Department of Health

Introduction to health boards and the Victorian health system- Director Induction Session 1 – July 2020

  • 03 August 2020
  • Duration: 1:12:27

    Welcome to this orientation session for newly appointed members to health boards in the Victorian health system and I know we've got plenty of people here today who are actually very experienced directors and chairs, and a number of people as well who are responsible as board secretaries or directors of governance.

    As we open the session today I'd like to acknowledge the traditional custodians of all the lands on which we are meeting. So if I could ask you to put up the slides, Glenn.

    And acknowledge the first peoples and traditional owners of the lands that we're
    meeting on the peoples of the Kulin nation and the other aboriginal people who are the traditional owners of the lands where you are today and pay my respects to their elders past present and emerging, and to all elders who joined us here today

    This is a slightly strange experience not being able to see your faces but I hope that you can see ours. We look forward to having an engaging hour and a quarter.

    It's a very important role to take on a governance role, an important board role in our health system in Victoria and it would be hard to think of a more challenging context in which those roles are being taken up than the context that we find ourselves in today. This won't be a COVID briefing, this will be an orientation session for boards about board director’s responsibilities but the situation we are in reminds us of some important things in terms of boards roles when there is a crisis and also of boards roles to ensure that the normal work of the organization proceeds, even though there's a crisis.

    So today is the first of three orientation sessions and the overview will be that will have a discussion about the role of a director just at a very high level and then Terry Symonds, who is the Deputy Secretary in the Department of Health and Human Services in the Health and Wellbeing area will look at the health system and the department and talk about board directors roles with some illustrations of how that plays out.

    And then Euan Wallace who is the CEO of Safer Care Victoria will talk about quality and safety for board directors, and clinical governance. And then we'll have a question and answer session. Now it's important that you use the question and answer function that we have so there's a capacity for you to post questions and a capacity for you to vote for questions that you like. 

    We've got some people from the Governance Team in the Department of Health and Human Services who will sort those questions and will try to give priority to those questions which have the highest interest level but if there are questions that refer to matters of fact, or where there are resource is available that we haven't been able to answer during the session will circulate those materials at the end. And we'll also circulate this slide set and reference to other resource materials that you might need. 

    It is also important just to indicate that the two followup sessions the first one the date of these haven't been scheduled but I think they certainly will be in this sort of webinar format.

    This second session is going to be on legal responsibilities and risk and then the third session on funding and accountability in the Victorian healthcare system.

    So let's get underway then with some focus at a high level on what is the role of a director. So board directors are bound by legal and ethical responsibilities that are outlined in the Health Services Act and there are a number of supporting guidelines. 

    Clearly this means that directors need to act in the interests of the health service at all times, act with integrity and in good faith, hold themselves and each other to account and obviously to be diligent about attending meetings and reading the board papers, but also in terms of how we behave.

    It's our role to be curious, to know about what's happening in our community and in the health system to keep ourselves well informed, and it's also important for us to look beyond the obvious and to work with the management of the organization to ensure that we've got good oversight of what's happening, but also that we're supporting management and holding them to account to deliver the best care that they can for your communities.

    That's a pretty significant set of responsibilities and I think it's important to recognize that we are supported in what we do principally by the organisations where we are on the board, by our board chair and fellow board members and by the management of the organization. But there's also a great deal of resource material available to us and I know that many of you who around boards are very well aware of the orientation materials and those of you who have just started this month have probably already been presented with a voluminous - in these days fortunately electronic rather than large folder - of relevant material relating to your own health service and to the Victorian government policies.

    And it takes most directors six months nine months really to feel as though they've got a good grip of the health service where they’re now taking on these roles. I know many of you have had experience in other sectors as directors but there's a lot to learn about health, and for those of you who are very well versed in health but haven't had significant governance roles before then there's a lot to understand in that world. But you're not on your own.

    There is a Directors Toolkit which contains a great deal of information about being a board director and it's available at that website. And as I said will circulate these slides and it basically sets out all of those things in those dot points there. It is currently being revised but it is available online and the new edition will be published when it's completed.

    So I want to just remind you about the question and answer the function that you have.  You should be able to find it on the bottom right of your screens to post a question and we encourage you to do that and to look through the questions that are already there and to vote for those that are of most interest to you.

    The next presentation will be from Terry Symonds who will speak to you for 15 or 20 minutes then we'll go straight to Euan Wallace who again will speak to you in about that same timeframe and then will start to address some of your questions.

    So I hope you enjoy the session and I do actually really seriously want to say that being a director of a health service in Victoria it's very challenging; it's a serious set of responsibilities, but you meet terrific people and it's really important work to do and it can be incredibly satisfying so I hope that’s your experience

    Now I will hand over to Terry.

    Thank you very much Jo, and thanks everyone for coming along to the session this afternoon. I'm Terry Symonds. I'm Deputy Secretary for Health inside the Department of Health and Human Services.

    I'll also begin by acknowledging that we're all meeting on Aboriginal land and pay my respects to elders past present and emerging, and any Aboriginal people with us in the meeting today.

    I'll begin with just a couple of comments about my role and the role of the department. I want to go through a bit of how I see the role of the department in the system particularly in relation to the health services that you govern and then I'll touch on what I think are some of the areas that I would propose are areas of focus for boards at the moment. 

    So I'm Deputy Secretary for Health and Wellbeing. The Department of Health and Human Services is a large department. We include probably the single largest budget spend on service delivery from the Victorian government along with schools and police. But we include family violence services, child protection, housing, family services; all of these are inside our department. Each of them have different parts of the department and my division looks after the spending on health services across the sector. Not just acute health services but other health services as well.

    Your Directors Toolkit that Jo’s referred you to has a lot of background information about the Health Services Act and the overall structure of the system from a formal kind of point of view.

    In my head, there are three key roles for the Department.

    One is a role of oversight.

    I know that board directors you understand their roles in terms of compliance and performance. Both of those things are part of our oversight role in the system so our department and my division other regulators for public health services in the state and it's our job – there are other regulators as well - but it is our job to make sure that the Act is being complied with - the Health Services Act is being complied - with and also to ensure partly on behalf of other departments that other pieces of legislation are also being complied with and that standards that are set down in statements of priorities and sometimes in legislation for health service delivery are also being met. 

    So that's one of our roles. Another part of our oversight role is performance. So the government spends a lot of money on health care to meet the needs of the Victorian population. And our divisions job is to keep score on how well the spend on health service delivery and the work of Health Services is meeting the needs of the Victorian population. So things like access to healthcare, how quickly can people get seen in the emergency department, but also equity, are our services being delivered in a way that meets the needs of all parts of the population. Where are there gaps and shortfalls in terms of care? 

    We have partners Safer Care Victoria who have a particular specialized role in terms of quality and safety, and you'll hear shortly from Euan, but we work together to make sure that the way in which services are delivered also meets expectations of the community and government. So they are all part of our oversight role in terms of ensuring that health services do the job that they’re set up to do and funded to do. 

    There is a second part of our role which I think of our system management. There is a few different ways to understand this. We have a lot of Health Services in Victoria. We've got a lot of separate entities responsible for health care in their patch but there are a number of challenges in healthcare delivery that can't get sorted in one geographical area alone but need to get sorted on a system wide basis or at least are better sorted on a system wide basis than they are by being done separately and differently across the system and those things fall into our bag under what I think of as our system management.

    It doesn't mean we deliver all those services but it does mainly have a key role in terms of designing and ensuring that things work in a coordinated way across the system. Examples of what I'm talking about might be our trauma system. 

    We have a designated system to ensure that serious road accidents for example are not dealt with by every service because we don't have the capability and the infrastructure around the clock to provide the highest quality care in every health service around the state. So we work with Ambulance Victoria and other services to ensure that those serious injuries get to only a very small handful of services around the state; The Alfred, The Royal Melbourne, The Royal Children's Hospital to make sure that they can be dealt with affectively. 

    Likewise we have a major burn service and two major bones services in the state on the same basis. There are other examples if I think about supply chain for health care, which is a bit of a work in progress.

    There are something like 50-odd warehouses around the state separately stocking and sourcing supplies for healthcare and one of the things on our mind at the moment is whether that shouldn't be wouldn't be better sorted and managed through a small number of large warehouses providing scale and better efficiencies for the health system. So that's an example of something which is a live case and a work in progress.

    There's another aspect system management which is that health needs to interact with other parts of service delivery and other portfolios of government. So if I think about family violence for example there are dedicated agencies for responding to family violence but it is health services, it is GPs and emergency departments who are the first port of call in 80% of cases where victims actually come forward and seek help.

    And so there's a burden of responsibility on health care to be sensitive to family violence, child protection, a range of other issues. We need to understand the needs of people who are homeless and work with our partners in housing.

    We need to understand the needs of people who come into contact with the criminal justice system so some of those interfaces between health and other parts of government and society are things that our department also manage is kind of on behalf of the sector. They also exist at a local level but we work at a statewide level to try and make sure some of those interfaces work a bit better.

    So that all fits under the second role which I think of our system management, and the third role really has to do with long term direction for the health sector.

    There's two parts to this one. One is that we are a translator of the government's own vision for healthcare. So part of the department’s job is to take the policy priorities of the Victorian government and their policy directions and translate those into workable directions for health services. Partly through documented Statements of Priorities, but to be honest mostly on the fly in conversations and meetings and guidance to particular boards, feedback on particular documents and initiatives from your health service to try to make sure that the public health sector is in tune with where the government wants to go. 

    So that's part of translating. But we aren't just translators of governments direction.   We also work with you and other partners, professional bodies, consumers and so on to influence government. 

    So government wants advice. They don't take advice only from the department. Sometimes it feels like they don't take much advice at all from the department, but we are one of a wide range of sources of advice for government, and our hope would be that we will listen to you, will take advice from health services and will transmit that back up to government so it's an opportunity to also influence the government's long term direction. 

    So in both directions or in both aspects translating and transmitting out but also feeding back up and sort of developing policy advice for government they're all part of that responsibility for direction. 

    So they’re my three ways to understand the department's role.

    Oversight, system management and long term direction or strategy. 

    So I'll leave it there in terms of the department’s role. The Directors Toolkit includes a few more technical aspects to our job and some of the legal responsibilities that we have so read those at your leisure.

    I want to touch before I finish on some things that I think are priorities for boards particularly at this time. I know Jo said it's not a COVID briefing and I don't plan on covering the specific challenges around COVID but I do think covered in the pandemic has forced some parts of the board’s role into very sharp focus.

    So I think about risk for example. We are living through what would be technically defined as a crisis. It's seriously challenging our health system and community in a way that we have not been challenged for a very long time and it's disrupting many of the things that we had sort of held to be steady and we're having to rethink how we go and deal with serious and urgent health concerns so what is the role of a board in a crisis. I think here about what I've always heard which is that boards focus on governance and CEOs and management focus on operations, and that is clearly still true.

    In a crisis I think we do expect, the department expects, and government expects, that boards pay more attention to operations then they would usually. It is not something that can be only left to a CEO on trust. 

    I think we expect that boards will request plans, review plans, that management have for managing the operational challenges that the pandemic and the current situation requires, asked the right questions of management about whether those plans are working, have been implemented, that they're producing the results that we expected them to have, do we have plans for if they don't work, what scenarios have we actually thought about. 

    They are the questions about operations They don't involve boards doing the CEOs job but there are questions about operations that we think should be a very high priority for boards at a time when our health services are operationally challenged, as I said, in a way that they haven't been before I might also add that part of that attention to operations is support for the executive team.

    I've worked in the Victorian public health sector for 15 years now I have never seen our leadership teams as stressed and stretched as they are now and I would say that it's part of the board's job to be mindful of the welfare of the executive team. And so I would urge you to keep an eye out for that. 

    I assure you that your executives are working hard and it's part of the board's job to make sure they have the resources and also had the support of the board while a board maintains its appropriate role in terms of challenging and questioning.

    But also make sure that they know they have the support of the board during a very tough time.

    The crisis will end, we will come out of this second surge. In terms of COVID I think it will be here for a long time to come but it does mean that recovery from the crisis has to also be on the board's mind and I think it is the job of the board like it is the job of the department to be thinking ahead to what will happen when we come out of this. It can be hard for management I think to think that far ahead sometimes although we have some terrific farsighted executives and CEOs in our system and clinicians.

    But it's part of the board job to also be thinking about what lies ahead and there are I think it is safe to say that things will never be the same again There are some terrific  opportunities that are there for the health system.

    In the way that the pandemic reshaped healthcare some of these I think now pretty obvious the way in which care has shifted digital technology. The technology we're using for this forum today which I venture to say many of us were not comfortable with or not familiar with until a few months ago but now other way that almost all of our meetings are conducted in order to stay safe. 

    But actually we're going to keep this technology going because it's also a way to provide care to people in their homes. It's a way which your clinicians in your health services will now be delivering many of their outpatient appointments where we used to insist on people coming to hospital and packing a lunch and spending half or most of the day there waiting for an appointment they now can have many of their kind of care needs at least in that context In terms of outpatient and specialist consultations met remotely through digital technology so that's one example.

    There are changes in the in the workforce. There are some changes in the way we engage with the community around healthcare. We now have the community engaged, very engaged in a conversation about their own health and health behaviours in a way that we have never had before. We don't want to lose that level of engagement and we have to work out how to build on what we've got for the future.

    So that kind of thinking about where to, and the long term reform is also I think a key role for the board and they fit under the boards traditional role in terms of strategy.

    So I guess what I've tried to give you here I've got a brief taste of is that the risk and strategy is among several of the board’s key roles are particularly important both during the crisis and as we think about coming out of it and that they're both very much in our mind and we do expect that they are very much on boards minds and that's what we're looking for in our conversations with boards. 

    So I might pause there or stop there and hand over, and I look forward to the question and answer session and coming back to discuss some of these with you a bit later on but right now I'll hand over to Euan Wallace, the CEO of Safer Care Victoria. Thank you.

    Thanks very much, Terry, and will get Euan set up.

    Thanks Jo, and is that visible now? I'm hoping you can see that, so welcome everyone on this afternoon and thank you for joining us. So both like Jo and Terry can I first acknowledge that we're all meeting on Aboriginal land and pay my respects to elders both past and present. 

    And thank you for sharing your time this afternoon 

    So as Jo said I'm the CEO, Safer Care Victoria. I'm a clinician by training and I delighted to share with you my thoughts and I hope the thoughts of Safer Care around quality and safety from the perspective of board directors. 

    Let me be a wee bit selfish to start with and just tell you for those of you who aren't overly familiar with Safer Care just in one slide a bit about us. So we were established just over 3 1/2 years ago as a response, a specific response, to Targeting Zero review view of essentially clinical governance across our public health sector in Victoria, and the recommendation was made to create a deliberate separation of quality and safety from the other functions that Terry has shared with you around the department with intent then of elevating the importance of quality and safety, calling it out separately and giving it an agency whose sole function was to concentrate on quality and safety and hopefully bring an independent approach and voice to quality and safety improvement.

    Can I just recommend if you are not familiar to, with these resource, these two resources, they are not weighty resources.  One is delivering high quality health care: the Victorian Clinical Governance Framework. Actually I think one of the very first products that Safer Care launched and very proud to launch but I do acknowledge it was written by those who came before us. So really on start-up I inherited what was essentially a finalized framework work and very grateful to the contributors who wrote. 

    And then the Institute of Health Care Improvement with whom Safer Care has a five-year strategic partnership. 

    They launched their white paper – Framework for effective board governance of health system quality - in December last year and thankfully the two very closely aligned. There are slight differences in words and phrasing but the fundamentals are identical in both of them and are available readily on the web. Just Google them and download them as PDF. I hope you'll find extremely useful resources.

    So I want to come first summarize what is clinical governance because the more you read about clinical governance there more views you will get. So really what is it, what's the what and so this is how we define it in the Victorian framework and the integration of systems process is leadership and culture that at the core of providing safe effective and person centred healthcare, and underpinned by continuous improvement and I've just added in square brackets there with measurable goals and I might come back to that.

    I bolded systems process is leadership and culture because you're trying to get your head around, wrestle with what is clinical governance, particularly for new board directors and you should be able to compartmentalize what you are seeing in those four categories. Systems process is leadership and culture and in your conversations around quality and safety and broader clinical governance and you should be
    looking for metrics and in each of those domains.

    And also wish to remind ourselves of the Institute of Medicine’s definition of high quality care and it’s a definition that Safer Care uses at its core and it has six components to it. I don't want to go through them in detail but just to remind you that high quality of care is defined as being safe, effective, person centred, and that means of course that the care may differ for the same condition between quite different individuals, because their values and their wishes differ. 

    It should be timely, it should be efficient and it should be equitable and the IHI’s document talks about STEEEP - they just reordered those six components. But again at the core of our IHI document and the core of Safer Care training in clinical governance and quality and safety improvement. STEEEP., 

    The why. Why do we need clinical governance and this really doesn't do it service but I do wish to leave time for questions. It just reminds us that in a very complex health care system that we have, that most nations have, patient harm avoidable, harm is everywhere.

    WHO have assess patient time is the 14th leading cause of global disease burden and in the US medical error in our hospitals is the third most common cause of death. And on average and this is true for Victorian hospitals as it is for New South Wales or overseas. About one in 10 and one in every 10 patients is harmed. 

    And about half of that is thought to be wholly avoidable and if we could prevent that harm particularly avoidable harm things that we should be able to avoid we could realize 15 percent of health spending that's billions of dollars a year. In Victoria we could build a new hospital, not that we want to, but we could build a new hospital almost every year in the money we would save if we could prevent the avoidable harm.

    So many years ago or three or four years ago that Kings Fund in the UK and in the review led by Don Berwick from IHI to the review of high performing NHS trusts in England and the described and I've rephrased but they describe what a good hospital looks like. 

    So what is a good hospital look like. It's a hospital's health service that has specific and quantifiable quantified goals for improving hear your hospitals should say.
    And this is how good we are, but this is how good we want to be. The health services used systematic transparent measurement and reporting of progress. So they plotted trendlines and where they are towards their goal and how they were going against them. And they used established methods of quality improvement in a sustained manner so they didn't have one unit using one method somewhere and another unit using another method in another place. 

    And actually this is the approach of Safer Care taken for the whole of state through our partnership with IHI using their so called model for improvement and key and remember those four domains that underpins that describe clinical governance key is that there is clinical leadership and teamwork and engagement of the clinical workforce, and at all levels through the whole organisation, and a culture in which patient care, quality and safety are valued. This is a workforce that gets up in the morning to do good.

    And it's about growing that innate desire to do good and supporting it. And there's been much written particularly in the last few years and particularly the time of this pandemic about fear among our workforces.

    And it's one in a good service is one that calls it out and seeks to measure it and seeks to reduce it. And then good service uses both the workforce and their patients, their customers, to design and redesign workflows. Process is provision of care. Ask the users of your service; What did they want to see improved in their care.

    And encourage you to be asking of your board reports where is the patient voice here and many boards start with the patient story or patient feedback. And increasingly, and Terry and his Department are asking health services to look beyond the four walls because the solutions too much of the burgeoning burdon that we have actually outside the hospital. They lay out in the community and many, many of our services: outreach programs, preventative programs, but also care provision programs community and in the community as Terry said care increasing but particularly driven by the pandemic is done through telemedicine in the patients own home. And that's how it should be.

    And you'll hope that's what missing from this list of what good looks like is compliance. It's not to say the compliance is not important but if you have a compliance approach that drives quality you will fail because everyone who does that fails.

    So this is an approach of continuous improvement harnessing the innate desire of your workforces is to do good when they get up in the morning. Ultimately in terms of governance and the provision of high quality and safe care the board, you as directors, are accountable.

    You're accountable for the clinical governance system and you're accountable for the care that is provided under that system. And the AICD reminders in their clinical governance training packs and what will happen without active clinical governance. So the board cannot be sure that quality is being delivered. 

    It cannot be sure that avoidable harm is being prevented, that risks are being managed, that accreditation will be maintained, that the required external reporting whether it's to us at Safer Care and the government or nationally is happening. And of course at the organization will survive and prosper so that's what things look like if you don't have good clinical governance And of course then that the reverse of that is what you're going to be looking for and your board discussions, safety and quality committee and discussions, etc.

    So the how we don't have time to go into this deeply and we have a specific clinical
    governance training workshop for new board members or existing board members. Again I will refer you to our own framework resource and then it we describe and five key domains Leadership and culture consumer partnerships the workforce risk management and clinical practice. With monitoring essentially quality assurance evaluating and improving as a continuous cycle, continuous improvement goal setting trending monitoring reflecting, changing, improving.

    You will get lots and lots and lots of information. In fact arguably you get too much information in the department. VAHI, that is our sister agency for health information, and ourselves are constantly reflecting and refining how we provide you with information that is digestible and accessible. But I think the overarching comment I would say is if you get information that you don't feel is accessible that is not acceptable to you don't understand it, then put up your hand because there will be loads of other people around the table who don't understand it either and it is not a reflection of lack of knowledge or ignorance if you need to be provided with the information in a way that you can access it and understand it to allow you to ask the
    questions that we expect you to ask as a board director.

    So this is VAHIs premium product. For boards it's the board safety and quality report is a distillation of a number of different reports and it presents a lot of key indicators. Health indicators, reports of adverse outcomes and all sorts of things for you, we hope in a digestible format and Lance Emerson who's the CEO over there and his team continued to refine and improve this and essentially it prompts you to ask what I think are the three key questions. 

    How good are we and in particular are we improving? How good are we compared to others? And how good do we want to be. And that's that goal setting component and you'll see lots of reports of this just happens to be the Staphylococcus aureus blood infection rate and you can see the hospitals are listed by name so publicly open document. If you like you can compare yourself to others that look like your health service.

    So if you're in a small rural service you might not want to compare yourself to Royal Melbourne Hospital. You might want to compare yourself to other small rural services and will show you your performance now. And it will show you performance in the past and it will show you performance compared to others allowing you to ask the first 2 questions and then it's up for you and the health service to say how good do we want to be and plot that road.

    You will at times for sure feel like you're drowning. Some board reports and board quality reports, quality and safety committee reports feel just overwhelming. Just break it up and ask about trends. Can I ask you: Is this getting better or is it getting worse? And how does this compare to the hospital up the road that looks like us. 

    Benchmark yourself against peers. And what is our goal for this measure, and do we have a goal for this measure and are we on track to get it? And if the answers to those are actually the trends are getting worse or not on track or not as good as everybody else what actions are we going to take So you don't have to understand the diseases or the adverse outcomes in detail? You don't have to be clinically skilled. It's just asking very basic questions and so that you have assurance that we have you have a service, you're part of a service that is goal and improvement oriented.

    We also furnish a sentinel event report once a year. It's a report of the most serious adverse events in our system. I don't want to dwell on this but I just wanted to make you aware of it and in the report to date we do not identify hospitals individually and because numbers are small but that's the direction we're heading in and you at the front of the report we give a summary outcome of root cause analysis and in progress towards. 

    But the reason I show this afternoon is that we are on a journey with Health Services who I have to say have embraced this enthusiastically to have consumers on the review committees that review these incidents and having external experts from other services sitting on those committees so you get objective independent advice and so if you have a sentinel event so called root cause analysis report as part of your board papers simply asked the question was there a consumer on this review committee?

    And was there an external expert on this review committee and that will take you immediately to impart the quality of the RCA review?

    And lastly I wish to take us to national standards because we have 8 national standards that are governed by the national by the Australian Commission on Safety and Quality in Healthcare. I'm not going to delve into those standards in detail but many of you, if not all of you, will find your board quality committee reports and perhaps some of your board reports clustered and themed and structured around those eight standards. It is no accident that standard number one is clinical governance, because without good clinical governance and without directors who are skilled and trained in clinical governance, and there is no system by which the other seven can be supported and improved.

    Thank you.

    Thanks very much Euan. So before we start to delve into the questions I just want to do a little bit of housekeeping. First of all I'm sorry that there were some people who had some difficulty logging and I hope you managed to catch up with where we're up to. Secondly we do have a live Q and A. You can post a question using the button on the bottom right of your screen and you can like questions that have already been. asked and that helps us to decide how to prioritize the questions and there has been a question about the slides. 

    The slides will be circulated to all participants after the event and also these questions about a lot of detailed questions which we may not get to today but when you get the package after the event it will point you to resources where that's relevant including the Director's Toolkit which is available on the DHHS website, is a very detailed document to deal with so I think we might start with a couple of questions for Euan. 

    Thanks for your presentation Euan. So just as I look at those questions there is one question about whether Targeting Zero is actually a realistic thing or whether it's just a catch phrase and I'd like your commentary on that and then there is some question about benchmarking and you started to talk about that a bit but could you talk about other resources that people might find helpful in benchmarking their quality and safety performance.

    Thanks Jo. 

    So Stephen Duckett and his committee some would say mischievously and certainly challengingly entitled their report Targeting Zero and the whole point about it was to have zero avoidable harm and there's been much commentary. And those of you who follow the quality and safety literature. There's been much commentary, particularly recently that a relentless pursuit of zero avoidable harm perhaps distracting us from other components of the whole system. Actually chasing us down rabbit holes to prevent very rare events and at the same time we've got substandard care going on in another quarter and I think it goes back to the Institute of Medicine’s description of high quality care - STEEEP - of which only one element was safety.

    I think the key thing about avoidable harm is that we should try and identify, we should try and understand why it happened and we should try and make the system process s changes that will make it less likely to happen again. It is rarely, rarely is it due to a single clinician or single person’s efforts. Usually a clinician’s failure, whether it's a nurse or a doctor and more a midwife or a physio or whoever usually, and if they've had a failure it's because the system has failed them rather than them.

    And sorry draw the second question on benchmarking, there are lots and lots of resources and so there are lots of reports increasingly where benchmarking is a core component. There's a statewide annual maternity report for example that compares now some 20 odd measures in maternity and by individual hospital public and private that you can make those comparisons and increasingly benchmarking is made in real time and many of our services, particularly the larger services, subscribe to organizations like Health Roundtable that provide them with very rich benchmarking reports. 

    I think particularly as new board members, you should just simply be asking the question, do we have data on this that compares to others and probably not accept if the response no, no there's no one quite like us and so we can't compare ourselves 'cause that would be a real thing and reach out. 

    So very recently I did some work with the service that was looking for and benchmarking data for their psychiatric health care facility and through Terry’s aged care unit we were able to provision some data that allowed them to compare themselves with a like service albeit a slightly sort of bespoke a boutique service. 

    So I think benchmarking and I think we're benchmarking is going is actually not just allowing you to compare yourself with someone else but to do it in real time and really bringing the data and timely and in accordance with incident medicines definition and into the hands of clinicians and patients first and foremost 'cause that's where the data matter most and then board members and executives and so on.

    Thanks for that Euan

    Terry, we've got a number of questions that are more in your bailiwick. There's a few questions about budget particularly in the context of this potentially very constrained financial circumstances that the country and the state will find themselves in.

    But how that will flow through to what we expect of boards and management teams in terms of accountability? And there are also some questions about cyber security risk and how the Department may support health services and boards in addressing those risks.

    Thanks very much Jo 

    It's a good reminder actually that I should have added before that one of the responsibilities I think for boards and management during a crisis is business continuity. It’s making sure that while COVID or some other crisis occupies the front of mind we're not forgetting about other parts of the operations and necessary requirements of the organization, so we have been reminded a few times about that during the pandemic.

    So cyber security is one and I mentioned the question on cyber security. Unfortunately, for reasons I cannot explain there are forces that will take advantage of times of weakness like pandemics to launch even greater attacks to try to steal data or compromise organizations operating. We've seen an increase in the number of attempted attacks upon organizations and the health industry. I think is probably now the most popular target for hackers in the world across industries in terms of cyber security so it's an example of why we can't let our guard down.

    Our own experience with cyber security the Barwon health region health services were attacked late last year and a number of critical systems were compromised for a period of time. The most serious attack on the public sector I think in Victoria's history and a few things we learn from that. 

    The first is that cyber security is something that has to be on the board's agenda. It is not something that can be relegated to IT department as if it's just replacing servers. Cyber security requires attention right up the chain and the board needs to be clear on the organization's plans and protections around cyber security. There are good standards. 

    The Auditor General considers that the Department standards on cyber security are as good as anywhere. There's about 70 righty of them. It's about I think 13 from memory that I considered mandatory and absolutely non negotiable in terms of protecting the organization. We’ll disseminate those again but I guarantee you that your executive teams have access to those so please ask for them and ask the question about whether the organization has implemented them, when was the last time we checked to make sure that we were up to speed with those and what's our plan for working our way through the other standards? 

    That's a good place to start and a lot of good works been done to set those out for organizations and provide support. Finances is another example in terms of business continuity. No one is going to come out of COVID better financially than they went in, in any industry.

    But we cannot afford to take our eye off the ball. COVID has both compromised revenue for some organizations and also added on significant cost. It's not uniform across the board so there has been a surges and lapses  in demand for key services but sometimes costs have to be maintained even if activity falls off in revenue therefore falls off to back up those costs so understanding the impact of COVID on the organization’s finances is an example of something that we would expect boards to be across. 

    I'll say something very general about finances because I think I did see a question before about someone who joined the Finance Committee and spent most of the time talking about the department. When you are running a public health service, you have your own balance sheet, but you're also part of the state balance sheet and it it's not unreasonable for organizations finances and financial considerations to be considering the department's signals and parameters because we represent probably the majority or easily the majority of your funding. Ninety percent would be my kind of rough guess in terms of funding. 

    Our rules around funding are going to drive your financial performance to some extent but not determine it. And there are significant levers that local management have in terms of financial control and I do think it's important that boards understand those.

    Our, we have a bit of a Targeting Zero approach to finances to our public health services. We don't expect them to be banks. We don't expect them to be large private enterprises generating large surpluses. But we do expect a balanced budget in ordinary times, acknowledging there are plenty of times when that's not possible and this pandemic is one of those times when that's unlikely for many organizations to be achieved. But we do expect organizations to do the best they can with government funds remembering that every dollar that is spent in the organization could potentially be spent on something else. 

    So if it's wasted that's a dollar that could be spent on service delivery somewhere else, so that kind of approach that you are stewards of taxpayers funds to ensure that they are spent in the best way possible and avoidable costs are reduced is our expectation on boards and board finance committees and executives. 

    I don't have to answer all the questions that were asked around finance. That might be a good sort of general guide.

    Thanks very much, Terry.

    There's a few questions there about, and understandably Terry's posted a comment about directors and officers liability insurance, about medical manslaughter laws and I think when people start to ask those questions that it highlights that you are taking your responsibility seriously. And that's a really good thing.

    But I think also it's important and I'm going to have a go at answering those questions at least in brief as a non-lawyer because I had participated in a training session recently about the workplace manslaughter laws where there were six lawyers who argued with each other. It was a well-meaning effort but the clear message about the medical manslaughter if you have proper systems in terms of Occupational Health and Safety and you take care of your employees in the workplace then you will be meeting your obligations. 

    In terms of whether there's risk of people being charged for medical manslaughter and I think it's a very important role of directors and it will come later in these orientation sessions but Occupational Health and Safety and particularly in the health sector, present with a high risk of occupational violence it's something that boards need to be really aware of and constantly getting reports on diving into and having high expectations of how the management team will create a safe workplace.

    And certainly avoid any sense that normalization of violence are in a health work setting is acceptable. In terms of directors and officers liability insurance then there are standard policies that cover directors. And again if you're a director acting in good faith conscientiously then I don't think that you need to be concerned but again it is important that each director is assured that their organization holds proper insurance and it's a proper question to be asked to make sure that that's true and Terry's answer his report referred to the VMIA, which is another.

    Victoria Managed Insurance Agency that is the body that's responsible for insuring most of us. It provides advice and their website can talk to you about that.

    There's also some questions there about how do boards engaged locally and how do you kind of share experiences with other health services and the answer to that really is two things. So the big thing that's missing from this orientation session today is your capacity to network, to meet people that you've met already or make new connections. But don't let that stop you reaching out to regional health services, neighboring health services, like health services or unlike health services.

    People are generally extremely willing and interested to talk to you about what you're doing to talk about what they're doing and to share resources. And there's an enormous commitment and generosity and I think it comes back a bit to Terry's point that none of us wants to waste time or money If we've got good resources or systems or reporting templates for something or documents about how we do things people generally are very, very happy to share them.

    And it's great to just have a forum to talk to people. Whether it's small groups. So there is a question here about whether the department can facilitate on a regional level and perhaps that can be done but again it's something that you can set up with like health services and generally as I said, you'll find a very receptive response.

    There's a question here which I'm going to refer to you Terry about in the post COVID environment. What's the Department view on rural and regional rationalization and amalgamation collaboration which could lead us a bit to clusters going forward.

    Thanks Jo.

    I think this is a question that gets some people very excited because Victoria has a lot of separate entities and there are some commentators who will say that's the source of various problems in terms of health care delivery.

    And they're welcome to their view. My own view is that there are rural boards are a very important part of connecting to community. I worked in Queensland for sometime and grew up in QLD before I moved to Victoria. 

    Queensland with a relatively centralized state everybody working in hospitals around Queensland where members or employees of one organization. We didn't have boards when I worked in Queensland Health. We had district advisory committees that had zero authority, little influence in my opinion upon government or the dealings of the health service and everybody knew that all roads lead to Charlotte Street in Brisbane as the source of all authority.

    When I moved to Victoria I was a bit frustrated that there was sometimes a lack of coordination, sometimes duplication, sometimes not good sharing, sometimes competition between health services, but particularly in rural Victoria there is a very strong attachment of community to their health services.

    And I think we have to begin by acknowledging that and realizing that's an asset in a strength in terms of health care and the way in which health services respond. 

    Having said that I think that our department and the government actually I think now has, I guess, a way of approaching questions that come up, proposals for new services or new initiatives which would be if it's a good idea in one place why wouldn't it be done the same way across the state.

    Is there a reason why we would make a virtue out of necessity and not first seek to scale something and replicated across the state to ensure that if it were producing good outcomes in one part of the state we are also producing the same good outcomes for everybody regardless of the post code they live in. Likewise, and this kind of gets to my points about finances given that we are spending taxpayers funds, why would we duplicate the infrastructure required for some of
    these proposals and services when if we put our heads together and shared infrastructure we might actually free up funds for direct service delivery instead of on
    administration or managing certain services. 

    So we do now look for opportunities, and I guess over the example of warehousing before but there are others. We look for examples of where things can be shared across services. It doesn't necessarily lead to amalgamation of entities although there's been three, four of those in the last 12 months where services have volunteered to join forces and become one entity. And I think they've been very successful and actually been very healthy conversation for the most part for the communities involved but mostly it doesn't lead to amalgamation of services. 

    What it leads to is entities sharing infrastructure, sharing workforce, sharing oversite in a way that produces both better value for money for government and usually better services for the community. If it leads to less entities down the track that's a by-product of that conversation, but that’s our approach at the moment. 

    I might also just say finally on service delivery it is, and this came up actually in Stephen Duckett’s report, Euan referred to Duckett’s report it is the case that there are some services that are being done in small numbers in certain services that are not safe. Or not as safe as I would be if they were done in larger numbers but that doesn't mean that the department or Safer Care or government are moving services wholesale to Melbourne. 

    What it means is that we have to think about where services are delivered to get scale and that might be in regional centres. It might be that those regional centres then provide services out to rural communities. It might be that it leads to actually coverage in terms of service delivery that are slightly random distribution that we sometimes have at the moment. So a more thoughtful approach to where services are to both ensure safety and ensure equitable access is probably key to service delivery. 

    I don't know if that answer the question though but that's my thoughts on that.

    Thanks very much Terry. There's a number of questions up there about building board capability, about positive board dynamics and about board self assessment and evaluation and I'm going to make a couple of comments on those and then throw it both to Terry and to Euan. 

    But I think it's very important. I mean for a board as an entity the board is responsible for its own culture and I put up at the beginning a set of things about acting with integrity and in good faith and being conscientious and so on.

    But I think the board has to embrace the responsibility for ensuring that there is a positive dynamic and, or if any of you are in a situation where there isn't
    a positive dynamic, then I think it's important that you acknowledge your own discomfort about that. You see if you can find somebody on the board to talk to. So hopefully the board chair or other board directors sort of sound out your perceptions and then have a frank conversation, and if you're not sure whether you can do that or how that would play out then the Governance Unit in the department can offer you some advice.

    If you're a regional area the regional department can offer you some advice and again it's an opportunity to reach out to people that you are on health service boards. Sometimes to talk something through with somebody in a reasonably confidential way helps you to clarify what you're thinking. 

    But I come back to the point that I think the board is responsible for its own dynamic and needs to make sure it's a positive healthy dynamic because one of the board’s key roles is influencing culture in the health care organization. If the board itself doesn't have a positive culture then that’s sending all the wrong messages, so I think it's a really, really critical point in terms of board evaluation.

    There are lots of tools. Some are better than others, some are more expensive than others. Some can be done internally, some facilitated but again most boards have got processes that they've used. There are some recommendations about those processes in the Board Directors Toolkit.

    The reason that I'm chairing this forum today is that I’m the chair of the Boards Ministerial Advisory Committee which advises the minister on appointments to health service boards, and part of that remit is about making sure that the boards have an appropriate skill mix on capability and so the sort of broader area about what sorts of development opportunities need to be available for boards and how can they connect to them is part of our advice but also an important role for the department. 

    So as I said Terry, I'd be interested in your responses about those questions and then I'll ask Euan.

    Thanks Jo, I'll just put one plug in here for the sectors own body. The Victorian Healthcare Association is a membership body which most health services in the state are members of and contribute to. They have a long established Centre for Health Care Governance I think it's called. They have a program of board development. They provide support to boards with self-assessment, with reviews. They hold annual conferences for Directors and I work closely with the department around ways to promote board capability so I would encourage you to check out the VHA's website

    Make contact with, I think it's Jo-Anne Moorefoot is the Executive Director of the Centre for Governance there, and make contact with them and reach out and find out what they can offer to you because they do have a range of programs available. 

    Jo, I agree with your comments about culture. You’re much better equipped than me to talk about this, but my comment would be that I grew up in Bundaberg in Queensland. Bundaberg’s got its own history in terms of failures in healthcare. 

    Our experience locally with failures in maternity services in New South Wales experience that Cambden/Campbelltown the culture of the organization, what it values what it prozes, the messages that come from the top of the organization about whether chasing key performance indicators is the key thing or whether it's valuing the experience and quality of healthcare for consumers in the community.

    Those messages go all the way through the organization and they begin at the
    board level and there is absolutely where it must begin and where it sort of stands
    or falls. It's not the only part of the equation. There's a lot of other work for management and boards to do to ensure that it flows through but if it's not there in the board and not felt by the board, then the rest of it is one hand tied behind its back and really has to fail. So there my comments on culture Jo.

    Thanks very much Terry. Euan?

    Look, thank you and I would echo that I think culture is actually everything and then it goes to some of the questions in the chat line about engagement of clinicians, engagement of consumers, engagement of the workforce more broadly, we're moving out of what I hope we are moving out of what Don Berwick might call a compliance era where it's all measures, it's all reporting against some sort of imposed goal from above or from outside the organization. 

    I agree with Terry that these are this is self generated and culture about improvement and about reaching out to the people to whom your service performance matters most which is the patients and the families that are coming through your doors and signal to them that their values are your values. Because at the end of the day you're only you as a board your executive and then operations and your conditions

    You're only there and to service them. But I would be mindful. Things that we can constantly raise with in our board training sessions is to just touch into your consumers but touch into your clinicians and ask them how are they asked to walk the wards, stop and speak to the junior nurse by the training physiotherapist ask how their day, is what is working well for them and is there anything you find challenging and you as the board you have freedom to walk the wards of your hospital. Maybe less so now during the pandemic. Maybe we might do that remotely but in the normal course of events you should be walking the floors of your hospital and meeting your staff and trying to touching to the culture of your organization because I agree with Terry and Jo the culture is really the foundation stone that's going to drive high quality care. 

    I guess the only other resource I would share is that the Australian commission itself runs particular sessions on governance quality and safety for boards and l would highly recommend those that they've been good products in the past.

    Thanks for that Euan. 

    So I see that we're heading into the last few minutes of this forum so I'm going to ask both Terry and Euan for some final comments about anything else that's there in the
    question chat room or any other final comments that you'd like to make. So first you Terry.

    Thanks Jo.

    I suppose I'll just make a brief comment and just talk about the board's relationship with government and with the department. I would encourage a frank and robust relationship through the chair. I enjoy every contact I have with the boards of our organizations. I think it's easy for boards, and it can seem easy for Directors who don't come from a health background, to rely on management for the relationship with the Department. And they are responsible for more than 90 percent of the interactions with the department. 

    All of the day to day dealings with the department about funding and operations and performance and risks will be ably conducted by your management with myself and officers of the department. But I would encourage through the chair that boards do have a relationship with the department. I think sometimes we and boards can fall into the trap of leaving it out just to kind of managerial relationship and I think it is important to the boards are clear, hear directly from department if they're not clear what it is that department expects.

    The managers can clarify that but chairs are very welcome to reach out and on behalf of their boards to clarify things from myself or other people. Or the minister because it is to the minister that chairs are accountability. They're not accountable
    to myself or other officers the department there accountable directly the government and bought chairs have a responsibility I think to raise questions and concerns and it challenges us that helps us.

    It helps us to calibrate and correct things that we might have got wrong so we work very well with your staff and with your executive teams but I'd encourage you to feel like this an open door for boards to reach out to you and myself
    to other staff in the department and through the chair as well to the minister. If there are things that are not clear I think we all benefit from that kind of interaction and say I've learned from every single one I've had with boards of organization, so please take this as an open invitation and thanks again for your time today.

    And I would echo that I think I would hope that it's an enjoying and fulfilling role for you, particular ones that are joining new to a health service board. And like Terry I think please feel free to reach out.

    We are at our core a learning organization and if there's anything that Safer Care can do for you even if it's just to point you in the right direction of resource is But is anything we can do for you then please reach out to us and we are only here actually to service health services including boards in the same way that you are there to support and guide and your health services to deliver care and we don't have
    the privilege of delivering carousel. So our role is to support you.

    And so if there's anything we can do and then please reach out. We would like to do so.

    Thanks very much Euan. From me just a couple of points. Firstly I would echo the message about reaching out because I think you're not in this on your own, and it's also really important that we don't become insular in our own health services, that we look beyond that and we encourage people from our service to albeit possibly virtually at the moment teams from other health services and share experience. 

    I also just as supporting what Terry said about reaching out to the department or to the Minister. I would encourage you generally, if that's happening, that needs to go through your chair and not direct approach from an individual director and normally should be discussed with the CEO preferably before unless there's some complete breakdown of trust between the board chair in the CEO, which of course sadly sometimes does happen. It is a very serious situation but it's just good courtesy in good communication to make sure that people are informed both before and after you make those contacts. 

    So I hope this session has been useful for people today. I do very much appreciate your time and your engagement which I can assume from the chat line and as I said at the beginning, it's a bit unfortunate not to be able to see you, but that's how it is. 

    I'd like to just remind you that there's a follow up session in August which will be about legal responsibilities and risk management and follow up session in September which will be about funding and accountability in the Victorian health system. And there will be some clinical governance training from Safer Care Victoria, probably later in the year which will be well advertised and at this stage I guess it probably looks like that will also be something that happens virtually. 

    So there are plenty of resource is out there and we will follow up by sending you the slide pack, pointers to some resources and address some of those questions that were in the chat line where there's a clear answer but there are many questions in that chat line that would be great for you to have an opportunity to discuss with your own boards about how can you reach out to others in what ways can you look at building board capability, how can you evaluate your own performance, how can you benchmark what you're doing and so forth. 

    So thank you very much indeed again for participating. Thanks to the team in the department for putting things together. Thank you very much to Terry and Euan. I think the fact that we had such a high lot of registrations today probably says a lot about the quality of the speakers that we had lined up, and so appreciate both of you are here today and your direct and forthright comments to people. 

    So that's the end of the session. I wish you all well. Please stay safe. Wear masks. I think it's good practice everywhere but particularly in those areas where that's mandated from tonight and will look forward to the next meeting of this group. 

    Thanks very much, everyone.

The department is hosting a series of webinars for new and reappointed directors to the boards of public health services and public hospitals. Three webinars are being held during July - September.

The first webinar was held on 22 July facilitated by Dr Joanna Flynn, Chair of the Boards Ministerial Advisory Committee, with presentations by Mr Terry Symonds, Deputy Secretary, Health and Wellbeing, and Prof. Euan Wallace, CEO, Safer Care Victoria.

This is a recording of that webinar.

Reviewed 03 August 2020


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