The Royal North Shore Hospital inquiry: an analysis of the recommendations and the implications for quality and safety in Australian public hospitals

In October 2007, the New South Wales Parliament convened a Joint Select Committee to conduct an inquiry into several allegations of poor patient care at Royal North Shore Hospital (RNSH) in Sydney.1 RNSH is a major teaching and referral hospital, with internationally recognised specialty units and a reputation as a centre of clinical and research excellence.

The inquiry was initiated in response to an incident involving a patient who had a miscarriage in the toilets of the RNSH emergency department. This incident was widely reported in the media and occurred primarily due to a lack of immediate bed availability for assessment and treatment of the patient in the emergency department at the time she presented. There was general agreement that the miscarriage was inevitable and there was no medical mismanagement.

The Revd Hon Fred Nile (Christian Democratic Party, NSW Legislative Council) chaired the Joint Select Committee of both houses of NSW Parliament, with four members of the Australian Labor Party (Government), two Coalition members (Opposition) and one Independent member. The inquiry’s broad terms of reference (Box) focused principally on matters relevant to RNSH, but the Committee was given scope to apply its findings and recommendations to any hospital in NSW if considered appropriate. The Committee received 103 submissions and held four public hearings involving 78 witnesses, including the NSW Minister for Health, NSW Department of Health bureaucrats, clinical staff and patients.

The Committee handed down its final recommendations in its report released on 20 December 2007.1 The 45 recommendations included 17 further “reviews”, and other suggestions for “monitoring”, “reporting”, and “prioritising discussions”, as well as developing and implementing clinical service plans for both RNSH and its parent body, the Northern Sydney and Central Coast Area Health Service (NSCCAHS).

The clinicians at RNSH were supportive of the inquiry and hopeful it would address a number of long-term administrative and structural issues in the hospital. However, it is fair to say that many of the hospital clinicians and others who gave evidence at the inquiry were disappointed with the recommendations, which were generally thought to be too broad and lacking in specific details to effect any significant improvements in the hospital’s major administrative and budgetary issues.

A key element consistently stated in evidence given at the inquiry was the lack of clinical governance at the hospital. There was a clear disconnect between clinicians and hospital management, which was manifest at many levels. The clinicians had only advisory input (seldom heeded) into the planning of clinical services, and there was poor delineation of the hospital’s role both as a local community hospital and as a tertiary referral hospital. It was argued at the inquiry that the hospital was chronically underfunded, resulting in large recurring annual budget deficits and a focus on budget targets rather than excellence in clinical outcomes as a primary objective. The Committee recommended a number of reviews to confirm these deficiencies, but gave no clear direction for fixing the problems.

The inquiry was advised by the Australian Medical Association (NSW) and by other clinicians that RNSH needed an extra 70 beds opened immediately to bring the hospital bed occupancy to an acceptable 85% level. Despite this, the Committee subsequently recommended that the NSCCAHS should “work with senior clinicians to determine if the RNSH needs additional beds”.1

As a result of the funding problems, many other serious deficiencies were noted, including:

• a dysfunctional information technology system;

• a radiology department lacking a picture archiving and communication system (PACS);

• obsolete or broken equipment unable to be replaced or repaired;

• inadequate cleaning (miraculously addressed after years of neglect on the weekend before the Committee members visited);

• a dysfunctional and depleted human resources department;

• endemic bullying;

• a Medical Staff Council sidelined from input into decisions regarding the provision of clinical services both for the hospital and the NSCCAHS; and

• doctors who were either not aware of or unable to report adverse incidents through the NSW Health Incident Information Management System.

The presence of all these factors in a seriously stressed system, with the hospital operating at and above 95% capacity, resulted in inefficiency and created a high-risk environment for adverse events. In response to these issues, the inquiry recommendations included statements such as “development and implementation of a ... clinical services plan by April 2008”, “a review across all Area Health Services ... to ensure that the percentage of Information Technology infrastructure and support funding is at appropriate levels”, and “NSCCAHS [should] ensure that the recommendations from incident reporting are implemented”.1

When benchmarked against other Australian hospitals, RNSH is actually relatively safe and is one of the few hospitals that measures its adverse events by a quality assurance (QA) process. Dr Ross Wilson (Director, Quality Assurance Royal North Shore [QaRNS] Program) stated in evidence that the adverse event rate at RNSH is about 9%, compared with 16% for other Australian hospitals.2 He stated that “the rate of adverse events [at RNSH] is lower than anywhere that we know and that despite the increasing complexity of its caseload, the hospital’s adverse incident rate has remained steady over the past 10 or 12 years”.1

This begs the question: if RNSH is relatively safe compared with other Australian hospitals, what is happening at other hospitals where adverse incidents are less well measured?

Dr Jeffery Hughes, an orthopaedic surgeon, gave evidence at the inquiry that although the QA process at RNSH recorded patient misadventures, little had been done to correct many of the problems identified due to lack of resources and staff as a result of the hospital’s significant budget constraints.

RNSH was the scene of another widely publicised incident in November 2005: the tragic death of a teenage girl, Vanessa Anderson, after she was hit in the head by a golf ball. Her case was referred to the Deputy State Coroner, who noted in his January 2008 report that he was aware of a number of previous inquiries into the NSW Health system, which “was testimony to a health system that is labouring under the pressure from the demands placed upon it”.3 He noted that:

The NSW Government subsequently announced a Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, with broad terms of reference and a relatively short timeframe. If significant recommendations are made by this Special Commission, it remains to be seen whether the NSW Government has the will to provide the resources necessary to implement them.

Following the announcement of the Special Commission, the NSW Minister for Health announced the state government’s response to the RNSH parliamentary inquiry on 22 February 2008, stating that the government had accepted 43 of the 45 recommendations and that their “response details the significant action that has already been taken to implement those recommendations”.4

Despite this “response”, there is still a significant shortage of inpatient beds at RNSH, with only four new beds opened so far (12 of the 70 needed were promised by the NSW Health Minister at the time of the inquiry), no immediate increase in the budget, and the recent resignation of the hospital’s eighth General Manager in 11 years. The major problem with the government response is in its generalisations and vagueness. Many of the inquiry’s recommendations are only “supported in principle” and some of the “supported” responses are largely meaningless.5 A good example of this is Recommendation 42: “That NSW Health in conjunction with the Clinical Excellence Commission examine the use of systematic audits of medical records, such as QaRNS.” There is no mention of the scope or timeframe of this review, nor of any action that might follow.

One of the more positively supported recommendations relates to “the monitoring of trust funds be[ing] improved”.5 This will be a litmus test of the NSW Government’s commitment to addressing a number of the problems revealed by the inquiry. The management of trust funds raises issues of probity and competence in managing millions of dollars of donated funds for health research and development and other specific reasons. Evidence given at the inquiry suggested mismanagement and inappropriate allocation of some bequest monies, which are a vital source of support for RNSH. Rectifying this situation requires no additional resources, but it does require a change of culture in hospital administration, with transparency, tight financial management and reporting, and the close involvement of experts in the disciplines for which the money is targeted.

The conditions that led to the recent adverse incidents at RNSH have been incubating for many years and are clearly endemic across the NSW public hospital system. So, what are the problems with the public hospital system, and why does the NSW Government seem unable to fix them?

Professor David Penington, an experienced reviewer of the Australian public hospital system and former Vice-Chancellor of the University of Melbourne, recently stated in a newspaper article on health care reform that “incidents such as a miscarriage in an emergency department [are being] used as a measure of hospital quality” and that we have a “hospital system under financial stress and no measures of quality associated with funding”.23 He also stated that, according to good evidence from the United Kingdom, if we support research in our major hospitals, it is possible to achieve improvements in the quality of care by attracting high-quality staff, and embracing innovation and constant assessment of the quality of outcomes. Penington notes that:

Would a federal takeover of public hospitals deliver a better and safer system? There would be definite advantages to having one funding source, which would eliminate the funding blame game between state and federal governments, but doubt remains that the federal Department of Health and Ageing would have the ability or the resources to administer a national public hospital system. This doubt was raised in the previous federal government’s mishandling of the hasty and poorly planned takeover of the Mersey Hospital in Devonport, Tasmania. The new federal Minister for Health is now working with the Tasmanian Health Minister “to provide a safe and sustainable hospital service” for the area.22 A single funding source would also streamline provision of care for the aged and those with chronic disease in the community, as well as the more difficult areas of disease prevention and Indigenous health, which will require a long-term focus to achieve satisfactory solutions.

There is also a clear need to rationalise the number of hospitals providing acute medical or surgical care, due to limitations in both staff and resources; these decisions must be made independently of political considerations.

The new federal government is committed to a review of the Australian health system with a National Health and Hospitals Reform Commission.13 It has also threatened a takeover of public hospitals if state governments fail to meet certain benchmarks by 2009, such as:

• reducing preventable hospitalisations and readmissions;

• reducing non-urgent “accident and emergency” presentations;

• decreasing waiting times for people requiring elective surgery;

• increasing access to medical and specialist services in the community; and

• providing more appropriate non-acute care for older Australians.

How they intend to measure these benchmarks is not stated.

The new federal government is heading in the right direction by linking increased funding to hospital performance by publishing “scorecards” that compare performance between equivalent hospitals.24 The ability already exists to compare similar hospitals for events such as unexpected deaths, complications of treatment, infection rates and length of stay. However, such performance comparisons will require support with extra resources and funding, as this work is labour-intensive, and will require political will to address problems as they are identified. It was disappointing that the first meeting of the Australian Health Ministers’ Conference under the new government did not take up the federal Health Minister’s proposal for a public hospital scorecard approach, but they did agree that “further work was needed to identify specifically which performance areas should be included”.24

One of the challenges for hospital administrators and funding bodies is to measure the quality of care provided in public hospitals, publish the results and provide adequate resources and staff to ensure a safe and equitable level of health care. Health Ministers and their departments should seek advice and implement recommendations from clinicians who are clinically active rather than from bureaucrats who have little or no clinical experience and are motivated by concerns related to meeting budget targets. Until there is recognition that the community has a right to know what quality of care is being delivered in all public hospitals, and governments acknowledge they have a responsibility to provide safe and appropriate care, there will continue to be adverse events and unnecessary deaths in our public hospitals.