Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals
On 29 January 2008, Her Excellency Professor Marie Bashir AC CVO, Governor of NSW, issued Letters Patent appointing Peter Richard Garling SC to inquire into issues affecting the delivery of acute care services in NSW public hospitals and recommend changes to address those issues.
On 27 November 2008 Peter Garling's final report was publicly released. It contained 139 recommendations. The following is a summary.
The divide between health service management and clinicians was identified as a key impediment to improvements in the quality and safety of patient care.
To address the issue it was recommended that NSW Health establish an Institute for Clinical Education and Training which would develop and introduce a leadership training program for clinicians and establish defined career paths for those wishing to assume senior leadership, management or administrative roles.
In addition it was recommended that NSW Health create (within each area health service) a position entitled "Executive Clinical Director" to be occupied by a qualified medical practitioner who would:
- provide independent advice on all matters relating to clinical practice and the medical workforce directly to the Chief Executive of each area health service;
- be responsible for championing ongoing clinical practice improvements;
- act as the public spokesperson, where required, for the area health service on all matters relating to clinical practice, quality and safety of patient care;
- conduct regular forums for all clinicians to ensure that they are kept informed of all clinical practice and health system improvements and give them the opportunity to provide feedback.
Interdisciplinary health care teams
To help address health workforce shortages and better meet patients’ multi-disciplinary health care needs it was recommended that area health services encourage healthcare professionals to adopt shared models of patient care, supported by the appropriate rostering systems (to ensure that the right number health professionals with the right skill-mix are available to meet patient needs) and clinical support staff to alleviate the burden of clinicians administrative work.
To improve medical workforce planning and management it was recommended that all area health services:
- start collecting information about their current medical workforce according to specialty, qualifications, location and stage of training;
- display complete list of all vacancies on NSW Health intranet together with the date on which the position first became vacant;
- establish a central register of all doctors who are available to fill casual shifts or act as locums for specified periods;
- conduct annual performance reviews for all employed or contracted doctors (other than doctors in training) against performance criteria set-out in their contracts.
NSW Institute of Clinical Education and Training (ICET)
To improve education and training in NSW public hospitals it was recommended that NSW Health establish an Institute of Clinical Education and Training which would design and implement:
- a clinical education and training program for all new postgraduate clinical staff employed at NSW public hospitals;
- leadership training program for clinicians;
- train the trainer programs for those delivering ICET education and training programs;
- performance evaluation programs for clinical postgraduate trainees;
- a hospitalist training program for medical practitioners.
It is envisaged that the proposed ICET would liaise with the specialist medical colleges to ensure that the training programs delivered take into account both hospitals service delivery requirements and medical college training requirements.
The respective roles and responsibilities of the ICET and area health services (in providing postgraduate education and training programs) would be specified in government policy and their compliance would be audited against criteria set out in performance agreements signed by NSW Health and the area health services.
To reduce the risk of mistakes being made due to miscommunication of patient information it was recommended that NSW Health implement and audit compliance with mandatory policies and protocols for:
- patient transfers from emergency departments to inpatient wards;
- ordering of pathology tests;
- safe clinical handover;
- GP-hospital interface handover including provision of patient discharge summaries and care plans; and
- admitting medical officers to regularly assess clinical notes written by junior medical staff relating to their patients.
To improve access to patient information and continuity of care it was recommended that NSW Health cooperate with and support the National E Health Transition Authority by developing the policies and platforms required to permit specialists, general practitioners and allied health professionals outside NSW public hospitals hospital to gain access to the relevant parts of their patients’ medical records.
Clinical Innovation and Enhancement Agency (CIEA)
To improve existing or develop new evidence based protocols or models of care for common surgical interventions, diseases or syndromes encountered in NSW public hospitals it was recommended that within 12 months NSW Health establish a Clinical Innovation and Enhancement Agency (CIEA).
The CIEA would include personnel with expertise in change management, project design and support, business management, health economics, as well as clinicians involved in continuous clinical re-design. The CIEA would report directly to the Minister for Health and the Director General of NSW Health.
Quality and Safety Recommendations
To improve quality and safety of patient care it was recommended that NSW Health:
- encourage each health service to have regular meetings involving all clinicians to review cases of morbidity and mortality at each facility;
- make the Clinical Excellence Commission become the body primarily responsible for safety and quality assessment in NSW Health;
- develop processed that would allow for better use of information captured by the NSW Incident Information Management System and Root Cause Analysis process.
To improve identification of patients at risk of rapidly deteriorating it was recommended that NSW Health develop and implement:
- a specifically designed vital signs observation chart;
- escalation protocols to manage deteriorating patients, which would include a rapid response system;
- detailed education and training programs, aimed at recognising and managing the deteriorating patient;
- ongoing collection and analysis of appropriate data to monitor the implementation and progress of the program.
Bureau of Health Information
To improve use of health information currently collected is was recommended that NSW Health establish a Bureau of Health Information that would be responsible for:
- monitoring area health services', hospitals', units' or wards' performance;
- publicly reporting on performance data;
- analysing data and reporting on specific issues;
- evaluating the cost effectiveness of new policies and programs;
- commissioning research into health system's performance;
- developing and publishing patient care performance criteria.
In addition to the above a range of recommendations were made for the improvement of medical services (emergency, mental health, surgical, pathology and medical imaging), equipment and infrastructure. For more information on the Garling Report please visit;