In the past year I have had discussions and debates with my Principal Medical Advisor, the Health and Disability Commissioner, DHB quality managers, the Safe and Quality Use of Medicines Committee, the Flinders people and so on. I’ve read and read, to try to understand, including the special series of seven articles in the New Zealand Medical Journal last year. In November I had settled on a number of important questions that needed to be answered and a few of us travelled to Boston to put them to Dr Don Berwick of the Institute for Healthcare Improvement; possibly the foremost quality institution in the world.

We spent a day there. Dr Berwick did not answer my questions. Instead he said they were the wrong questions and he kindly gave me other questions to ask. He answered these ones instead. They were very good questions and very good answers. In short my story is that quality is on my agenda and will stay there.

Problem definition must precede solution definition and around the world a body of uncomfortable or even distressing data and information is now to hand.

Let us briefly recap lest we forget. The practice of medicine is unreliable, health systems are unreliable, and that unreliability has many faces. The inverse care law is one such face. High variability is another. Health disparity is a third. Error rates for this or that are others. Seven years ago the Institute of Medicine described health care as the 8th most common cause of death in the USA. Five years ago a New Zealand study suggested that 30 cents in every hospital dollar is spent addressing adverse events.

So it is a big problem, which is fine by me as it presents a big opportunity.

Seizing the opportunity is hard. If it weren’t then it would have been done by now.

But I think there are four things about quality improvement that are generally true, generally able to be relied upon and therefore generally the place to start.

The first is to place the patient at the centre of thinking about change in the design of care. From a patient’s perspective, poor quality comes in the form of delay, poor access, over, under and mis-medication, over or under delivery of service, technical errors and so on. This is more or less the quality improvement agenda. But viewing the issue from the patient perspective at the outset and then blending the needs of the institution later will always deliver a better result than doing it the other way around.

A second starting point is to think about the business case for quality. Quality improvement nearly always saves money. Sometimes it is the patient’s money that is saved, sometimes it is health dollars that are saved; usually it is a combination of both. Medication error or infection self-evidently cost everyone. Inequalities cost those that cannot gain access, and a decade later they cost the health system too. So while quality initiatives should always start from a health gain perspective they should also be accompanied by a full business case. In my mind quality and value for money are closely linked ideas. It is true that quality investments must precede gathering any quality benefits and it is true that benefits can depend on unproven assumptions. Sometimes a risk has to be taken on quality, but that is a feature of many areas of human endeavour.

A third starting point is that quality initiatives depend on very good communication. Many quality ideas are disarmingly simple, or even embarrassingly so. A question that is often on my lips when a quality improvement has been explained, is, “Given that this isn’t rocket science, what took you so long?” This is the same question that is asked when a quality improvement has been made somewhere but hasn’t spread anywhere else. Not across the county. Sometimes not across the corridor. How does that happen?

My answer is that our health system, any health system, is complex and somewhat cellular. Fiefdoms abound. Traditions abound. Egos abound. Rituals abound. But fiefdoms, tradition, egos and rituals cannot withstand good communication. A good, simple idea, well communicated, will sooner or later prevail.

My fourth and final starting point with quality, quite closely related to the third, is that quality involves everyone and that progressing a quality initiative involves everyone. There must be buy-in and that buy-in must be solidly built. Shortcuts take longer. Someone can be the champion, for sure, but they can't be the Commander. They may lead but they may not instruct.

So those are my starters. Look through the eyes of a patient, do the business case, pay careful attention to communication, and build a collaborative.

I have recently revamped National Health Epidemiology and Quality Assurance Advisory Committee and it is now operating as the Quality Improvement Committee or QIC.

The new committee has revised terms of reference, which will focus more on developing a shared learning environment in the health sector, so that innovations that improve health care can be adopted more quickly throughout the sector. It will be responsible for identifying examples of innovation or best practice in health, drawing from international or local initiatives that could be used in New Zealand.

New members on QIC are experts in their field and the presence of a DHB Chair and a Chief Executive signals to the sector that Quality Improvement initiatives will be driven through the existing mainstream accountability mechanisms. Quality may not be ghettoised.

Pat Snedden who chairs the Counties Manukau DHB, also chairs QIC. Other new members are Barbara Crawford, Kevin Hague, Jean Hera, Alan Merry, Catherine Rae, Mary Seddon, Judi Strid. Robin Youngson, and Jim Vause have been reappointed for a second term. Cindy Farquhar, Barbara Greer and Barry Taylor continue as members.

The new committee is in receipt of a gift. The gift is a report dated last November called “ Scoping The Priorities For Quality” and the report scopes six such priorities. One of them, you will be pleased to learn, concerns patient flow.

The report is a gift because QIC has yet to decide its work plan. However when it does I am sure the report will closely inform its decisions.

Note there are only six priorities, not sixteen or thirty-six. This is important. The committee will not be short of additional suggestions. Indeed it will have to continually guard against drowning in good ideas. Making good progress on a few fronts is always better than glacial progress on many.

And so, to patient flow, where I shall start with a story. When I became the Minister Of Health I set myself the task of spending one whole day at every DHB each year. I'm on my second circuit now and have clocked up about thirty such visits. They are hugely valuable to me. I get to glimpse a little of everything and I get to talk to hundreds and hundreds of people. The last DHB I visited before writing this speech was Capital and Coast. So my story comes from there. Though it could have come from anywhere.

The oncology unit decided to survey their patients to see how they felt about their chemotherapy service. The answer was the patients had to wait, for hours, before their first chemotherapy commenced. The reason is that this is a same-day service and after a patient’s chemotherapy needs are established someone rings the pharmacy then and there to get the cocktail made up. Except that the pharmacy might be busy and some of the cocktails are complex. And expensive. The hours tick by.

Some of the cocktails are, however, simple. They are also cheap. And they have a shelf life too, though only of a few days. So the innovation was to predict the demand of simple cocktails and pre-order it. Half the problem solved, and with very little wastage. The other half was solved too, because the surge at the pharmacy was halved and became thoroughly manageable.

Happy patients. But no business case. Remember the business case? Well no matter, because the gains came anyway, in the form of reduced overtime for the chemo nurses. When patients wait, so does everybody else. This story has no downsides. None. This change is embarrassingly simple and yet it took a long time to achieve. An embarrassingly long time. “Why, oh why?” asked the exasperated visiting health minister. “Communication” came the one-word answer from the senior clinician whom I deeply suspect was the champion, though he would only acknowledge that he was part of a collaborative team.

So, there is a simple story, which illustrates three of the four common features, which I mentioned earlier. Patient-centeredness, communication, teamwork. The business case took care of itself in this instance.

Because good ideas don’t easily travel, and because praises aren’t readily sung, I put the story in my speech in the hope that, in this case, the treatment of chemotherapy patients around the country will flow more freely.

As to patient flow and safety in general, I intend to keep my remarks relatively brief.

Chapter 4 of the quality priorities report I mentioned earlier is a fine read for anyone who, like me, feels they are beginners. It has a good working set of objectives, an indicative timeline and more. It also draws on what is already going on in the area, on the techniques the Institute for Health Improvement has developed for rapid dissemination of innovation and so on. Read it.

I have an eclectic list of five things to say about patient flow that might not otherwise be said.

The first is that a DHB with a significant capital programme has an opportunity and an obligation to address and radically improve patient flow as part of their development. In my experience DHBs do. Which is good. Woe betides a DHB that doesn’t.

Last year the Prime Minister opened an entirely new hospital in Masterton. It is just one of many capital investments made since the change of Government when my predecessor Annette King decided to ramp up the modernisation of facilities. From memory we have 27 large projects completed or underway.

In the following six months Wairarapa posted some astonishing results. Elective surgery caseweights rose 29 per cent. The proportion of patients now receiving surgery on the day of admission is 96 per cent.

Part of this is due to the increase in the range of services the new facility can deliver. But it is partly due to the efficiency gains and the improved patient flow that arose from seizing the opportunity that the new hospital presented.

The second of my comments on patient flow is precisely the opposite of the first. That is that patient flow is not dependent on having new kit.

Canterbury proves that. Of all the DHBs that are now engaged in one or more aspects of patient flow, and most are, Canterbury is for my money leading the way. It is not always smart for a Minister of Health to nominate a DHB as being best at something but in this case I am in no doubt. They are far enough through their “Improving the Patient Flow Journey” initiative that they can lay claim to eye-watering outcomes. The one I like the best is a 40 per cent increase in theatre efficiency. It is eye-watering because it is such a remarkable improvement, and like many things on Planet Quality it is also a crying shame it wasn’t secured earlier.

The Canterbury DHB has a conference in May on this stuff. They have a story to tell and I assert it is a story of consequence. They have, by some measures, out-Flindered Flinders. I can't go because I'm in Geneva. But you should.

The third thing I would like to say concerns information systems. Just as Annette King ramped up modernisation of our physical assets, from last July, I have ramped up capital investment in our electronic assets; our health information system. The detail around that is some other speech. But the benefits to patient flow of referrals e-discharges, e-pharmacy, e-labs and the like, are considerable. Information system modernisation is particularly important at the primary/secondary interface. It is a rich vein of opportunity.

Fourthly, let us please make sure that our attention to patient flow is mindful of what else is already underway. Cancer treatment networks is a case in point. So is the Elective Services Strategy, which sets time limits for first specialist assessments and elective surgery. This strategy is years old but no one had achieved its aims until last September when most DHBs fell into compliance. Some have not yet or are bouncing around on the boundary.

Remember also that working parties are at work on theatre utilisation, on addressing disincentives and so on.

And the last of my five remarks is one about the limits to the purpose of this conference. This conference is about patient flow and safety. It therefore must put the patient first and it must give the patient primacy. This conference starts and finishes with what’s good for the patient.

This conference is about systems but patients are not systematic. This conference is about streamlining but patients are not homogeneous. This conference is about codifying but patients are not predictable.

So where are the limits?

Sure, we can improve patient flow by getting the discharge plan together at the outset. By asking, for example, whether the patient has their house keys on them or whether any of their children are about. Or by putting their discharge time, to the nearest half hour, on their record within a day of arriving at the hospital. This is patient flow in action.

But what if they are different? What if standardised care, an increasing feature of a modern health system, doesn't work for the person who is in front of the clinician? What then? Where does standardised care give ground to customised care? And, when it does, what does that do for patient flow?

All of these questions are designed to allow me to introduce Richard Bohmer. He is a New Zealand doctor who works at the Harvard Business School. I commend his writing to you. He offers operational strategies for effectively combining custom and standard clinical practices. He allows me to begin to understand how to make the uncomfortable mix of custom and standard elements more comfortable.

So that concludes my remarks. I earnestly hope this conference is useful. The topic is very important and the potential health gains from progress on it are considerable.

The conference is entitled “Optimising Patient Flow and Safety”. It has an antonym. The antonym is “Exposing Patients to Delay and Risk”.

The antonym is not acceptable. So let’s not accept it. Have a very good two days.