Patient experience surveys are vital in the twenty-first century: let's put some myths to rest.

Patient-reported data derived from surveys places patient feedback at the heart of quality improvement and health system responsiveness. Such surveys are not without critics, however, who contend that there are better ways to collect feedback. Criticisms assert that response rates are too low and measures are not robust, valid or reliable, that patient experience surveys are neither valid nor reliable for Maori and Pacific peoples and that such surveys do not contribute to improved outcomes for patients. We debunk these myths in the context of the Te Tahu Hauora Health Quality & Safety Commission (Te Tahu Hauora) patient experience survey programme. We explain the centrality of a strong consumer and whanau voice in a twenty-first century health system, and that listening to and acting on this voice-including use of patient-reported data-is now a statutory requirement for health entities under the Pae Ora (Healthy Futures) Act 2022. We describe the different surveys in the programme and explain the differences between patient satisfaction and patient experience. We address sample size and response rates, including representativeness in the surveys of Maori and Pacific peoples' experience. We look at how survey data can be used for quality improvement and to guide us toward providing equitable, culturally safe care. We assert that, contrary to criticisms, the programme delivers valid, reliable, relevant, systematic and practical patient experience surveys and resulting data, with guides for improvement, and that we are both legally and ethically bound to listen to and use these results to improve the healthcare we deliver.

Using a randomised controlled trial to test the effectiveness of social norms feedback to reduce antibiotic prescribing without increasing inequities.

AIMS: Antibiotic overprescription is a key driver of antimicrobial resistance, and rates of community dispensing of antibiotics in New Zealand are high compared to other developed countries. We aimed to test whether a social-norm-based intervention successful elsewhere would have an effect on GPs with high prescribing rates of antibiotics. We also aimed to assess the effects on prescribing for Maori and Pacific patients. METHODS: A randomised controlled trial (n=1,214) tested the effects of a letter mailed to high-prescribing GPs that presented their prescribing data in comparison to their peers. RESULTS: In September-December 2019, after the letters were mailed, the antibiotic prescribing rate in the control arm was 178.8 patients prescribed antibiotics per 1,000 patients prescribed any medicine, and in the intervention arm it was 162.3, a relative difference of 9.2% (p<0.001). GPs in the intervention arm were responsible for an average of 173.5 prescriptions, versus an average of 186.8 prescriptions for GPs in the control arm, a relative difference of 13.3 or 7.1% (p<0.01). Exploratory analyses showed the intervention reduced prescribing to Maori and Pacific patients among historically high prescribing GPs but had no statistically significant impact on low prescribers. CONCLUSIONS: A targeted intervention using social norms reduced prescribing of antibiotics by high-prescribing GPs. Such an approach may be promising to address inequities in access to and use of antibiotics by Maori and Pacific peoples, historically underserved by prescribers, but further investigation is needed.

Beyond Targets: Measuring Better and Rebuilding Trust Comment on "Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?"

Tenbensel and colleagues identify that a target for emergency department (ED) stays in New Zealand met with gaming in response from local hospitals. The result is in line with studies in other jurisdictions. The enthusiasm for targets and tight performance measurement in some health systems reflects a lack of trust in professionals to do the right thing for altruistic reasons. However such measurement systems have failed to address this loss of trust and may, ironically, have worsened the situation. A more promising approach for both improving performance and restoring trust may depend upon collaboration and partnership between consumers, local providers, and central agencies in agreeing and tracking appropriate local responses to high level national goals rather than imposing tight, and potentially misleading measures from the centre.

The effect of implementing an aseptic practice bundle for anaesthetists to reduce postoperative infections, the Anaesthetists Be Cleaner (ABC) study: protocol for a stepped wedge, cluster randomised, multi-site trial.

BACKGROUND: Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Maori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces. METHODS: We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental "champions". Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle. DISCUSSION: If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000407291 . Registered on 21 March 2018.

Comparing initial and follow-up responders to a New Zealand patient experience survey.

AIM: This study investigates non-response bias in an inpatient experience survey with a low response rate by comparing sociodemographic characteristics and response behaviours of initial responders with responders to follow-up, and further explores the factors contributing to non-response. Prior research suggests non-response may be endogenously related to patient characteristics. METHOD: We re-contacted a convenience sample of non-responders to a nationally representative, cross-sectional inpatient survey conducted in New Zealand. Participants were given a subset of six items drawn from the initial survey and the opportunity to disclose reasons for non-response. Responders to follow-up (n=163) were subsequently compared with responders to the initial survey (n=910) using chi-squared tests of association and logistic regression to assess differences in sociodemographic variables and substantive responses. RESULTS: We find no significant differences in the responses given by initial and follow-up responders. The most common reasons for non-response were "can't remember" (33%), not receiving the survey (25%) or being too busy at the time (25%). CONCLUSION: Responders to follow-up have similar experiences of inpatient care in New Zealand to initial responders. Further study is needed to strengthen inferences regarding hard-to-reach patients.

The New Zealand Surgical Site Infection Improvement (SSII) Programme: a national quality improvement programme reducing orthopaedic surgical site infections.

AIMS: The New Zealand Surgical Site Infection Improvement (SSII) Programme was established in 2013 to reduce the incidence of surgical site infections (SSI) in publicly funded hip and knee arthroplasties in New Zealand hospitals. METHODS: The programme pursued a three-pronged strategy: 1. Surveillance of SSI with a nationwide system 2. Promotion of consistent adherence to evidence-based practices proven to reduce SSI 3. Monitoring and publicly reporting changed practice and outcome data. RESULTS: Between quarter 3 2013 and quarter 4 2016 there has been a nationwide increase in compliance with all process measures: correct timing for antibiotic prophylaxis; use of the recommended antibiotic in the recommended dose and alcohol-based skin antisepsis. The SSI rate in hip and knee arthroplasties has shown a significant improvement. The nationwide median rate has fallen to 0.91% since June 2015, compared with 1.36% during the baseline period of April 2013 to March 2014 (p<0.01). This equates to approximately 55 fewer infections between August 2015 and June 2017, savings of NZD$2.2 million in avoided treatment and avoided disability-adjusted life years (DALYs) of NZD$5 million. CONCLUSIONS: The introduction of a nationwide SSI reduction programme for hip and knee arthroplasties resulted in an increase in compliance across the country with best practice that was associated with a reduction in incidence of SSI since June 2015 from the baseline period of April 2013 to March 2014, sustained to June 2017.

What happens at the end of life? Using linked administrative health data to understand healthcare usage in the last year of life in New Zealand.

The end of life is often associated with increased use of healthcare services. This increased use can include over-medicalisation, or over-treatment with interventions designed to cure that are likely futile in people who are dying. This is an issue with medical, ethical, and financial dimensions, and has implications for health policy, funding and the structure of care delivery. We measured the annual use of nine pre-defined public healthcare services between 1 January 2008 and 31 December 2012 by elderly New Zealanders (65-99 years old) in their last year of life and compared it with that of the cohort of elderly New Zealanders who used healthcare in the period but did not die. We used linked, encrypted unique patient identifiers to reorganise and filter records in routinely collected national healthcare utilisation and mortality administrative datasets. We found that, in New Zealand, people do seem to use more of most health services in their last year of life than those of the same age who are not in their last year of life. However, as they advance in age, particularly after the age of 90, this difference diminishes for most measures, although it is still substantial for days spent in hospital as an inpatient, and for pharmaceutical dispensings.

Medication-related patient harm in New Zealand hospitals.

AIM: The purpose of this study is to identify patterns of medication-related harm from a national perspective, and to use this information to inform decisions on where to focus medication safety efforts. This study updates a 2013 study using the same methodology. METHOD: District health boards (DHBs) still actively using either the Adverse Drug Event (ADE) Trigger Tool (TT) or the Global Trigger Tool (GTT), submitted two years of anonymised ADE data (1 July 2013-30 June 2015) to the Health Quality & Safety Commission (the Commission) using a standard template. Analyses were conducted using aggregated data only. RESULTS: Of eight DHBs who submitted data, six datasets were included, representing a total of 2,659 chart reviews. From these reviews, 923 harms were identified in 751 patients, with 28% of patients experiencing one or more harms. Harms occurred at a rate of 34.7 per 100 admissions, 42.5 per 1,000 bed days and 28% of patients experienced one or more medication-related harms. Those harmed were more likely to be older, female and have an increased length of stay. Most harms (65%) occurred during an inpatient stay, however, a substantial number (29%) originated in the community and precipitated an admission. Across all levels of severity, the most common types of medication harm were constipation, hypotension and bleeding. In the more serious harm categories, bleeding, hypotension and delirium/confusion/over-sedation were most common. Six groups of medicines caused the greatest amount of harm: opioids (including tramadol), anticoagulants/antiplatelet agents, antibiotics, antianginals (beta-blockers, nitrates, calcium channel blockers and others), diuretics and other cardiovascular medicines (angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARBs), centrally acting agents and statins). Opioids and anticoagulants/antiplatelet agents not only accounted for 40% of all harm, they were implicated in the most severe harm. CONCLUSION: This paper confirms earlier work that medication-related harms are common, occur both in hospitals and in the community, and are a substantial burden for patients and our healthcare system. Work is underway at local and national levels to decrease this harm, with a focus on the high-risk medicines most commonly implicated.

Student-led intervention to inNOvate hand hygiene practice in Auckland Region's medical students (the No HHARMS study).

BACKGROUND: Hand hygiene is important in reducing healthcare-associated infections. The World Health Organization has defined 'five moments' when hand hygiene compliance is required. During 2013, New Zealand national data showed poor compliance with these moments by medical students. AIM: To improve medical students' compliance with the five moments. METHODS: In this prospective student-led quality improvement initiative, student investigators developed, implemented and evaluated a multi-modal intervention comprising a three-month social media campaign, a competition and an entertaining educational video. Data on individual patient-medical student interactions were collected covertly by observers at baseline and at one week, six weeks and three months after initiation of the intervention. RESULTS: During the campaign, compliance improved in moment 2, but not significantly in moments 1, 3, 4 or 5. Statistical analysis of amalgamated data was limited by non-independent data points-a consideration apparently not always addressed in previous studies. CONCLUSIONS: The initiative produced improvements in compliance by medical students with one hand hygiene moment. Statistical analysis of amalgamated data for all five moments should allow for the non-independence of each occasion in which clinicians interact with a patient. More work is needed to ensure excellent hand hygiene practices of future doctors.

Reducing harm from falls.

Serious adverse event reporting from district health boards (DHBs) brought in-hospital falls to the attention of the Health Quality & Safety Commission (the Commission) when it was incepted in 2010. In 2012, responding to the large numbers reported, the Commission began planning for a three-year programme to reduce harm from falls, initially to run 2013-2015. In this article we discuss the serious consequences of falls, and the challenges and practical considerations involved in reducing the risk of falling and the rate of falls. We explore the Commission's choice of an adaptive approach in its programme, and show how a targeted measurement framework and national action has led to a nationwide statistically significant reduction in fractured neck of femur (hip fracture) and associated costs resulting from in-hospital falls, from a median of 12 per 100,000 admissions to eight per 100,000 admissions, sustained as at June 2016 for six quarters. This reduction reflects nationwide implementation of two key care processes: 1.) the percentage of patients 75 and over provided with an assessment of their risk of falling upon admission to hospital has risen from 77% in the first quarter of 2013 to 91% nationally in June 2016, 2.) the percentage of those with identified risk who were provided with an individualised care plan that addressed those risks has risen from 77% of older patients in the first quarter of 2013 to 95% nationally in June 2016. (These results are also reflected in a 14% decrease to 30 June 2016 in numbers of falls reported by DHBs as serious adverse events). Finally, we give a call to arms to the disparate health practitioners and services across all settings for individualised responses to prevent falls one patient at a time, and for leadership responses that promote an integrated approach to falls in older people.

The measurement of New Zealand health care.

The effective and economical measurement of the quality and safety of health and disability services in New Zealand is of signal importance. The Health Quality and Safety Commission has overseen the introduction of an architecture of interacting measures. These include quality and safety indicators, or QSIs, which are whole-system measures; quality and safety markers, or QSMs, which are targeted measures of quality and safety interventions comprising process and outcome measures in sets; and the New Zealand Atlas of Healthcare Variation, which illustrates the differences in the health care received in different regions and by different groups of patients within New Zealand.

The Health Quality and Safety Commission: making good health care better.

New Zealand has one of the best value health care systems in the world, but as a proportion of GDP our spending on health care has increased every year since 1999. Further, there are issues of quality and safety in our system we must address, including rates of adverse events. The Health Quality and Safety Commission was formed in 2010 as a crown agent to influence, encourage, guide and support improvement in health care practice in New Zealand. The New Zealand Triple Aim has been defined as: improved quality, safety and experience of care; improved health and equity for all populations; and best value for public health system resources. The Commission is pursuing the Triple Aim via two fundamental objectives: doing the right thing by providing care supported by the best evidence available, focused on what matters to each individual patient, and doing the right thing right, first time, by making sure health care is safe and of the highest quality possible. Improvement efforts must be supported by robust but economical measurements. New Zealand has a strong culture of quality, so the Commission's role is to work with our colleagues to make good health care better.

More for less: best patient outcomes in a time of financial restraint.

In many countries, expenditure on health care has increased dramatically over recent years. There have been parallel improvements in many indicators of population health, but too many patients continue to be harmed by health care or receive care that is supply-sensitive, ineffective, or poorly aligned with their needs and values. In addition to human costs, this translates into substantial waste of resource. The world has recently faced economic challenges unseen since the great depression of the 1930s. The financial situation of a country can, like a business, be expressed in three sets of accounts: statements of financial position, financial performance, and cash flow. A key test of solvency is the ability to pay debts as they become due (whether from current account or further borrowing). In general, this is a function of public debt, which for many countries has become very high. However, private debt and net financial position are also relevant to a country's financial prospects. Ultimately, borrowing is not sustainable indefinitely and given limited prospects for growth in income in the coming years, most countries will likely need to reduce or at least constrain expenditure on health care. This implies obtaining better value from the resources that are available, and we suggest that the key to this lies in improving the quality of care and, in particular, reducing variation in health care. In the United States, new legislation promoting accountable care organizations may help to do this. Cardiac surgery can be particularly effective in extending patients' lives and in improving the quality of their lives. Our ability to continue to provide cardiac surgery in the face of constrained economic times will depend on engaging more actively in ensuring that what we do is the right thing: that our operations are effective and that they truly meet the needs and values of our patients. It will also depend on doing these operations right the first time.