Single Patient Safety Organisation Urged

Responsibility and accountability for national patient safety intelligence in Ireland should be assigned to an independent organisation in order to ensure effective national oversight of patient safety and also to inform policy development, according to HIQA.  Maureen Browne reports.

This new model for coordinating patient safety intelligence is among ten recommendations made by HIQA to improve the coordination of patient safety intelligence to drive patient safety.

They include the implementation and rollout of the national incident management system across the health and social care system and new legislation to support incident reporting, improve data quality and use of incident information.

The 2014 Chief Medical Officer’s report on perinatal deaths in the Midland Regional Hospital, Portlaoise recommended the establishment of a National Patient Safety Surveillance System in Ireland.

HIQA said a review of what was currently being done in Ireland for reporting, analysing and implementing learning from patient safety incidents and adverse events at a national level showed that there was a need for better governance and coordination of national patient safety intelligence in Ireland.

It urges the need to embed a ‘just culture’ within services to ensure timely review of incident information and place an emphasis at a local and national level to learn from such incidents.

HIQA has also reported a need for an effective ICT infrastructure to assist the coordination of patient safety intelligence combined with effective governance arrangements for sharing learning from patient safety incidents locally and nationally. Implementing a national incident management system

It says services must share and act on information about patient safety incidents, and learn lessons to prevent similar incidents happening again.

Dr. Kevin O’Carroll, Acting Director of Health Information with HIQA, said “There is currently no single agency in Ireland with responsibility for the governance and coordination of patient safety intelligence and for sharing learning between the numerous agencies which collect patient safety intelligence. The diffusion of this information is a lost opportunity to provide early warnings of potential patient safety risks.”

The agencies in Ireland which hold patient safety intelligence at present, include the HSE, the HSE Health Protection Surveillance Centre, HIQA, the  State Claims Agency, the National Office of Clinical Audit, professional regulatory bodies, the Health Products Regulatory Authority  and the  Mental Health Commission.

HIQA’s recommendations follow public concern about the safety of Irish maternity services and were, it says,  informed by a comprehensive review of patient safety intelligence systems in operation in other countries and a review of how patient safety intelligence is currently gathered and used in the Irish health service.

“In addition, key stakeholders from across the health and social care sector in Ireland also considered the options for patient safety surveillance in Ireland and helped to shape the HIQA recommendations.

It urges the need to embed a ‘just culture’ within services to ensure timely review of incident information.

Dr. O’Carroll said: “To inform our recommendations, we carried out an in-depth international review of patient-safety surveillance systems in health systems in four countries, Canada (in British Columbia), Denmark, England and Scotland. A key theme from this international review was the importance of coordinating and sharing patient safety intelligence.

“Many of the countries studied as part of this international review are now focusing on triangulating intelligence from the reporting and learning system with other sources of intelligence, such as from coroners’ reports, the public, and public health agencies, in order to identify patient safety concerns. This allows the pooling of patient safety intelligence from a range of sources to ensure a more accurate risk profile is identified.”

“The primary purpose of patient safety reporting systems is to learn from when things go wrong for patients and staff, and to try and prevent such incidents happening again. The most important function of a reporting system is to use the results of data analysis and investigation to share recommendations for addressing patient safety risks. These systems must encourage healthcare workers to actively report incidents through the establishment of a reporting environment which  balances the need to learn from mistakes with accountability.”

A review of governance arrangements for the operational management of the National Incident Management System (NIMS) should be conducted.

The following are the HIQA recommendations:

  1. An independent national organisation should be established with assigned responsibility for the governance, coordination and dissemination of national patient safety intelligence to ensure national oversight of patient safety, risk profiling and to inform policy development.   This organisation should report directly to the Minister for Health.
  2. The Director General of the HSE should ensure that effective governance arrangements are in place for quality and patient safety groups within hospitals, hospital groups and across all community health organisations.
  3. An effective information governance framework should be put in place to support sharing of relevant intelligence between national agencies to enable the coordination of patient safety intelligence.
  4. The HSE’s Knowledge and Information Strategy should be implemented in order to promote interoperability of information systems and to enable the coordination of patient safety intelligence.
  5. A review of governance arrangements for the operational management of the National Incident Management System (NIMS) should be conducted in order to enhance the ownership and responsibility of the reporting system within the HSE and therefore facilitate learning and support a ‘just culture’.
  6. The upgraded National Incident Management System (NIMS) should be implemented in a standardised way across all hospital groups and community health organisations as a priority.
  7. The Health Information and Patient Safety Bill and other relevant legislation should be introduced into law as a priority to allow the introduction of mandatory reporting of specified patient safety incidents in order to promote a culture of quality and patient safety.
  8. Effective information governance arrangements should be put in place to ensure that incident information reported to the National Incident Management System is quality assured.
  9. The use of, and access to, patient safety information reported to the National Incident Management System should be optimised through the use of effective governance structures.
  10. The Department of Health should review and implement previous recommendations made in relation to incident reporting and patient safety intelligence.

The ten recommendations have been approved by the HIQA Board and have been sent to the Minister for Health for the Minister’s consideration.

The process of developing these recommendations involved conducting an international review on patient safety surveillance systems and an ‘as-is’ analysis of current patient safety intelligence systems and structures in Ireland.

Following this, an expert advisory group was convened by the Authority, which together formed the basis of the evidence for the recommendations in this report.

HIQA report and recommendations available: https://www.hiqa.ie/publications/recommendations-coordination-patient-safety-intelligence-ireland