SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY Key Functions, Approaches and Pathways to Implementation 1 SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY KEY FUNCTIONS, APPROACHES AND PATHWAYS TO IMPLEMENTATION SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY © OECD 2020 2 Copyright page This document and any map included herein are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area. The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law. © OECD 2020 SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY © OECD 2020 3 Acknowledgements This report was produced by the OECD for the 5th Global Ministerial Summit on Patient Safety, which was scheduled to take place in Montreux, Switzerland on the 27th and 28th of February 2020. The work was enabled by a voluntary contribution from the Swiss Federal Office of Public Health. The authors of this report are Ane Auraaen, Kristin Saar and Niek Klazinga. The authors would like to thank the Swiss Federal Office of Public Health and Dr Anthony Staines for valuable support and collaboration during the planning of the Global Ministerial Summit on Patient Safety and drafting of the report. Many thanks also to Pr. Jeffrey Braithwaite, Dr. Ingo Häertel and Dr. Ernest Konadu Asiedu for their insightful feedback and guidance in this process Authors would like to acknowledge and warmly thank the survey respondents and the patient safety governance experts who participated to in-depth interviews during the drafting process of this report. Within the Health Division and the Directorate for Employment Labour and Social Affairs, we are very grateful to Katherine de Bienassis for authoring Chapter 3, as well as Ian Brownwood and Luke Slawomirski for valuable contributions and inputs on this project. The authors also want give many thanks to Frederico Guanais, Francesca Colombo and Mark Pearson for their feedback and support and Hannah Whybrow and Duniya Dedeyn for administrative support. SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY © OECD 2020 4 Table of contents Acknowledgements 3 Executive summary 6 1 Introduction 9 2 Safety governance in health 13 Tailoring safety governance to health systems 13 Establishing patient safety through health systems based on learning, inclusion, and accountability 18 3 Can looking to other high reliability organisations help improve patient safety governance? 26 Is making healthcare “highly reliable” an achievable goal? 26 Safety governance in high-risk industries 28 Application of TAPIC Framework to the Energy Sector 31 Does health still have something to learn? 35 4 System-level safety governance in OECD countries 38 Safety governance in the OECD – how do countries assess the strength of safety governance in their system? 39 Safety governance functions are widely implemented by OECD health systems 41 Building safety governance models that enable continuous learning and improvement 56 Adapting safety governance functions to the TAPIC framework – how does health compare to other high reliability industries? 66 An incremental road to safety governance – country experiences in developing and implementing safety in governance functions 67 Shift of paradigms in patient safety governance towards increased trust and openness 71 5 Conclusion 77 References 80 92 94 FIGURES Figure 1.1. Taking a system approach to patient safety improvement 10 SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY © OECD 2020 5 Figure 2.1. Characteristics of complex adaptive systems 15 Figure 2.2. Complementary use of Safety-I and Safety-II 18 Figure 2.3. Patient safety governance adapted to the TAPIC framework 19 Figure 3.1. Interaction of Organisational Control and Predetermination 28 Figure 3.2. Three contrasting approaches to safety 37 Figure 4.1. Assessed strength of safety governance across levels of care 40 Figure 4.2. Legislation and measurement/monitoring are considered the most important safety governance functions 42 Figure 4.3. Plan-do-study-act cycle adapted to safety governance for continuous learning and improvement 56 Figure 4.4. Alignment of patient safety governance functions in OECD countries 58 Figure 4.5. Frequency of alignment of functions 59 Figure 4.6. Experts’ assessment of the strength of alignment of governance functions 61 Figure 4.7. Experts’ assessment of alignment of governance functions across levels of care 63 Figure 4.8. Redesigning self-regulation 72 Figure 4.9. Broadening slowly, but surely from Safety I to Safety II 74 Figure 4.10. While trust is the goal, punishment is still prevalent in many health systems 75 TABLES Table 3.1. Regulatory and industrial consequences to improve safety following catastrophic events in the petroleum industry 30 Table 4.1. Patient safety governance functions 41 Table 4.2. Functions reported as implemented to clearly define roles and responsibilities at the system-level 43 Table 4.3. Functions reported as implemented for measuring and monitoring progress 47 Table 4.4. Functions reported as implemented to ensure key accountabilities 50 Table 4.5. Functions reported as implemented to ensure capacity-building and the right level of skills and competences 52 Table 4.6. Functions reported as implemented to ensure involvement of key stakeholders 53 Table 4.7. Patient safety governance functions within the TAPIC framework 66 Table A 1. Responding countries 92 Table A 2. Country experts participating in semi-structured interviews 93 Table A 3.Quality governance in the OECD 94 Table A 4. Implemented governance functions in OECD countries 96 Table A 5. Functions implemented to define roles and responsibilities in safety governance 97 Table A 6. Functions implemented to enable measuring and monitoring progress and outcomes 101 Table A 7. Functions implemented to ensure key accountabilities 103 Table A 8. Functions implemented to ensure right skills and competencies 105 Table A 9. Functions implemented to ensure involvement of key stakeholders 108 SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY © OECD 2020 6 Executive summary Box 1. Key Findings 1. There is no ideal patient safety governance model. It is more important that patient safety governance (a) complements overall health system governance and financing, and (b) aligns its individual components and functions. 2. The scope of patient safety governance should include all healthcare settings. 3. Safety governance should foster continuous learning from both harm and success. The focus should broaden from reacting to harm to risk assessment and management. 4. The basis of safety governance must be what is best for the patient, whose perspective should be included in the design, implementation and execution of governance models. 5. Governance should foster a culture of openness and trust among health professionals and regulators. 6. Safety governance should align with and influence other policy areas, notably data privacy/security policies and workforce preparedness. 7. Safety governance should encourage health care financing and investment that result in a better balance between costs made to address errors ( failure costs ) with costs to prevent errors ( prevention costs). Likewise payment systems should reward good patient safety and punish poor patient safety. 8. Political leadership should include patient safety among the top priorities in its health policy agenda. 1. Patient safety is a critical policy issue. Safety failures can result in harm that profoundly affect patients and their family and carers. They also weigh heavily on the shoulders of healthcare professionals and leaders and exert unnecessary pressure on healthcare budgets. Previous OECD reports on the Economics of Patient Safety emphasised that safety failures are largely system failures. Strategies aiming to improve and strengthen patient safety must therefore take a systemic approach – and align with other policy measures. This also applies to governance of safety in health systems. 2. Safety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. A need for a system-wide approach to safety governance is increasingly appreciated. SYSTEM GOVERNANCE TOWARDS IMPROVED PATIENT SAFETY © OECD 2020 7 Legislation is the cornerstone of safety governance models, but stakeholder involvement can be strengthened 3. Safety governance is applied through a set of functions that are implemented across different levels of care and in specific parts of the health system. These functions comprise: defining roles and responsibilities establishing systems of measuring and monitoring safety, defining key accountabilities, ensuring capacity-building of personnel applying appropriate tools and strategies, and involving key stakeholders in safety governance and practice. Such key stakeholders include political leaders, boards of healthcare-providing organisations, health professionals, managers, administrators and, critically, citizens and patients. 4.