Resources

As the COVID-19 pandemic continues to cast a shadow over the health of the world, we continue to learn about clinical governance at scale. We have previously drawn analogies to Australian government responses with clinical governance principles - however the parallels don’t stop there. Across the world, the economic impact of the pandemic has been palpable and is illustrative of the co-dependent relationship between health and money, where better health outcomes are known to correlate with better economic outcomes.

So what does this tell us about clinical governance? As the gatekeeper to safety and quality in health care - and, importantly, person-centred outcomes - it is well worth the investment.

While quality will mean different things to different people, a common denominator to all perspectives is safety - that is, ‘avoiding harm to patients from the care that is intended to help them’. The bottom line is, ‘Safer hospital care reduces harm to patients and saves money for taxpayers.’

Consider the cost of complications for example. In a 2019 report on ‘The State of Patient Safety and Quality in Australian Hospitals’, the Australian Commission on Safety and Quality in Health Care (ACSQHC) reported that up to 16.5% of total hospital expenditure in 2013 was a direct result of adverse events. In relation to a more recent fiscal year (2017-2018), it also reported that the cost of nosocomial infections in public hospitals amounted to $4.1 billion, or 8.9% of total hospital expenditure.

In the year prior to this publication, the Grattan Institute reported one in every nine inpatients developed a complication in Australia - where a complication was defined as an additional diagnosis that did not play a role in the patient’s initial presentation to hospital. It noted an over-emphasis on complications identified a being ‘preventable’ - whereas the aim should be to reduce all complications by understanding how excellent outcomes are achieved (hence applying a ‘Safety II’ Culture). A later Grattan Institute report in 2018 (‘Safer Care Saves Money’) revealed the costs of these complications to exceed $4 billion a year for public hospitals, and more than $1 billion a year for the private sector. This latter report further concluded that if performance of all hospitals matched those in the top 10 per cent, about $1.5 billion would be saved per annum. These savings would then be available to treat another 300,000 patients.

The issue is not confined to Australia. In 2017, the Organisation for Economic Co-operation and Development (OECD), comprising 38 member countries (including Australia), issued a report entitled ‘Tackling Wasteful Spending on Health.’ It too identified that one in ten patients of OECD countries is ‘unnecessarily harmed at the point of care’ and that more than 10% of hospital expenditures ‘goes to correcting preventable medical mistakes or infections that people catch in hospitals across a range of OECD countries.’

However, the wastage stretches beyond safety to quality. Quality means different things to different people, and therefore outcomes must be person-centred. For example, what one person considers an optimal outcome in their particular circumstances may differ from what another person considers an optimal outcome in different circumstances. From this perspective, good clinical governance will deliver ‘value’ in health care.

Both clinical governance and value-based health care are aligned in their focus on patient outcomes. Optimising patient outcomes, therefore reducing the need for ongoing care, will ultimately reduce the cost of care.

‘Value-based’ health care is said to be ‘about achieving the best care possible for each patient while maintaining an efficient use of resources’ and ‘provides a common goal for patients, clinicians, provider organisations, administrators, governments and policy makers, because it places patient outcomes as the focus for health system performance.’ Value-based care therefore remains person-centred, as the desired outcomes hinge on the patient experience. On the basis of this view, ‘value-based health care’s focus on better health outcomes aligns clinicians with their patients… Measured health outcomes demonstrate clinicians’ ability to achieve results with patients and families and drive improvement in the results that matter most to both patients and clinicians.’

Value-based care is therefore a welcome by-product of the person-centred care which is central to clinical governance; commensurate with clinical governance principles, it requires engagement with patients. As with clinical governance, there is no ‘one size fits all approach’ in value-based health care - however it ubiquitously puts the spotlight on quality outcomes (and therefore safety), with the benefit of improving health care spending. The OECD identified that patients commonly receive ‘unnecessary or low-value care that makes no difference to their health outcomes.’ This goes beyond complications, but includes over-diagnosis, over-treatment, or care that is ineffective or inappropriate.

Wastage of health costs can reflect weaknesses in governance. Whilst the cost of care is not the primary driver for clinical governance and person-centred care, it should at least support a business case for it. As indicated by the Grattan Institute’s analysis, poor quality care costs money. Robust clinical governance resulting in better care will affect savings through reduced complications and improved patient experiences, which can then be siphoned back into health systems already stretched for resources.

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All accessed on 24 January 2022:

‘A clinical governance perspective on politics, politics aside.’ AICG, 4 July 2021. Accessed at: https://www.aicg.edu.au/resources/a-clinical-governance-perspective-on-politics-politics-aside/

I Noy and N Doan. ‘COVD-19 cost more in 2020 than the word’s combined natural disasters in any of the past 20 years.’ The Conversation, 20 April 2021. https://theconversation.com/covid-19-cost-more-in-2020-than-the-worlds-combined-natural-disasters-in-any-of-the-past-20-years-156646

D Cutler and L Summers. ‘The COVID-19 Pandemic and the $16 Trillion Virus.’ JAMA, 12 October 2020. JAMA. 2020;324(15):1495-1496. doi:10.1001/jama.2020.19759. Accessed at: https://jamanetwork.com/journals/jama/fullarticle/2771764

Australian Budget 2021-2022. Accessed at: https://budget.gov.au/2021-22/content/covid.htm

‘All complications should count: Using our data to make hospitals safer.’ Grattan Institute, February 2018. Accessed at: https://grattan.edu.au/report/all-complications-should-count-using-our-data-to-make-hospitals-safer/

S Duckett and C Jorm. ‘Safer care saves money. How to improve patient care and save public money at the same time.’ Grattan Institute, August 2018. Accessed at: https://grattan.edu.au/report/safer-care-saves-money/

‘The state of patient safety and quality in Australian hospitals 2019.’ Australian Commission on Safety and Quality in Health Care, 2019. Accessed at: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/state-patient-safety-and-quality-australian-hospitals-2019

‘Switching the Paradigm: Safety-I to Safety-II.’ AICG, 28 November 2021. Accessed at: https://www.aicg.edu.au/resources/switching-the-paradigm-safety-to-safety/

‘Tackling Wasteful Spending on Health: Highlights’. OECD, January 2017. Accessed at: https://www.oecd.org/health/tackling-wasteful-spending-on-health-9789264266414-en.htm

‘The State of Patient Safety and Quality in Australian Hospitals 2019’. Australian Commission in Safety and Quality in Health Care. Accessed at: https://www.safetyandquality.gov.au/publications-and-resources/state-patient-safety-and-quality-australian-hospitals-2019

E Teisberg et al. ‘Defining and Implementing Value-Based Health Care: A Strategic Framework.’ Acad Med. 2020 May; 95(5): 682-685. Published online 2019 Dec 10. doi: 10.1097/ACM.0000000000003122. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185050/

‘About value based healthcare’. NSW Health. Accessed at: https://www.health.nsw.gov.au/Value/Pages/about.aspx

C Mjaset et al. ‘Value-Based Health Care in Four Different Health Care Systems’. NEJM Catalyst, November 2020. Accessed at: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0530