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Cartwright Improvements at
National Women's
Contents
The Cartwright Report was released on
5 August 1988. This Report of the Cervical Cancer Inquiry into activities at
National Women's Hospital focussed on carcinoma-in-situ (CIS) treatment and
research that occurred at the hospital during the 1950s and up-until the early
1980s.
Although the report was very critical of National
Women's, the recommendations in the report have provided a strong impetus for
change within the hospital. There is now a new style of management at National
Women's that supports a women-centred approach and quality systems are in place
to ensure the services provided to women are appropriate.
In 1998, the General Manager carried out an audit
of the hospital's performance in meeting the requirements and intent of the
recommendations articulated by Judge Silvia Cartwright in her report. This audit
outlined what has been implemented at National Women's as a result of the
report. It also included recommendations for making further improvements to
National Women's services.
Some of the changes that have taken place at
National Women's in response to the Cartwright Report include:
 providing
women-centred care
The Cartwright Report emphasised the need for the focus of the service to shift
from the doctor to the patient. National Women's now has a mission statement
that is based on providing women-centred care.
A comprehensive quality of service programme is
now in place. This includes a full-time Quality of Service Manager whois
responsible fo the development and review of policies. Hospital-wide plus
service-based multidisciplinary quality forums include a consumer
representative and regular service audits. There is a focus on collaboration
and liaison within the hospital as well as with other health services and
community groups.
Treatment guidelines and protocols are
developed using an evidence-based approach. Consumers are involved in the
development of policies, guidelines and protocols to ensure a consumer
perspective is included.
A Maori Health Advisor is based at the hospital
as part of the Maori Health Service's vision to recognise the concept of
Mana Wahine in the delivery and planning of women's health services at
National Women's.
respecting
the rights of patients
In response to the Cartwright Report, legislation was passed in 1994 by the New
Zealand government to establish the Office of the Health and Disability
Commissioner. The first Commissioner developed a Code of Rights for Health and
Disability Consumers and established a national advocacy service, which is
independent of health care providers.
The Code outlines the rights of all consumers
using a New Zealand health or disability service. The Code requires that people
be treated with respect and dignity; receive treatment that is free from
discrimination and of a satisfactory standard; be given information in a manner
that is meaningful and can be understood; be informed about their condition,
treatment options, risks and benefits, and other relevant details necessary to
make decisions and give informed consent. People also have the right to have a
support person with them, make a complaint and access an independent advocate.
These rights also apply to teaching and research settings.
Advocates from the local independent Health
Advocates trust are available for women who are using, or who have
used a National Women's service. They are also available to advise staff on
matters relating to the Code of Rights.
Auckland Healthcare has developed a leaflet
called `Your Rights' which is given to everyone using a National Women's
service. This leaflet is based on the Code of Rights and is available in a
range of languages. Copies of the actual Code of Rights and information
about the advocacy service are also available throughout the hospital.
In keeping with the Code of Rights, staff at
National Women's pay particular attention to obtaining informed consent
before any treatment and procedures are carried out. A wide range of
information is available to inform women about various conditions and
treatment options as well as the different services provided by National
Women's staff.
Interpreters in a range of languages are
available and can be organised for women who are in need of one. A Chinese
Liaison Midwife is employed to address the particular needs of
Chinese-speaking women.
Staff also take particular care to respect the
privacy of women at National Women's and to make sure information about each
woman (and baby) is treated confidentially.
Code of Rights audits are carried out to check
that the requirements in the Code are being adhered to and that staff have a
good understanding of the rights of consumers using a health service.
A user-friendly complaints process is now in
place. An information sheet outlines how complaints can be made and all
complaints receive a prompt response. National Women's has a commitment to
taking seriously all concerns and complaints and to making changes that will
improve the service provided to women.
A process is also in place to assist women who
want access to their clinical records. One of the antenatal clinics tried
hand-held records so women were responsible for their own maternity records
during pregnancy. Copies of the records can be available for women to
keep if they wish to, after their baby is born.
A women's health information unit has been
established to provide information on a comprehensive range of health
topics. In addition to pamphlets and posters, a range of other resources are
available for people to use. These include research computer databases, the
International Cochrane Library, the Internet, videos, reference books,
journals, and CD-ROM health programmes. Anyone can use the Unit and
information can be mailed out to people unable to visit. Unit staff are
available to assist people needing information Monday-Friday 9am-7pm. Unit
staff co-ordinate the development and review of on-site written information
to ensure it is up-to-date, easily accessible and consumer-friendly.
An annual report is produced with detailed
statistics about the services provided at National Women's. This information
is available to the public.
improving
gynaecology services
During the Inquiry, the Judge discovered there were differing views within the
hospital about cervical screening as well as the management and treatment
provided to women with cervical abnormalities. The prevailing view was revealed
to be out-of-step with international standards. There was an absence of
effective peer review processes and treatment protocols to provide guidance to
practitioners, and safeguards for patients. This was of particular concern
because of National Women's role as a large teaching hospital. The Judge was
also keen to see a specialist gynaecological service developed at National
Women's to ensure women received good quality appropriate care.
At a national level, the National Cervical
Screening Programme (NCSP) was established in 1989, in response to Silvia
Cartwright's recommendation that a national population-based screening
programme be implemented immediately. This programme is actively supported
by National Women's and the Auckland-based part of the National Cervical
Screening Register is managed by Auckland Healthcare.
The Auckland School of Medicine, which has an
obstetrics and gynaecology department based at National Women's, teaches
students about carcinoma in situ (CIS) according to internationally accepted
standards. The medical school has also introduced ethics and patients rights
into its curriculum.
The cases of all the women who received
inappropriate management of their cervical abnormalities have been reviewed
and appropriate treatment implemented where indicated. National Women's
acknowledges the special duty of care owed to these women and has taken
steps to ease their access to any further assessments and treatment at the
hospital. A review of the clinical management of cervical dysplasia at
National Women's from 1965-1988 has been carried out.
A specialist oncology service for the treatment
of invasive cancer of the genital tract has been established at National
Women's. Specialised training programmes are in place for staff working in
this area as well as a peer review process. Competency standards and a
professional development programme (PDP) have been developed for gynaecology
nurses.
A national protocol has been developed for the
management of women with abnormal cervical smears. National Women's has
established a process for the development of evidence-based guidelines for
the treatment of gynaecologic diseases to provide guidance for health
professionals and to inform women. Information leaflets are also provided on
various conditions and treatments so that women are able to make informed
decisions about their care.
Following a colposcopy review a clinical nurse
specialist was appointed to work with the medical staff within the
Colposcopy Clinic. The clinic carries out colposcopies for women who have
had an abnormal smear with dysplasia. The nurse also provides a smear-taking
service in a clinic set up for women staff members.
The review of National Women's gynaecologic
oncology services looked at ways to improve the service further and in
particular, focus on the role of nurses in the service. This assessment of
the service included contact with other New Zealand and overseas services.
using
an ethical approach to teaching and research
The Cartwright Inquiry revealed a lack of robust ethical review processes to
ensure that research proposals and new treatments to be carried at National
Women's were properly scrutinised. The hospital ethics committee that existed at
the time was an in-house arrangement that failed to provide proper safeguards
for research participants. Criticism was also directed at the Auckland School of
Medicine for involving patients at National Women's in teaching situations
without their consent.
All research carried out at National Women's
must be approved by a North Health regional ethics committee. This is an
accredited committee, with health professionals, researchers, lay, Maori and
Pacific Islands members, that is independent of the hospital. Research
proposals must include a consent form and patient information as well as
meeting specific requirements before they are approved by the ethics
committee.
Informed consent must be given and the official
consent form signed by each participant before they are involved in a
research project at National Women's. Participants are able to change their
mind about being involved in a research study, and can withdraw at any time.
Their health care is not affected if they withdraw from a study.
Auckland Healthcare has established a Research
Development Office with two research co-ordinators to work with and advise
staff involved with research activities. They are available to assist
researchers at National Women's and provide information about the ethical
and other approval processes that are required. They have set up an on-line
manual and produce a monthly report of research activities. They also liaise
with Maori Health Management to make sure Maori perspectives are addressed.
There are approximately 480 research projects registered with the Research
Development Office.
A display board has been set up in the main
entrance of National Women's (outside the Women's Health Information Unit)
to inform people about the research activities in the hospital. Leaflets
about particular studies are also available. There continues to be a high
level of interest in this display from members of the public.
Staff are required to obtain consent before
involving a woman, or a baby in a teaching or training situation. Consent
must also be obtained for situations where observers are present. Although
National Women's is a teaching hospital, women have the right to refuse to
participate in teaching. If a request to be involved with teaching is
declined the care provided is not affected in any way.
Instead of practising on hospital patients,
medical students are now taught vaginal and pelvic examinations through a
gynaecological teaching associates (GTA) programme as a part of their
training.
In
conclusion
National Women's has made significant changes in the years since the release of
the Cartwright Report. The recommendations and the intent of the Report have
been incorporated into the provision of services to women. When the care
provided is disappointing or not in keeping with expectations, there are
effective processes in place for people to complain and for feedback to be used
in positive ways to improve the service. National Women's welcomes and
encourages suggestions that will enhance the way we care for women.
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Ministry of Health