Victorian hospitals

Who in earth designed this VHIMS system and why haven't they been sent to prison? How many people have suffered by this? The Victorian Health Department relies on this evil joke of a system: http://www.health.vic.gov.au/clinrisk/vhims/ The policy of promotions by 'merit' somehow finishes up keeping anyone intelligent or principled out of executive jobs in this field. I have actually used the VHIMS system and the absolute failure of management to care that it made things worse contributed to my growing sense of danger and injustice. The attitude to safety and the law in public hospitals is absurd - no better than in Florence Nightingale's time. Hospital managers are reckless; they are laws unto themselves. Inside excerpt from Auditor General's shocking report on Victoria's hospitals.

Auditor General exposes dangerous, dysfunctional hospital reporting system which seems designed to cover up, not collate

In the Auditor General's report:

3.4 Incident reporting system [1]
"The incident reporting system used by public hospitals in Victoria is called the Victorian Health Incident Management System (VHIMS) and is licensed to the Department of Health (the department). Incident reporting is a key element of a safety management system. Over 2 500 OHS incidents were reported annually by around 16 000 employees of the four publ ic hospitals visited.

During the site visits, VHIMS was found to be not fit-for-purpose as an OHS incident reporting system. It does not enable, as the Department of Human Services-Public Hospital Sector Occupational Health and Safety Management Framework Model (OHS Management Framework) states, 'a formal process by which accidents, incidents, near misses or potentially unsafe si tuations are reported to people with the responsibility to investigate and institute any required corrective ac tions'. Issues with the VHIMS system include:

- Some mandatory fields-such as whether the OHS incident was disclosed to visitors of patients-are of no relevance to OHS incidents as they are designed for clinical incidents. Repeatedly filling in irrelevant fields makes reporting unnecessarily time consuming, which can deter staff from reporting minor incidents and near misses.

- There are no fields to capture vital OHS information, such as:

- signs and triggers leadi ng to frequent occupational violence incidents-for example, assaults-which carry t he most severe consequences for public hospital staff x OHS training of the staff mem ber who reported the OHS incident.

- Staff interviews and site visits showed that categories to cla ssify OHS incidents are complicated, unclear, too numerous-124 to choose from-and sometimes irrelevant or overlapping.

For example, occupat ional violence can be classified as 'inappropriate contact' or 'physical aggres sion'. This limits the usefulness of aggregated management reports, and hinders accurate and consistent input by the reporting staff member.

- - The incident severity rating is also of questionable value as it:

- is based on clinical risk and is inappropriate for OHS incidents. For example, a patient needing medical attention as a consequence of a patient safety incident is rightly seen as significant and is assigned a high severity rating. On the other hand, staff needing medical attention after an OHS incident may not necessarily be given such a high rating.

- Does not capture probable consequences if the incident occurred again, or the likelihood of a repeat occurrence. A near miss arising from faulty equipment could have much graver c onsequences next time.

-

Interviewed staff report - and site visits confirm - that training in the incident reporting system is inadequate, with brief overviews given during staff induction and no follow-up training offered at any of the public hospitals visited. The system complexity requires a more in-depth approach, particularly for work ers who may not be computer proficient.

Of the 42 staff interviewed, 36 reported that the incident reporting system was not user friendly. All 16 OHS directors surveyed stated that they believe there is under-reporting of both OHS incidents and near misses.

Code blacks are called in public hospital s when staff are physically threatened, and each is recorded in a security log. Comparison at one public hospital between this log and occupational violence incidents in VHIMS found that 70 per cent of incidents where staff were physically threatened and a code black was called were not reported in VHIMS.

This is a systemic and longstanding issue, as both the 2005 Victorian taskforce on violence in nursing report and the 2011 Parliamentary Inquiry into Violence and Security Arrangements in Victorian Hospitals and, in particular, Emergency Departments found that the incident reporting system was difficult for staff to use, and that under-reporting of OHS incidents was a significant issue.

Reporting was also not timely, which means that staff may be exposed to an OHS risk several times before control measures can be put into place or management is aware of the hazard. At one site, 87 per cent of OHS incidents were not entered into VHIMS within seven days of the incident occurring. No reason was given for this, although staff report that entering an OH S incident into VHIMS often has to wait until a shift is finished or a computer is available.

The VHIMS used by hospitals has been designed to capture clinical patient safety incidents and has not been appropriately modified to readily capture OHS incidents.
This undermines the stated departmental VHIM S project objective to 'develop a statewide, standard methodology, for the wa y incident information is reported within publicly-funded health services'. Figure 3A illustrates shortcomings in VHIMS for one particular OHS risk - occupational violence."[1]

Hospital management culture a danger to public

After more than a decade working in one major hospital in Victoria, I came to the conclusion that management were on a power-trip and had completely lost touch with what hospitals are there for - to help seriously unwell people get better.

It seems that being able to rapidly fire orders downwards to an army of professionals and skilled workers who rely utterly on references from management and cannot answer back simply goes to the heads of those in charge.

The experience of many nurses is of a sadistic, self-indulgent management that employs specialist human-resources professionals to help them silence the complaints of their victims. Tools like the VHIMS are made to order for these bullies. Victoria's industrial laws are close to useless and health sector unions seem to be in league with hospital management. Thanks are due to the Auditor General for validating the perception of those who toil below decks in these whitewashed over-insured laughably credentialed concentration camps. There should be mass-sacking of Victorian Hospital Management, notably the CEOs of the four hospitals examined and their salaries should be redistributed to the lowest paid workers in those places.

NOTES

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Public hospitals present hazardous challenges that demand OHS management of the highest standard. The audit found that while there are instances of better practice among the audited public hospitals, there are also significant shortcomings which put staff at unnecessary risk. In addition, weaknesses identified with the role of the department as the health system manager, and with WorkSafe as the OHS regulator, have contributed to the failure to achieve better management of OHS risk by public hospitals. Neither the department nor WorkSafe has a comprehensive understanding of sector-wide OHS risks or emerging trends in public hospitals.

Statements from the Auditor General's Report, November 2013

There is insufficient priority given to, and accountability for, OHS (Occupational Health and Safety) in public hospitals.

Staff safety needs to be given a higher priority by senior management and the department, and managers within public hospitals should be held to account for the OHS performance of areas under their control. Sustained improvement in the public hospital safety culture is not likely to occur without greater priority and clear accountability.

Neither the department nor WorkSafe has a comprehensive understanding of sector-wide OHS risks or emerging trends in public hospitals. WorkSafe cannot demonstrate that its project activity reduces OHS risk in public hospitals. Collaboration between the department and WorkSafe has been poor, with missed opportunities to reduce sector-wide OHS risk. Wide variability between public hospital OHS management practices—such as quality assurance of safety management systems and safety inspections—highlight the need fo r stronger sector-wide leadership.

These issues collectively warrant a future review of public hospital OHS risk to assess whether the level of protection for public hospital workers has improved.

Top down dereliction

The Victorian health services governance handbook states that the department plays a key system-level role in the performance of health services. This involves ‘shaping and enabling health services to function effectively’. The Health Services Act 1988 states that part of the department’s role is to enc ourage safety and improvement in the quality of health services provided by healthcare facilities.

However, the exact role of the department—as the health systems manager—in worker health and safety is not clear. Key documents governing the relationship between the department, the Minister for Health and public hospitals make no mention of OHS management in public hospitals, or outline the department’s expectations.

[...]

Although policy at each of the four audited public hospitals states that the board of the public hospital, as employer, is ultimately accountable for OHS, there is a breakdown in the chain of account ability below the board:

- Unit managers who are responsible for the day-to-day management of work units are not held accountable for OHS performance—this is also the case for the executive directors of public hospital departments. While there is a policy commitment that managers are responsible for maintaining a safe working environment, there are no mechanisms or targets to hold these managers to account for OHS performance.

- Ownership of OHS risk does not reside with the manager where the risk occurs.

At an organisational level, risk registers identify the corporate services area as the owner of OHS risks, despite OHS risks presenting predominantly in clinical departments.

"Under the devolved governance model, described in Part one of this report, the board and Chief Executive Officer of a public hospital play key roles in providing a safe and healthy workplace."

Occupational health and safety priority and accountability
Victorian Auditor-General’s Report
Occupational Health and Safety Risk in Public Hospitals

Managers are not accountable for occupational health and safety performance

Although OHS policies at each public hospital did state that the board, as employer, is ultimately accountable for occupational health and safety, there is a breakdown in the chain of accountability below the board:

- managers of clinical areas, where OHS risks predominantly present, are not held to account for the OHS performance of that unit or department

- ownership of OHS risk does not reside with the manager where the risk occurs.

However, there was no evidence that they were ever held to account at the four audited public hospitals. The OHS Management Framework states that ‘performance of OHS responsibilities is part of established job performance assessment process’.

None of the four audited public hospitals could demonstrate that mechanisms were in place to hold unit managers to
account for OHS performance. For example, even though the position descriptions of nurse unit managers NUMs)—who have direct responsibility for frontline staff and daily tasks—allocate them responsibility for overseeing OHS at the work unit level, half of the NUMs interviewed were not sure of their OHS responsibilities. Even those who understood their OHS responsibilities were not required to demonstrate how they fulfilled those responsibilities.

Managers to whom NUMs report are also not held to account for OHS performance. Position descriptions of executive directors, who are responsible for the day-to-day management of the clinical departments, assign responsibility for OHS in these areas. However, there was no evidence that they were ever held to account at the four audited public hospitals. The OHS Management Framework states that ‘performance of OHS responsibilities is part of established job performance assessment process’.

The audit team did find some examples of better practice at public hospitals that were not part of this audit. For instance, one public hospital requires NUMs to report on OHS incidents and control measures in their unit. NUMs at this public hospital are also required to develop an action plan where gaps have been identified, and these action
plans form part of their annual performance review.

Lack of occupational health and safety reporting against set targets

Managers need to receive regular reports against the targets set on OHS performance in the workplaces under their control if they are to be held to account. Neither reporting nor target setting was found at the work unit or department level of the public hospitals audited. Unit managers and clinical executive directors do not receive regular reports or trend data of OHS incidents in the work units for which they are responsible. As there are several unit managers rostered on during any month, without aggregated reporting it is difficult for each manager to know whether OHS performance is deteriorating or improving, or how their unit compares with other workplaces in the
organisation. The OHS Management Framework emphasises that ‘Health and safety performance is regularly reported’.

Growth is choking our city, our public transport, our parking lots, and streets and causing more and more "shortages", and rising costs - particularly in hospitals. Does it take a death of someone waiting to get some funding? More democracy in the system would solve a lot of the problems. When workers are too scared to complain vigorously, the patients aren't heard either. Does anyone have a choice in this system? Who is responsible?

Never enough money for hospitals with this rate of population growth

(Article adapted from a comment on deaths in hospitals on 10 October 2011.)

A May 2010 proposal for the Austin Hospital in Melbourne described the emergency department as treating about 16,500 more patients a year than it was built to manage, blowing out waiting times for care. The nearby Ivanhoe district had been declared an "activity centre" for more population growth. This means 17,000 NEW residents are planned for this small catchment area of the hospital in the next decades. The Austin Emergency Department (Casualty) now sees over 20,000 more patients/year than it was built for, or 40% more than a safe capacity.

Add all the other "activity centres" and the demands on this and all Melbourne's other hospitals will be compounded and escalate. Obviously this will further detract from medical care in rural areas. We are in a bottleneck gridlock of growth, and funding simply can't keep up. The two industries our State government largely rely upon- housing construction and foreign students - are both on shaky grounds, and both inherently require ongoing population growth. Most of this growth is fed by high immigration but its impact on hospitals is erroneously blamed on a small rise in the number of elderly patients, who are progressively being sidelined out of the main hospital system.

Does it take a death of someone waiting to get some funding?

There are already plenty of deaths, and other adverse events, but that doesn't stop it. And the deaths don't just occur to people on waiting lists. They happen to people who have already made it into hospital beds. Deaths in hospitals are 'managed' on paper until it becomes more or less impossible to attribute them to anything except isolated circumstances, or some scapegoated individual, sacrificed to the institution's survival. Inquiries almost never affect management; only hands-on staff, although management dictate how the hands-on work and often, to satisfy their own projects, interfere with common-sense priorities. It is very hard to sue a hospital. Their every step is managed by their insurers who have created a paper virtual system like wall-paper over what really happens. Hospital accreditation seems to be largely a protection racket, adding to costs and boosting the legalistic virtual system.

Unbalanced management layers crush basic services

Hospital management is top-heavy. Highly paid CEOs take their orders from a State Government keen to have a lovely virtual hospital for political reasons. Human resources teams interpret events according to the letter of very unfair workplace laws, to save money and to preserve power away from hands-on practitioners. There is a wad of middle managers dominated by narrow efficiency and treatment ideologies whose jobs and mortgages depend on them enforcing unworkable rules. Some are completely cynical, some are ignorant, some are so narrowly focused that they cannot see the wood for the trees. Others are fighting to make money to feed and house their own families and take no prisoners.

Unworkable rules suffocate resistance on the ground

The unworkable rules function to suppress on-the-ground criticism of conditions for patients and staff. The way this works is that, whenever a nurse or doctor stands up to management, some inevitable failure to document a detail will be raised as if it is a major issue of safety and professional competence. If the nurse or doctor tries to defend him/her self, the matter will be formalised into a first written warning. This is only two steps away from the sack. A professional can lose their ability to practice just by irritating management enough to have them find cronies to express unjustified alarm about that person's practice. Or they can be in the wrong place at the wrong time, when someone more powerful or popular or enmeshed needs a scapegoat. The workers are judged by boards which accept hearsay. Victorian law does not recognise defamation in Victorian workplaces, so management can say anything about a worker without proving it. They only way defamation can be pursued is after a person loses their jobs if the can show that it led to unfair dismissal, and we know how little power is left in that option.

How it works

Medication errors are a good example of vulnerability in practitioners. Medication mistakes are inevitable in practice. People under pressure make mistakes frequently. This is however not taken into account, although everyone knows that the pressures are becoming intolerable. Mistakes may be frequent, and every member of staff will make them, but management can still arbitrarily designate one of two identical incidents as an unusual and serious mistake and the other as inconsequential. They can ignore mistakes, as they often do, or they can decide to punish them. But if they choose to punish someone, the person accused has no access to the comparative statistics and information about other mistakes made that week, month, year by others, which would place their own mistake in perspective. In the 'merit system' different staff get different treatment according to how much management can rely on them to toe the line.

Toeing the line means that you don't protest against too many admissions, poor treatment of patients, lousy decisions.

Documenting death to death

Deaths are managed by insurers and lawyers. If you have something to say about a death, you had better have had the clairvoyance to document your concern in writing at the time, otherwise it 'did not happen'. "If it's not documented, it did not happen" is a common phrase. Everyone can know, but no-one dares to say. In fact most of what doctors and nurses do is done using speech or action; they cannot document everything in writing, but if they don't they cannot admit to it.

Australian nurses and doctors now spend enormous amounts of time documenting that they have done certain things required by law. It does not actually matter in a court of law whether or not they actually did these things; only that they wrote that they did. Very hard to prove a person didn't do something days or months later when they wrote down that they did. The system is full of cumbersome checkboxes indicating that you observed a patient, monitored them, and checked equipment and medications. For the last decade there have been several computers on every ward and nurses and doctors spend most of their time entering in notes about what they are supposed to have done. How much time does that leave to actually do what they are checking off? Not much.

The Faulty-Towers world of virtual hospitals

This is the age of construction, under duress, of virtual hospitals with virtual wards and virtual patients by real nurses and doctors who are, incidentally, trying to care for real patients. To survive psychologically it is necessary for nurses and doctors to cultivate cynicism. This way of working is exhausting because nurses and doctors spend most of their time and energy 'documenting' their virtual practice, and then squeezing in the real work in wards where there are continual admissions on top of the people already there who need care. No wonder people die. No wonder it is hard to staff hospitals.

Bosses who can't say no to politicians

And the doctors in charge of various departments seem to be chosen for having a style where they never say, "No." They never say, "Enough." They never say, "We have x beds and they are full, so we cannot take any more patients." So the wards and the country are in overshoot. And the nurses and doctors in the ranks have to wear this.

Keeping workers disorganised

One way that management wallpapers over the huge cracks in the system and to avoid revolts is to import workers from overseas. These nurses and doctors depend utterly on their jobs. They don't have access to free health care or unemployment benefits, so they are simply not going to blow the whistle. This is why having immigrant workers whose right to stay in the country depends on their retaining their job undermines nursing and medical care in Australian hospitals and working conditions. It also disorganises solidarity. Long-term staff cannot plan together to feedback sensibly to management in a workplace dominated by insecure new workers who won't back them up.

Accident Compensation Edifice without substance or compassion

Workers who suffer undue stress because of unfair accusations will often seek protection under the Accident Compensation System, only to find that their claims fail because disciplinary action was involved at some stage of the claim and the Accident Compensation laws have clauses that make it almost impossible to claim for treatment or illness if a disciplinary action was involved. Hospitals are quick to find coincidental reasons to formally discipline any worker who brings in a union. The Accident Compensation laws also allow huge lee-way for management decisions, which effectively means that if management give some reason, any reason for their action, however unreasonable, it will be deemed okay in Accident Compensation. It also doesn't have to be substantial; it can be a mere opinion.

It is also very hard for a worker to maintain any kind of resistance to unreasonable demands when they are defending their reputation and their ability to earn a living in an unfair system that does not really allow for reasonable human error. A system which talks about human rights for patients, but does not apply these to their staff, makes human rights impossible to uphold.

Bullying laws

Bullying laws also don't work because they are administered not to work. Unions describe individual cases with excellent documentation, but management and the law administrators simply avoid compliance with bullying law.

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