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

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

Experience of a systematic approach to care and prevention of fragility fractures in New Zealand.

This narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health. PURPOSE: This review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030. METHODS: In 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change. RESULTS: In 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services. CONCLUSION: Widespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

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

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

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

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

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

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

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

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

Reducing harm from falls.

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

A new surgical site infection improvement programme for New Zealand: early progress.

Two to five percent of those who have an inpatient surgical procedure will experience a surgical site infection (SSI). The Health Quality & Safety Commission has instituted New Zealand's first national Surgical Site Infection Improvement Programme (the SSII Programme), delivered jointly by Auckland and Canterbury District Health Boards. Through a combined package of surveillance and improvement interventions the SSII Programme aims to reduce the incidence of SSIs in New Zealand hospitals, beginning initially with hip and knee arthroplasties. Within one year of the programme starting there has been a significant nationwide improvement in the timing of surgical antimicrobial prophylaxis (p<0.0001), and the administration of the correct dose (p<0.0001). National compliance with an alcohol-based skin preparation remains high at > 95 %. In this paper we describe the purpose, background, structure and rationale of the programme and provide results to date.

The measurement of New Zealand health care.

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