Bending the quality curve.

With this paper, we initiate the Supplement on Deepening our Understanding of Quality in Australia (DUQuA). DUQuA is an at-scale, cross-sectional research programme examining the quality activities in 32 large hospitals across Australia. It is based on, with suitable modifications and extensions, the Deepening our Understanding of Quality improvement in Europe (DUQuE) research programme, also published as a Supplement in this Journal, in 2014. First, we briefly discuss key data about Australia, the health of its population and its health system. Then, to provide context for the work, we discuss previous activities on the quality of care and improvement leading up to the DUQuA studies. Next, we present a selection of key interventional studies and policy and institutional initiatives to date. Finally, we conclude by outlining, in brief, the aims and scope of the articles that follow in the Supplement. This first article acts as a framing vehicle for the DUQuA studies as a whole. Aggregated, the series of papers collectively attempts an answer to the questions: what is the relationship between quality strategies, both hospital-wide and at department level? and what are the relationships between the way care is organised, and the actual quality of care as delivered? Papers in the Supplement deal with a multiplicity of issues including: how the DUQuA investigators made progress over time, what the results mean in context, the scales designed or modified along the way for measuring the quality of care, methodological considerations and provision of lessons learnt for the benefit of future researchers.

Assessing the quality of care for paediatric depression and anxiety in Australia: A population-based sample survey.

OBJECTIVE: We examine the prevalence of quality care (as measured by adherence to recommendations in clinical practice guidelines) for Australian paediatric patients (⩽15 years) with depression and/or anxiety, using data from the CareTrack Kids study; a population-based study of the quality of healthcare practice in inpatient and ambulatory healthcare settings. METHODS: A multistage stratified sample identified records of 6689 children. Of these, 156 records were identified for depression and 356 for anxiety. These were assessed for adherence to 15 depression and 13 anxiety indicators, respectively, using a review of medical records. RESULTS: Adherence to assessment and management guidelines was low for both conditions: assessment bundle (depression = 33%, 95% confidence interval = [20, 48]; anxiety = 54%, 95% confidence interval = [43, 64] and depression management bundle = 35%, 95% confidence interval = [15, 60]). Across both conditions, the highest adherence was recorded for indicators that addressed prescription of medications (e.g. venlafaxine, 100%; benzodiazepines, 100%; selective serotonin reuptake inhibitor, 94% and antidepressants, 91%), while compliance was the lowest for ensuring children with depression had an emergency safety plan (44%), informing parents of the risks and benefits of prescribed anxiety medication (51%) and assessment for other causes (59% for depression; 68% for anxiety). CONCLUSION: These findings suggest that strategies are needed to improve guideline adherence for mental health disorders in children and adolescents, particularly among general practitioners. Learning from these indicators could inform clinical prompts in electronic medical records, as well as links to additional information, to assist in decision-making and streamline work practices.

Assessing guideline adherence in the management of type 1 diabetes mellitus in Australian children: a population-based sample survey.

INTRODUCTION: To estimate adherence to clinical practice guidelines in selected settings at a population level for Australian children with type 1 diabetes mellitus. RESEARCH DESIGN AND METHODS: Medical records of children with type 1 diabetes mellitus aged 0-15 years in 2012-2013 were targeted for sampling across inpatient, emergency department and community visits with specialist pediatricians in regional and metropolitan areas and tertiary pediatric hospitals in three states where approximately 60% of Australian children reside. Clinical recommendations extracted from two clinical practice guidelines were used to audit adherence. Results were aggregated across types of care (diagnosis, routine care, emergency care). RESULTS: Surveyors conducted 6346 indicator assessments from an audit of 539 healthcare visits by 251 children. Average adherence across all indicators was estimated at 79.9% (95% CI 69.5 to 88.0). Children with type 1 diabetes mellitus have higher rates of behavioral and psychological disorders, but only a third of children (37.9%; 95% CI 11.7 to 70.7) with suboptimal glycemic control (eg, hemoglobin A1c >10% or 86 mmol/mol) were screened for psychological disorders using a validated tool; this was the only indicator with <50% estimated adherence. Adherence by care type was: 86.1% for diagnosis (95% CI 76.7 to 92.7); 78.8% for routine care (95% CI 65.4 to 88.9) and 83.9% for emergency care (95% CI 78.4 to 88.5). CONCLUSIONS: Most indicators for care of children with type 1 diabetes mellitus were adhered to. However, there remains room to improve adherence to guidelines for optimization of practice consistency and minimization of future disease burden.

An innovative outcomes-based medical education program built on adult learning principles.

An innovative medical curriculum at the University of New South Wales (UNSW) has been developed through a highly collaborative process aimed at building faculty ownership and ongoing sustainability. The result is a novel capability-based program that features early clinical experience and small-group teaching, which offers students considerable flexibility and achieves a high degree of alignment between graduate outcomes, learning activities and assessments. Graduate capabilities that focus student learning on generic outcomes are described (critical evaluation, reflection, communication and teamwork) along with traditional outcomes in biomedical science, social aspects, clinical performance and ethics. Each two-year phase promotes a distinctive learning process to support and develop autonomous learning across six years. The approaches emphasize important adult education themes: student autonomy; learning from experience; collaborative learning; and adult teacher-learner relationships. Teaching in each phase draws on stages of the human life cycle to provide an explicit organization for the vertical integration of knowledge and skills. A learning environment that values the social nature of learning is fostered through the program's design and assessment system, which supports interdisciplinary integration and rewards students who exhibit self-direction. Assessment incorporates criterion referencing, interdisciplinary examinations, a balance between continuous and barrier assessments, peer feedback and performance assessments of clinical competence. A portfolio examination in each phase, in which students submit evidence of reflection and achievement for each capability, ensures overall alignment.

Imperatives in medical education and training in response to demands for a sustainable workforce.

Factors to be considered in planning our medical workforce to meet future needs include: Need for outcomes-based curricular designs in medical schools and postgraduate training. Shortening the length of medical training. Improving career flexibility to permit professional re-invention. Developing awareness within the profession about how innovation happens.

Postgraduate medical education: rethinking and integrating a complex landscape.

A key responsibility of the healthcare system is to develop a sustainable workforce through education and training. The complexity of postgraduate medical education and training in Australia requires: recognition that there are many stakeholders (junior medical officers, registrars, teaching clinicians, health departments, governments, colleges and society) with overlapping but competing interests and responsibilities; a national dialogue to clarify the necessary resource investments and to assign explicit accountabilities; and improved coordination and governance, while maintaining appropriate flexibility. In other countries, stronger mechanisms of governance for oversight of postgraduate medical education have emerged, and Australia can learn from these.

Leadership in medicine: where are the leaders?

Despite leadership roles being critical, we persist with outmoded models of organisations and pay inadequate attention to developing individual leaders and new models of leadership within the medical profession. New forms of leadership are required. Among many important roles, leaders are called on: to enhance the meaningful identity of a profession; to create effective linkages with other healthcare professionals and stakeholders, as well as with healthcare system managers; to interpret complexity so that their institutions and followers can operate successfully in uncertain times; and to consistently model ethical behaviour.

Declarations made by graduating medical students in Australia and New Zealand.

OBJECTIVE: To survey the use of declarations of ethical commitment made by graduating medical students in Australia and New Zealand. METHODS: Information, obtained by email and telephone, from faculty officers of all faculties of medicine (or medicine and health sciences) in Australia and New Zealand. RESULTS: Declarations are made by graduating medical students at seven of 12 Australasian faculties of medicine. To date, declarations have been based on the Declaration of Geneva or the Hippocratic Oath or have been formulated by academic staff or the students themselves. In six of the seven universities, declarations are made as part of a special declaration ceremony (usually combined with a prize-giving ceremony). One university includes a declaration as part of the official graduation ceremony. DISCUSSION: We discuss the relative merits of a declaration selected for students by staff members and a declaration written anew by each group of graduating students.