I wasn’t actually going to write anything about this.
But after everything I have written about the problems in our emergency department over the years, it just seemed a little…..well….. a bit of a cop out, not to document it here.
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Gaming the statistics:
It has been an awful few weeks in our emergency department. For many reasons.
Following the detection of anomalies in waiting time data, a senior executive admitted to ‘gaming’ the statistics to make hospital performance appear better than it is.
The subsequent forensic analysis conducted by PricewaterhouseCoopers (PwC) found that around 11,700 performance records – about six percent of all records had been altered from within the Emergency Department Information System (EDIS).
The report also noted: “The executive’s admission to Audit does not appear to account for all of the changes to EDIS records that have been made to improve timeliness performance.”
Manipulation of data was found to have been relatively easy due to the use of generic logins and inadequate user password security. ( Those of you running EDIS in your own ED, or any other electronic patient management system for that matter, can take heed and read more about our security issues here.)
The audit estimated that in the last 12 months, achievements in meeting targets for just one single group of patients triaged as Category 3 (urgent, should be seen within 30 minutes) had been overstated by at least 19 percent.
Data gaming was thought to have occurred as far back as late 2010.
Now, there may be many others involved, but I can tell you that I know the person who has admitted to gaming the EDIS data.
She worked extraordinarily hard at developing strategies to improve the flow of patients through our department.
Damn hard.
As have we all.
So personally, I feel it is a sad and totally demoralising situation that this person felt that:
“The only thing that worked to achieve benchmark targets was to alter the data.”
There is no question that she did wrong. And she betrayed the trust and admiration of many.
But she is a good person. A fact that makes it all the more painful.
Gaming the politics:
So. It is all a bit of a mess right now.
It is an election year and the whole thing has become charged with a political ugliness.
The name of the person involved was ‘accidentally’ leaked to the media.
The fact that the Chief Ministers own sister is a senior nurse working at the hospital was hung on an insinuating hook by the political opposition, despite the fact that the investigation found that she had no part in any data gaming.
That was just nasty, and whomever did it is far worse than all the people combined who might have altered data in my book.
As I said, a real mess.
It might have all been worth something if a politician or member of health directorate executive had said: well hang on here, the environment of access block and emergency department overcrowding is far worse than we have been led to believe. There is some bad shit going down here. This is not an emergency department problem, this is a hospital wide problem. Our first priority must be to apply expert resources to immediately ease this situation. And then re-evaluate what we are doing to ameliorate it.
Because we are well aware of its adverse impact on patient care.
Remember: There is very strong evidence now that increased length of stay in our emergency departments leads to increased morbidity and mortality amongst these patients. At the very least is has a direct impact on quality of patient care. So this is no small matter.
Instead, the distraction placed on executive right now seems to be directed towards data security, password protection re-evaluating the inaccurate data1. Cleaning up the political fallout. Damage control.
Meanwhile, our doctors and nurses (and yes, management) are so busy trying to maintain a quality service from within a critically overcrowded department that they barely have time to jump up an down to try and get someone to pay attention to the real data that is being corrupted:
Blood pressure. Pulse. Respirations. Pain score. Access to care. Bladder circumference.
Overcrowding and access block is a serious problem in emergency departments all over the world. Implementing accurate systems to track key performance indicators is a vital part of improving the state of play. But I have no doubt that some form of data manipulation at one level or another is widespread. Especially when targets are linked to funding. And especially, especially, when meting targets are linked to political performance (which is always).
Not that it is an excuse, but perhaps our own dirty laundry might lead to scrutiny of other hospitals performance data. Data that might be obfuscating the real issues we face.
Post Script:
Do you want to know the biggest stress that clinicians (doctors, nurses, physiotherapists, clerical staff, wardsmen) in any emergency department experience?
- Is it data security?
- Is it meeting the National Emergency Access Targets?
- Is it the workload?
No, it is the day to day, pernicious, internal conflict arising between the external need to comply with their own directorate policy, organisational requirements, confidentiality and professional expectations……and the internal need to address any ethical and moral issues around delivering effective, quality and compassionate care.
Those two needs should not conflict. But, in many emergency departments, they can. They can stretch us apart.
For nurses, this conflict might well be intensified by studying our own national competency standards for the registered nurse:
National Competency Standards for the Registered Nurse:
1.2 Fulfils duty of care.
Clarifies responsibility for aspects of care with other members of the health team
Recognises the responsibility to prevent harm.1.3 Recognises and responds appropriately to unsafe or unprofessional practice.
Identifies interventions which prevent care being compromised and/or law contravened
Identifies behaviour that is detrimental to achieving optimal care2.4 Advocates for individuals/groups and their rights for nursing and health care within organisational and management structures
Identifies when resources are insufficient to meet care needs of individuals/groups
Anyone who has read this site for a while will know that my own internal conflict has resulted in many posts on the effects of access block and overcrowding on our patients.
Many might say that I can on occasion be a little naive and foolhardy and unprofessional and step over the line of advocating within organisational and management structures. Yup…point taken.
I have gotten in trouble. And I know that hospital executive watch this site regularly to see if might step over any line some more.
(Hold me back people, hold me back).
So to them I respectfully shout out without putting my hand up: the real issue here is not about data. Or about politics.
Pull your heads out of the spreadsheets and dashboards for a bit. Come down and visit our department on a Monday night at 8 o’clock. Or a Friday night at 7 o’clock.
Spend a few hours, talk to the staff, see what is behind the data. You will learn a whole lot more.
The real issue here is about our patients, their families and our (your) colleagues.
But most importantly for me, the issue here is about being a nurse. How about you?
- incredibly important activities…..granted [↩]
Our Prime Minister Julia Gilard has said that our public hospitals are inefficent!
The AIHW own figures show that over a decade hospital admission rates have increased by 30%.
So public hospitals as a group, have increased their efficiency by 30%, yet at the same time the number of available public hospital beds continue to decrease.
there is an end point where regardless of initatives, it will be totally impossible to improve performance.
Addit:
I have always wondered how you could determine the cost factor of a ward considering patients are all individuals whose health needs fluctuate from one person to the next. This has been a problem with managers as they need a static cost factor to project their calculations on. When I worked in retail one of the theories was that you had to know how much turnover was required against the operational floor area. This means to understand the profit and loss side of the retail cycle so when it came to pricing your stock you knew how much was needed to get over the operational cost factor of business.
If health management looked at the clinical operational cost factor of a ward for the last five years it would provide some (analysis) of the overall operational cost. It’s just a hunch but maybe they could determine a ball park figure and factor in inflation etc to calculate what should be needed clinically for the next financial year. Just an idea ?
When I was studying Clinical Governance a lot of research indicated a gap between what was expected from management to what was required clinically on the floor (ward). This was due to the fact that people in management had high qualifications in business operations but next to nothing in clinical knowledge. This from my personal view extends in the aged care sector where corporate board members dictated how much budget was allowed per year for clinical operations. One of the textbooks I used while doing Clinical Governance was ” Managing clinical processes in health services” by Roslyn Sorensen and Rick Iedema (2008). My view is that whilst we have executives in health with limited clinical knowledge making decisions it will cause systemic problems within the organisation.
Anyway I think as time progresses clinical management will improve but probably not as fast to ensure best practice outcomes.
Same applies to all areas of the hospital. Take Pathology for example, more patients in ED = more pathology testing to determine course of action for treatment and admission. But like many areas Pathology is chronically understaffed and still required to provide and accurate and timely service. When they can’t they are on the receiving end of some very unpleasant and unfair criticism from medical staff because in their eyes, they have the only patient with samples to be tested. So the stress from ED filters out to the wards, pathology, imaging etc etc. In the end it’s about patient care and positivie outcomes and those of us at the coal face doing the best we can and earning a pittance are sick of being told how to do our job by a bunch of suits with no training, medical understanding but earn heaps of money and a bunch of figures in front of them to meet their unrealistic targets. The reaction by the Opposition this week was unprofessional and petty. How about helping to solve the problem? Volunteer some time in the
ED or in the hospital and get a feel for what a great place it is to work. Most of us are professional and committed to just getting on with it. The minority sit in their offices justifiying their own existance with unrealitic policies and targets for the real workers to achieve but with no additional resources or thought for the detrimental effect on patient care. So there.
Some really relevant and interesting comments. Some lessons to be learnt out of this fiasco. Unfortunately, it takes something like to happen before the powers that be start to pay any attention. In the meantime, our #1, the patient, is the one suffering. We call that SNAFU…. (Situation normal, all F*cked up).
interestingly the programs that are used to collect the data that is used against hospitals, are the very same programs that are in part responsible for the slow passage of patients through the emergency dept.
our wait times increased by over 30% with the introduction of our EMR (we changed from EDIS to FIRSTNET).
the busier we get, the less able we are to document safely or pt care suffers. sometimes there just isnt time between pt care to find a free computer, log on, open the chart, double click the icon, find the pt., double click the file, open the chart, type the obs, log out…….
if you didnt chart it, it didnt happen, therefore its possible that we’ve assessed and treated a pt before we get a chance to dot the electronic i’s and cross the cyber t’s. when this happens we fail our KPI.
of course the data eventually gets entered but if you dont go to the trouble of ensuring every time bracket is changed, we still fail KPI. if we do change time brackets we are doctoring the stats.
so pt care can be excellent while the stats can look dreadful.
it bothers me greatly that the EMR system has been designed almost with the sole purpose of stats collection and pt care, information storage and relevance to clinicians seems to have been secondary.
mroe focus needs to be on actual patient outcomes and staff experiences within the department.
good luck canberra, we’re right behind you
People come BEFORE computers entry/data/logistics/b*sh1t. It’s not much of an excuse to say ‘he arrested when I was entering his data in FirstNet!! Then the next patient comes in, and the next and the next!!! Why are you SURPRISED that the data is doctored…we’re freaking HEALTH CARE WORKERS, NOT data-entry clerks!!! Slows treatment by 50% at least…and you can’t keep your eye on the patient at the same time either…DANGEROUS for that patient. Oh God I hate Bureaucratic insistence on ‘data/statistics’!!
Have you ever thought about how much it actually costs to collect data?
Collecting data in a health care system is a very expensive and costly exercise. Previously hospitals would use different methods of collecting and measuring.
This had the effect of not being able to actually compare hospitals directly with each other.
The next step in the data process is that if it doesn’t show what the government wants, it gets turned into gooblygook.
Thanks Ian, for putting many of our thoughts & feelings about this out there!