Clinical Governance - was The "Panel"

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Dear Ken,

Wise words as usual.  We have recently been reviewing our own system here in
South Australia.  I have been involved in critically looking at business
governance recently and it seems to me we have a bit to learn (or to apply).


The issue of clinical governance is one we as a profession have not been
good at.  There is too much "I am an experienced/qualified
doctor/nurse/paramedic/EMT/RT (etc) and therefore what I say goes".  

Looking at our own retrieval/transport system in SA it seems to me that our
goals can be paraphrased as "Right patient, right care, right place, right
time at the right cost".

Right patient - how do we identify and then go to retrieve the patients we
should get, but don't get those we don't need to (accepting some degree of
over-triage).

Right care - maybe they need our specialist team, maybe a back-up paramedic
crew, maybe load and go by EMTs, maybe a local rural MD to attend a scene?

Right place - where to take them? - the major trauma centre for some, but
not all need to go there. In rural Australia this may involve some staging
via a local facility.

Right time - is this case really time critical, and if so to what extent and
in what way?  Getting care to the patient or getting the patient to care?
"Time critical" is really a spectrum not an absolute.

And right cost - not just about money, this is also about risk management.
How do we balance the risks of flying for each case?  In a mature system,
for a non-critical patient a few extra minutes transport time (say by road
vs. air) might be clinically very safe and might lower risk and incidentally
save money (as well as leaving the Aeromedical resource available for
another more urgent case).  We certainly need to be very wary of air trips
that actually take longer than a road trip would have.

Trying to do this all is not enough though.  We MUST measure our systems
objectively so we can 
- understand what we are really doing
- demonstrate to others what we are doing 
- work out how to improve.  

In medicine we seem to feel we are "too busy caring for patients" to measure
what we do, and so we fall back on the "trust me, I'm a
doctor/nurse/paramedic etc" or the "in my experience" approach.  We should
avoid this if we can find some actual data, and if we can't find it we
should seek to produce it.

One corporate governance model uses the sequence of..
- decide on clear goals, 
- work out detailed strategy, 
- operationalise this strategy, 
- start doing it, 
- measure what is done, 
- critically review measurements, 
- revise system based on results, 
- measure new system - and around and around the loop indefinitely.
(If people want to learn more try putting "Robert Tricker governance" into
your favourite search engine)

A number of recent Nobel Prizes for Economics have been given for advances
in the field of Behavioural Economics.  Briefly this field recognises that
people often do not make (economic) decisions on a rational basis.  Rather
we decide what we want to do, and then we look for arguments we can use to
support what we emotionally want to do.  I suspect we may also have some of
this happening in medicine.

Hopefully our real goal is optimal patient outcome rather than either (1) to
make money or (2) to fly because it is fun or "sexy"...

Finally and maybe this should have come first - my heart goes out to the
friends and loved ones of those who have died in the line of duty.  As with
many others on this list I have lost friends killed and injured to medical
aviation and I do know and understand the pain.  We cannot bring them back
but maybe in their memory we can improve our systems and minimise the risks
of the same fate befalling others. 

We must aim to improve.  Our dead colleagues deserve no less.

Best wishes

Bill


A/Professor William Griggs AM

Director Trauma Service
Royal Adelaide Hospital

Senior Aeromedical Consultant 
South Australian Retrieval Service

Ambulance Service Medical Officer
SA Ambulance Service

wgriggs at bigpond.net.au



-----Original Message-----
From: KMATTOX at aol.com [mailto:KMATTOX at aol.com] 
Sent: Sunday, 12 October 2008 04:32
To: trauma-list at trauma.org
Subject: Re: The "Panel"

In response to the discussion between the two Stephens: 
 
Perhaps.   However helicopters and LONG RANGE fixed wing air  ambulance 
services are ESSENTIAL in Australia, where distance, conditions,  weather
and 
review standards are agreed upon by the government, EMS, emergency
medicine, 
critical care, trauma surgeons, and nursing.   
 
If you analyzed the issues of:
 
Time
Distance
Diagnosis
Weather
Supervision
Review
 
in Australia and the United States you would find two totally different  
philosophies driven by two totally different  motivations.      Helicopters
and 
fix wing aircraft fly  every day in the US that would never be allowed to
take 
off in  Australia. 
 
Stephen:   We could really really benefit from your standards and  
regulations and review and discipline activities being available to the
"panel"  if a 
panel ever does convene.    Thank you for not only your  leadership in 
Australia, but also your participation in this discussion in the  US
regarding how we 
can make helicopter air ambulances safer for the crew and  patients, as well
as 
optimize the beneficial use of these  "birds".     Everyone would agree that

they should not fly  dui ring prohibitive weather, or for patients with 
conditions which are  trivial.   
 
k

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