North Shore Hospital report - New Zealand Doctor

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Health and Disability CommissionerOpinionGeneral commentsThe common contributions to the cases subject to this investigation are ECC overcrowdingand a generally overwhelmed acute care system at North Shore Hospital.As more patients, who should be in ward beds, accumulate in the ECC the less care each canbe afforded, so patient dissatisfaction and clinical risk compound. Good medical and nursingstaff (and I have no doubt that the staff at North Shore Hospital are good) will prioritise theirinterventions so that patient safety is preserved as best it can be. Non-essential aspects ofmedical and nursing care may be sacrificed simply to keep patients safe. Patients, and theirrelatives, who experience delays, crowding, and less attention than they would like, will bedissatisfied. The complaints under investigation reflect this.As patients accumulate it is the nursing resource that is stretched most. Eventually the safetyof patients is compromised as the patient load exceeds the capacity to observe them. At NorthShore Hospital (and at many others) the ECC bears the burden of patient dissatisfaction andincreased risk despite the significant contribution from things outside the ECC‘s authority(inefficient admission processes, lack of admitting rights, and difficult access to ward bedsbecause of high hospital occupancy rates, etc).It is my opinion that the concerns raised about the standard of care delivered by ECC havelegitimacy, but it is an injustice that the staff of ECC must defend themselves when theyappear to have worked well and hard against overwhelming odds. It must be particularlyfrustrating for ECC staff that they find themselves under this scrutiny after submissions tothose who might have been able to improve matters were not embraced.Specific AdviceIn relation to this discussion, and after examination of the information provided to me, I haveformed the following opinions:1. [Ms A] (and her partner) received discharge care below an acceptable standard.2. All of the patients under investigation received delays in care — less interaction thanthey (or the family) would have liked, and perceived deficiencies in communication.The delays are documented. The deficiencies in care and communication remainperceptions and are debated in the information provided. I suspect there is legitimacyin these perceptions, but I cannot identify any definite episodes of substandard care inthis respect.3. The substandard discharge care provided to [Ms A], the delays in care, and any realor perceived deficiencies in care or communication, do not appear to be due tofailings of any of the clinical staff, but rather to do with the context in which theywere working.4. An overwhelmed acute care service (specifically ECC overcrowding and anoverwhelmed acute General Medicine service) was the principal reason for thedeficiencies observed.5. Waitemata DHB had been made aware that acute care services at North ShoreHospital were overwhelmed and suggestions for increased capacity had not beenaccepted. It is my opinion that the failure to respond to the state of acute care at NorthShore Hospital, including the dismissal of specific requests for increased capacity,represents a failure to ensure services of an adequate standard.6. Concerns about overwhelmed acute care services in the hospitals of New Zealand,and ED overcrowding specifically, have been brought to the attention of the Ministry128April 2009
Opinion 07HDC21742of Health, and various Ministers over recent years, and have been a feature of anumber of reviews, investigations and publications of which the Ministry is aware.Despite these concerns DHBs remained without direction or incentives encouragingthem to take this issue seriously. It is my opinion that the Ministry and Ministers mustbear some responsibility for the deficiencies identified in this investigation. 100RecommendationsAlthough many of the following suggestions are being advanced, I will state, as is my brief,recommendations for improvement. I will make a comment after each, regarding myimpression of progress Waitemata DHB has made in relation to each recommendation:1. A programme for improving management of the acute patient at North Shore Hospital(incorporating the principles discussed above) needs to be advanced by WaitemataDHB with urgency, and embraced as being of the highest importance for the DHB.Components of such a programme would likely include:(i) Immediate actions for quick results.(ii) Medium and longer term projects commenced without delay, and consistent withlong term strategic planning for acute services. (Such projects, because ofcontinually changing context and demands, will be based partly on bestjudgement and good faith. They take time to bear fruit so should not be delayeddue to thoughts that things might change. In the extremely unlikely event that, atsome future time, acute capacity significantly exceeds demand then the DHBwill find itself with the luxury of a service which is happy and future proofed.(iii) Clinical Leadership.(iv) Management support and investment.(v) Adequate project management support.(vi) Capital investment.Specific actions resulting from such a programme would likely include:(i) Addressing capacity (bed and other recourses) needs of the ECC and thespecialty services.(ii) Addressing the staff needs (nursing, medical and other professionals) of the ECCand specialty services.(iii) Improving processes for patient care, based on the principles discussed above,and specifically improving the admission pathways for General Medicaladmissions (likely to include movement of General Medical patients out of theECC once referral has occurred, to a more suitable location for General Medical―work-up‖).Comment: Waitemata DHB has made a commitment to work of this type, although itmay be less comprehensive than suggested. The new CEO has an understanding of the100 In January 2009, the Ministry of Health published the Report of the Working Group for AchievingQuality in Emergency Departments, Recommendations to Improve Quality and the Measurement ofQuality in New Zealand Emergency Departments. In February 2009, in his letter of expectations toDHB Chairs, the Minister of Health set a formal responsibility for DHBs to ―Improve emergencydepartment waiting times — we expect improved service in EDs in relation to both the current triagetime indicators and the new emergency department length of stay target‖. A formal work programme isbeing developed by the Ministry of Health.April 2009 129
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North Shore Hospital report - New Zealand Doctor

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