Queensland Paediatric Quality Council

The Queensland Paediatric Quality Council (QPQC) is an approved Quality Assurance Committee under Part 6, Division 1 of the Queensland Hospital and Health Boards Act 2011.

The purpose of the QPQC is outlined below:

  • To collect and analyse clinical information regarding paediatric mortality and morbidity in Queensland to identify state-wide and facility-specific trends.
  • To make recommendations to the Minister for Health on standards and quality indicators of paediatric clinical care to enable health providers in Queensland to improve safety and quality.
  • Assist with the adoption of such standards in both public and private sectors.

To fulfil these functions, the QPQC has constituted two subcommittees, the Infant Mortality subcommittee and the Clinical Incident subcommittee.

Membership of the QPQC is comprised of people with knowledge and expertise in the areas of paediatrics/child health, nursing and midwifery, forensic medicine, child protection, indigenous health, quality/safety and academic research.

The QPQC Committee meets a minimum of three times per year.

Queensland Paediatric Quality Council staff

  • Dr Julie McEniery – Chair QPQC, Chair IMSC subcommittee
  • Dr Sharon Anne McAuley – Deputy Chair QPQC
  • Dr Kevin McCaffery – Chair, CISC subcommittee
  • Jodie Osborne – QPQC Coordinator, Principal Project Officer CISC
  • Diane Cruice – QPQC Coordinator, Principal Project Officer IMSC
  • Jayde Archer – Senior Project Officer QPQC
  • Melissa Schmiede – Administrative Project Officer QPQC

Infant Mortality subcommittee

The Infant Mortality subcommittee (IMSC) was established in March 2015 to undertake research dedicated to improving infant mortality in Queensland. The IMSC has a statewide research function that aims to generate high quality research evidence regarding the causes and contributory factors for infant mortality in Queensland and the translation of research results into clinical practice.

The QPQC has focussed on the identified excess in infant mortality in Queensland.1,2,3 Between 2007 and 2012 Queensland’s infant death rate was 36% higher than the rest of Australia, with a higher rate than all other jurisdictions except for the Northern Territory. Worryingly, the largest mortality gap occurs among post-neonatal infants, with our post-neonatal death rate 41% higher than the rest of Australia. Deaths in the post-neonatal period are largely due to Sudden Unexpected Death in Infancy (SUDI) (including Sudden Infant Death Syndrome {SIDS} and other undetermined causes), as well as perinatal causes, congenital anomalies, infection and injury.

Most of these infants have prenatal and post-natal risk factors, which if modified, may have prevented the death from occurring. Furthermore, post-neonatal mortality is an important measure of the effectiveness and availability of health services for mothers and children. The QPQC considers Queensland’s excess infant mortality to be unacceptable. Accordingly, a key priority area is the analysis of infant deaths.

The Infant Mortality subcommittee undertakes a detailed review of the circumstances and events surrounding infant deaths, as well as the infant’s clinical records, in an effort to comprehensively identify the factors associated with infant deaths (age range: infants who have left hospital to one [1] year). Deaths that occurred in 2013 are currently being analysed, with a particular focus on SUDI. This will be expanded to include deaths that occurred in 2014, with infant death review ongoing after the completion of this initial retrospective cohort.

Membership of the IMSC is comprised of people with knowledge and expertise in the areas of paediatrics/child health, nursing and midwifery, neonatology, forensic pathology, forensic medicine, child protection, indigenous health, and academic research.

The IMSC subcommittee meets monthly.

References:

  1. National Health Performance Authority 2014, Healthy Communities: Child and maternal health in 2009-2012.
    http://myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Report_Child_and_maternal_health_July_2014.pdf?t=1507075200026
  2. SCRGSP (Steering Committee for the Review of Government Service Provision) 2014, Report on Government Services 2014, E, Health, Productivity Commission, Canberra.
    https://www.pc.gov.au/research/ongoing/report-on-government-services/2014/health/download-the-volume/rogs-2014-volumee-health.pdf
  3. Queensland perinatal and infant mortality taskforce report, 2015. State of Queensland (Queensland Health) April 2015.
    https://www.health.qld.gov.au/__data/assets/pdf_file/0038/659495/qpimt-report.pdf

Clinical Incident subcommittee (CISC)

The Clinical Incident subcommittee (previously the RCA subcommittee) was established in March 2015 with responsibility for analysing themes and recommendations identified in Root Cause Analyses (RCAs) and other reviews conducted in response to serious clinical incidents in Queensland Health facilities involving children and young people aged less than 18 years.

Clinical incidents are events or circumstances which have or potentially could lead to unintended harm to a patient. A clinical incident does not always mean an error has been made. These incidents are classified by Severity Assessment Code (SAC).  A SAC1 classification indicates that death or permanent harm to a patient has occurred, which was not reasonably expected as an outcome of health care. Typically, RCAs are performed in response to SAC1 events.  An RCA is a quality improvement technique, usually conducted by the facility where the event occurred, that explores the contributory factors and makes recommendations for safety improvement. The Patient Safety and Quality Improvement Service (Queensland Health) provides resources for further background. 1,2

The CISC Subcommittee undertakes a detailed analysis of  RCAs, other clinical incident reviews and Coronial documents where available, to identify and describe factors that contribute to death or permanent paediatric patient harm. The review of 2012-2014 paediatric clinical incidents has been completed, and work will commence in 2018 on clinical incidents that occurred in 2015-2106. By using multi-incident analysis methodology and grouping analyses of events with similar themes, important preventive messages have been identified and shared statewide. Other aspects of the analyses have been to review the quality of paediatric RCAs and other clinical incident reviews, with a focus on identifying opportunities for improvement, for example in the strength of recommendations made by the CISC panel.

Membership of the CISC subcommittee is comprised of people with knowledge and expertise in the areas of paediatrics/child health, nursing and midwifery, forensic medicine, child protection, indigenous health, quality/safety and academic research.

The CISC subcommittee meets monthly.

References

  1. Queensland Health Patient Safety Unit.
    https://www.health.qld.gov.au/psu
  2. Patient Safety and Quality Improvement Service 2012, Patient safety: from learning to action 2012. State of Queensland (Queensland Health) April 2015.
    https://www.health.qld.gov.au/__data/assets/pdf_file/0022/423472/lta5.pdf

Publications

Infant Mortality subcommittee. Review of 2013 Queensland Post-Neonatal Infant Deaths: Queensland State Summary Report. Queensland Paediatric Quality Council, September 2018.

Clinical Incident subcommittee. Multi-incident Analysis of SAC 1 Paediatric Clinical Incidents 2012-2014: Queensland State Summary Report. Queensland Paediatric Quality Council, July 2018.

Young, J, McEniery J and Cruice D. SUDI: Infant Sleeping Position is still not reliably reported. Oral Presentation. International Conference for Still Birth, SIDS and Baby Survival, Glasgow, 2018.

McEniery, J and Cruice, D. Sudden Unexpected Death in Infancy: Comparison of neonatal and post-neonatal deaths Queensland Australia. Poster Presentation, Perinatal Society of Australia and New Zealand Conference, Auckland, 2018.

McEniery J and Cruice D. The Voice of the Infant. Cause of death coding does not always reflect what really mattered in the life of the infant who died suddenly and unexpectedly. Poster Presentation, Perinatal Society of Australia and New Zealand Conference, Auckland, 2018.

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