The Role Delineation Model as a Safety Check
The role delineation model can provide a useful tool for evaluating some aspects of clinical safety.
The model is not intended to be a complete guide to clinical safety issues. However, it can assist in identifying where there is a mismatch between the services being provided and the clinical support and other resources available (CHEEU, 1993a:2).
Where such a mismatch occurs, it can endanger patient safety. The assessors using the model to evaluate services at Waipukarau hospital considered
that in the health services in the 1990's there is an unacceptably high risk of clinical disasters occurring in hospitals where there is a lack of congruency between the complexity of services being offered to patients and the requisite level of support services for this level (quoted in CHEEU, 1993b:4).
The model also indirectly provides a safety check by considering the experience and "throughput" of hospital staff when assigning levels. It is generally agreed that better results are obtained by those carrying out a given procedure on a regular basis.
It is an unchallenged fact in medical practice today that for some services -particularly highly specialised, highly technical services - significantly better outcomes are able to be achieved at those centres performing more of the service (Core Services Committee, 1993a:7).
This link between volumes and competence applies not only to the surgeon, but also other theatre staff, support service staff, and so on. It is becoming more important as health care becomes more advanced and involves more complex technology, leading to the need for increased specialisation.
This can present a problem for smaller hospitals, who may have difficulties recruiting the specialist staff required, or who would under-utilise the technology and facilities required. Two areas present particular difficulties for smaller hospitals - Anaesthetists and intensive care. Unlike most countries, who use specialist anaesthetists, New Zealand has traditionally made considerable use of GPs in this role. Under the guidelines, this limits the level of surgery that can be undertaken. The recruitment of suitably qualified health professionals is a real problem for the provision of services in rural areas.
It should also be noted here, however, that technological advances have also produced a counterbalancing trend. Many procedures that previously involved major surgery, such as cataract removal, may now be performed on an daypatient basis, requiring a lower level of support services. Such procedures may be suitable for smaller centres, particularly where visiting specialists are used. In other cases, treatment may become more straightforward (e.g. drugs eliminating the need for surgery altogether) so that it may be appropriately carried out by a general practitioner or generalist surgeon.
The guidelines also make a useful distinction between levels of risk. Procedures may be acceptably performed at lower levels on low risk patients, while they should not be attempted on higher risk patients. Thus, rather than being unable to perform a given procedure at all, a hospital may be restricted to performing it only on patients who are good risks. Such an approach is currently widely used for maternity care. An appendix to the guidelines indicates risk factors for various procedures.
"Patch Protection?
It might be questioned to what extent these requirements are based on true safety requirements, or whether there is an element of "patch protection" by specialists and/or larger hospitals.
As pointed out above, it is generally accepted that better results are obtained by those performing more of a given procedure. It is also true that society's expectations of health services are rising, with greater demand for more complex procedures. This trend has resulted in a greater need for appropriately trained staff and suitable support services if a quality service is to be offered.
It is worth noting that these guidelines were developed by government, not by clinicians, although the latter were closely consulted. They were introduced into New Zealand by the National Interim Provider Board (NIPB), precursor to the CHE Establishment Unit (CHEEU, later CHEMU), and are currently used by management, not practitioners. This would indicate that the guidelines have not been "captured" by practitioner interests.
Those consulted did not consider that the guidelines were protecting the territory of a given group of clinicians, indeed the guidelines might be helping overcome the problem from the other direction. Currently there may be a tendency to "hang on" to patients that should, in terms of safety and quality of care, be referred on to another institution. The guidelines may provide an objective method for assessing when such a transfer should occur, with no loss of face to the smaller centre.
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