What legislative reforms have been made?
Amendments have been made to the Health Services Act, Mental Health Act, Ambulance Services Act and the Public Health and Wellbeing Act.
The changes include:
- adding quality, safety and continuous improvement prominently into the objectives and other key provisions of relevant legislation
- strengthening governance of quality and safety in public sector services - this includes:
- establishing a consistent nine-year limit for the tenure of board directors
- introducing mechanisms for government to set requirements about board composition, and for the Minister to set guidelines for boards
- improving oversight of Chief Executive Officer appointments
- aligning the requirements for boards and Chief Executive Officers across the public health sector
- allowing better regulatory oversight of private sector services - this includes amendments to:
- ensure that all facilities where surgery is undertaken are regulated, closing a loophole that has allowed cosmetic surgery to take place in unregulated facilities
- enhance registration requirements and ensure that quality and safety are considered at all points in the registration process
- introduce legislative requirements for national quality accreditation and compliance with national standards
- improve the capacity for government to oversee and act on quality and safety risks at all times while a private sector service is registered
- supporting better use of data to monitor and respond to quality and safety risk, and inform continuous improvement, by introducing new reporting mechanisms for public and private sector services
- ensuring that legislative powers of oversight or intervention can be exercised to identify and respond to quality and safety risks
- supporting engagement with clinicians by allowing an enhanced role for the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, and consolidating the role of the Better Care Victoria Board.
Why have the changes been made?
The reforms respond to recommendations from Targeting Zero: supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care, the report of the statewide review that was led by Dr Stephen Duckett.
While Targeting Zero acknowledged that reducing avoidable patient harm and variability in care are challenges facing health systems world-wide, it found that the Department of Health and Human Service was not adequately governing or overseeing the quality and safety of care being provided by Victorian hospitals.
Other key findings included:
- Better systems are required to ensure hospital boards are appropriately selected, skilled and equipped for their responsibility of ensuring that hospitals are safe and continuously improving.
- Oversight of governance and outcomes in the private and public sectors were not aligned.
- The department did not have the information it needs to be satisfied hospitals are providing safe and quality care, and did not use data it had to monitor patient outcomes and investigate red flags.
In response to these findings, and alongside action already being taken, the recent reforms have been designed to improve health service quality and safety by:
- strengthening the governance and oversight of quality and safety in the public health sector - by limiting tenure of public sector board members, allowing government to set requirements and guidelines for boards, and providing an expanded suite of oversight and intervention powers for government
- ensuring that public and private sector hospitals and cosmetic surgery facilities are subject to the same level of oversight in relation to quality and safety and
- providing new mechanisms for government to obtain information about services, to monitor and respond to risk, and strengthened powers to take action where risk is identified.
What about the other recommendations in the report from the review of quality and safety assurance in Victoria? How long will it take for all those to be implemented?
As Targeting Zero states, many of its recommendations can be implemented quickly (within 12 months) but others will require up to three years. Implementation of all recommendations will have commenced by the end of 2018.
The Bill addresses the recommendations that were identified as requiring early implementation through legislation, and represents the first stage of statutory reform. Other recommendations requiring legislative amendments will be the subject of additional consultation or complex analysis and will be addressed in a later stage of legislative reform. In addition, the government has committed to review the Health Services Act 1988. This will provide an opportunity to create a contemporary legislative framework consistent with the government's vision for quality and safety in Victoria's health system.
Many recommendations in Targeting Zero are being addressed through non-legislative means. You can read more about implementation of Targeting Zero reforms elsewhere on health.vic.
So far, key actions taken in response to Targeting Zero include:
- Safer Care Victoria has been established as the peak state authority for leading quality and safety improvement in healthcare
- the Victorian Agency for Health Information has been established, to analyse and share information across our system to ensure everyone has an accurate picture of where the concerns are and where we're getting it right
- the Victorian Clinical Council has been established as the body for engagement with the sector and consumers, with members including health service management, clinicians, consumer representatives and strong participation by rural and regional Victorians
- a Chief Nurse and Midwifery Officer and Chief Paramedic Officer have been appointed
- the Boards Ministerial Advisory Committee has been established to advise the Minister in relation to Board appointments and composition
- training for boards about clinical governance has commenced
- a new governance handbook and board skills matrix have been developed to assist boards in recruiting members skilled in clinical governance and consumer representation
- Regional Perinatal Mortality and Morbidity Committees have been established.
What are the changes for hospital boards and CEOs?
Targeting Zero identified instances of governance failures as a key contributing factor in the tragic events at Djerriwarrh Health Service and noted this as a potential problem across the system.
The recent reforms include a range of amendments to governance provisions, to establish a strengthened and consistent set of governance requirements across public sector health services.
Specifically, the amendments are designed to:
- ensure that the current quality and safety obligations on the boards and Chief Executive Officers of public health services (i.e. larger hospitals) also apply to all other public hospital entities
- make the appointment requirements for boards and Chief Executive Officers consistent across service types, aligned with the current requirements for larger hospitals
- include a phased-in requirement that no person serves more than 9 consecutive years on a public health sector board (with a Ministerial discretion to exempt from this requirement in exceptional circumstances)
- provide a power to make regulations to specify board composition requirements (for example, that boards must include clinical governance experience) which must then be taken into account during the appointment process
- establish a capacity for the Minister to publish guidelines relating to the role, functions and procedures of boards.
These changes do not mean current board directors will be removed prior to their term expiring. Considerations of tenure and board composition will only arise at the time of appointment/reappointment and after the amendments come into effect. The board tenure requirement has been introduced as a policy guideline ahead of the legislative amendments being made. The recent amendments include a three year transition period before the legislative requirements about maximum tenure would apply.
Likewise, new requirements relating to appointment of Chief Executive Officers will not impact any current appointments - they will only apply to appointments made after the legislative amendments came into effect.
What are the implications for rural and regional services?
The most significant changes for rural and regional areas are amendments that will change the requirements for governance of public sector services in those areas. The amendments will align those requirements with the provisions that currently apply to larger hospitals.
Many boards in rural and regional centres include members who have served over a long period of time and in doing so have provided a significant service to their local communities. Their service has been voluntary and provides immeasurable benefit to the hospital boards and our health system.
To ensure that hospitals are able to plan to respond to the legislative changes, the 9-year maximum tenure limit will be phased in as members' terms naturally expire. It is recognised that it may take a number of years to identify and recruit replacements for all these long serving individuals and so Ministerial discretion will still be available to over-ride the 9-year limit in 'exceptional circumstances'.
Board directors who have served the maximum number of years on a particular board are strongly encouraged to offer their services to the board of another service, so that their experience and expertise is not lost to the health system.
Targeting Zero found rural hospitals will benefit from having an external, comparative view from someone who does not reside in the immediate catchment of the hospital. This may be someone from a major regional centre or another town not served by the hospital.
The department will continue to support these services to respond to the challenges of the new legislative requirements and to recruit skilled directors.
What are the changes for private sector services?
Victorians should be able to expect the same level of safeguards in place to address and improve quality and safety of services, whether they receive care in the private or public sector.
The recent amendments for private sector services are designed to improve government oversight in a number of ways, allowing better monitoring and earlier intervention on quality and safety issues. These amendments include:
- ensuring that all facilities where surgery is undertaken is regulated in future - for example, cosmetic surgery facilities will be subject to registration requirements and departmental regulatory control
- allowing for flexible service delivery models - including, for example, hospital in the home services and mobile health services - to ensure that services delivered in those contexts are regulated and therefore subject to oversight and safeguards
- mandating reporting to the department, with most details of the required reporting to be specified in regulations. The Secretary will also be able to issue a direction to a service that the service provide specified information
- mandating minimum construction, fit out and equipment requirements for private hospitals to ensure consistency with mandated public hospital standards
- requiring services to obtain and maintain accreditation and notify the department if they fail to do so
- requiring that quality and safety are criteria considered during an application for registration or renewal and can be a basis for suspension and renewal of registration
- establishing an ongoing requirement for proprietors to ensure that services provided are safe, patient-centred and appropriate, and that there is continuous improvement of quality and safety at the service.
Key aspects of these amendments will be supported by regulations. The department is currently consulting with the sector and key stakeholders as it develops those regulations.
What does this mean for patients and their families?
Patients and families can be assured that safety and quality improvement are a priority in both public and private health service oversight. Patient experience and outcomes will be improved through an increased focus on matters of safety and quality and the capacity for a broader range of interventions to address safety and quality concerns.
Safe innovative patient centred approaches to service delivery in the private sector will be supported by regulation requirements that encompass a range of service delivery modes (for example post birth maternity beds off campus, hospital in the home services and mobile anaesthetic services) and ensuring all facilities where surgery is performed are regulated.
Patients and their families can be assured that safety is a priority in service governance. Boards will be better connected to their communities and maintain a broad perspective with an important focus on safety and quality. Consumers and families will be better informed about the role of Boards and expectations about how they should operate and can be confident of the government's support for the devolved governance model.
The recent reforms enable the collection of more comprehensive information to facilitate stronger regulatory oversight. Certain data sets will be provided to the Victorian Agency for Health Information to enable it to undertake its functions and ensure meaningful information is available to the public to inform their health care choices.
What are the changes in the Bill about monitoring and reporting?
The recent reforms include provisions designed to support improvements to the collection, analysis, use and reporting of data, to allow government to monitor quality and safety, identify issues of concern, and inform continuous improvement. In this area, a range of work is underway in response to a large number of recommendations in Targeting Zero.
The reforms include amendments designed to underpin that work, by introducing:
- for public sector services:
- a new power for the Secretary to the Department to issue a direction requiring the service to provide information to the Secretary as specified in the direction. This builds on a power the Secretary currently has to issue directions to public sector services.
- for private sector services:
- a new requirement to provide prescribed information to the Secretary - the details of the reporting requirements will be set out in regulations. Regulations would be developed after any legislative change is made. The process for making the regulations would involve consultation with affected stakeholders. An example of what might be included in the regulations is a requirement to report sentinel events (that is, serious adverse events).
- a new requirement to report to the Secretary on serious risks to patient safety.
- a new power for the Secretary to issue a direction requiring a service to provide information to the Secretary as specified in the direction.
When will the changes in the Bill come into effect?
The amending legislation provides that most of its amendments will come into operation on a date to be proclaimed, which must be on or before 1 July 2018.
The department will be issuing communications shortly about the commencement dates for the amendments. The dates will be chosen to allow sufficient time for the department and stakeholders to prepare for implementation of the various reforms. For example, it will be necessary to make regulations to support many of the requirements that are being imposed on private sector services.
What is Better Care Victoria and why does the Bill create a Board for it?
Better Care Victoria is a Victorian Government initiative to identify and embed innovation across the health system. It is responsible for advising the Minister for Health on health sector innovation and investment of the Better Care Victoria Innovation Fund, which invests resources to help the sector identify, scale and embed innovation effectively.
The Better Care Victoria Board is the decision making body of Better Care Victoria. It was a major recommendation of the report of the Travis Review - Increasing the capacity of the Victorian public hospital system for better patient outcomes.
The Board has assumed the responsibilities of the Health Innovation Reform Council and the recent reforms include amendments to formalise this. The change in name reflects the refocussing of responsibilities and better reflects the nature of the Board as the decision making body of Better Care Victoria. Beyond the functions of the Council, it is intended that the Board will be more active in its engagement with the public health sector to encourage, and facilitate, the dissemination of innovation and improvement across the Victorian health system. The recent reforms also include amendments to expand the functions of the Board so that they include an additional function of providing advice to the Minister and the Secretary on strategies to support innovation and improvements in the health sector.
How do the reforms change the work of the Consultative Council on Obstetric and Paediatric Morbidity and Mortality (CCOPMM)?
Established under the Public Health and Wellbeing Act 2008, CCOPMM reviews all cases of maternal, perinatal and paediatric mortality and morbidity (death and injury or illness) and advises the Minister and the department on strategies to improve clinical performance and avoid preventable deaths. You can read more about CCOPMM and its work elsewhere on health.vic.
The recent reforms include provisions to:
- introduce a new requirement that CCOPMM must report to the department on cases where it has identified that preventable harm involving mortality or severe morbidity is likely to have occurred
- make amendments to allow CCOPMM to issue guidelines, monitor compliance with guidelines and report to the department on non-compliance.
These amendments are designed to allow the department to access the unique expertise of CCOPMM to identify issues of concern. This, in turn, allows the department to be better informed and more proactive in monitoring quality and safety and responding to risks.
The legislation currently includes strong protections for the information that is reported to CCOPMM and held by CCOPMM. This has allowed CCOPMM to receive fulsome and candid information from the sector, which has allowed it to perform its role effectively. The recent reforms include similar protections for the preventable harm reports that are to be provided to the department by CCOPMM, to ensure that clinical engagement is supported. There is a capacity for the Secretary to override the protections if she considers that to be in the public interest, which is intended to ensure that the department is not constrained from taking necessary action in relation to any matters of serious concern that arise from the reports.
How do the reforms change the Mental Health Act? Why?
The recent reforms include amendments to the Mental Health Act that are consistent with the amendments being proposed for the Health Services Act. This includes amendments to insert quality and safety into key objectives and functions provisions, and amendments to ensure that the governance requirements for the Victorian Institute of Forensic Mental Health are aligned with those for other public sector hospitals.
How do the reforms change the Ambulance Services Act? Why?
The recent reforms include amendments to the Ambulance Act that are consistent with the amendments being proposed for the Health Services Act. This includes amendments to:
- insert quality and safety into key objectives and functions provisions
- ensure that the governance requirements for ambulance services are aligned with those relating to other public sector hospitals
- strengthen powers of oversight and intervention in relation to ambulance services to ensure they can be used to identify and respond to quality and safety issues.