Overview
The data described above represents a broad brush representation of current patient safety activities within Europe. If one takes the group of questions which could be interpreted as reflecting overall national involvement, Q1, 2, 3, 6, 7, 14 and 16, it is apparent that these key elements are present in a half or more of the countries for which data was collected (90% of the EU states prior to the entry of Bulgaria and Romania).
The approximate proportions for Q.1, having an agreed definition, are two-thirds, for Q.2, having a national agency, about half, Q.3, existence of a taxonomy of terms, about half. Q.6, a national reporting system, about two thirds (this reflects either an established system or systems in development and the same applies to the next question). For Q.7, local reporting, the proportion is about two-thirds (even if patchy), for Q.14, risk management training, about half, and similarly, about half for Q.16, more general training on patient safety.
The other group of questions, which would represent a wider commitment to patient safety activities nationally, is Q8, 12, 13, 15, 17, 18 & 19. With a certain amount of interpretation (using also responses within the Compendium as a guide) these elements are present for roughly a quarter to one half of all respondent countries. Thus, no fault/no blame compensation systems (Q.8), about one third. There is a national policy on whistle-blowing (Q.12) in about one quarter of respondent countries. There are both professional patient safety (Q.13) and patient-led patient safety organisations (Q.17) in about one third. Finally, in about half the respondent countries there are risk or safety managers (Q.15), even if not mandatory), national patient safety campaigns of some kind or another (Q.18) and local peer review schemes (Q.19), even if not specifically focusing on patient safety).
Three questions produce data which is too complicated to allow a simple summary. These are Q.9 (legal disclosure of patient safety information); basically a very diverse range of responses! The same applies to Q.11, on liability arrangements. Q.10, public availability of patient safety data, simply shows that data on clinicians performance is least available, that of organisations more so and national data the most accessible.
The responses from Q.4, 5, 20 and 21, although interesting, were not felt to be helpful in summarised form.
Conclusion 1:
while patient safety is recognised as a health quality priority across Europe, inevitably there is wide variation in the level of implementation of appropriate mechanisms for improvement.
General observations
The ‘health warning’ at the beginning of this document (p.4) underlines the point that, although useful, the results are not of a quality to justify any detailed level of analysis. The misunderstandings of language or terminology high-
lighted in the discussion of results above, under Q.2, Q.12, Q.13, and Q.17-19 make this plain. In some cases the questions were probably not put clearly enough, in other cases, availability of validating data or data from the Compendium allowed determination that some respondents were making errors. Nevertheless, these problems do not undermine the validity of the general overview and indeed, what were just now referred to as ‘errors’ often serve as learning points (as in quality improvement generally).
The overview allows us to stand back from the inherent complexity of the information collected and conclude that certainly the degree of involvement around Europe in the patient safety field that this survey identifies says some-
thing for the enthusiasm that patient safety evokes as a healthcare quality priority. This helps explain the relatively high response level to the project enquiry tools, with not only the questionnaire response rates referred to above, but 18 out of 25 countries i.e. 75%, providing good practice examples and these also demonstrate a wide deployment of patient safety activity.
Inevitably the degree of investment both financially and in institutional engagement will vary and will mirror to some extent the overall development of healthcare services in the country. The lack of convincing examples of good prac-
tice in patient safety elicited from Estonia, Poland, Lithuania or Greece compared to responses from Netherlands, Ireland, Austria and the Czech republic (putting on one side the ‘market leaders’ Denmark and England and Wales) presumably also reflects the national commitment to healthcare quality, which is relatively well-developed in the latter group of countries but at a much earlier stage in the former.
Spain, Sweden, Italy and to a lesser extent France and Germany are countries where regional development of healthcare services appears to be much more influential than national initiatives. In some countries other geogra-
phical differences (e.g. North/South dichotomy in Italy) are well documented. Evidence of these expected variations can be detected in the information so far collected in this study also, even at this ‘first cut’ stage (see p.4, above).
Conclusion 2:
there was a positive response to the mapping exercise from the majority of those approached and overall there is evidence of substantial expertise and good practice, scattered across Europe.
Direction of future work
This last observation raises the question, what next? One possible answer is that the model of mapping activity, gaining consensus on vocabulary, and expert consensus on tools such as indicators, could well be applied to other aspects of healthcare quality across Europe. The evolving public health agenda for the EU would be a guide to this.
Another alternative might be that investment in a particular topic, once made, needs to be capitalised upon. Indeed, if the momentum that has been gained through the Simpatie project is effectively mobilised, further fruitful activity could in itself help mould policy. What implications for future work arise if one follows the logic of the latter argument?
There has been some discussion in recent years around the notion, both at a national level and at the level of the individual healthcare organisation, of a ‘culture of safety’ as a critical factor in the successful implementation and sustainability of patient safety initiatives. The exploration of this concept might be seen as being partly elaborated by the questions in this study on no fault/no blame compensation schemes, public availability of clinical safety data, whistle-blowing, patient safety campaigns and use of patient safety tools. A further study could allow ‘drilling down’ to determine in more detail how the understanding of the concept and steps to implement the relevant elements to promote and sustain it, are reflected in activity within European healthcare services. An underlying assumption of this and similar projects is that of the virtue or benefit of sharing information across country borders, of learning together and from each other, which in itself however is an act of faith until there is more robust evidence for its value.
A second option would involve maintaining and enlarging the databases established in the course of the Simpatie project and further work, for example on the indicator element of the project (work package 4), but the latter no doubt will be dealt with in the concluding report of that work package. The innovative element would be to manage these activities through a network arrangement that drew in representatives of all EU countries, thus enhancing opportu-
nities for information exchange and learning. This idea was discussed at the first EUNetPaS meeting in Paris on 18.12.06, which was enabled by the Commission.
Thirdly, colleagues from Greece have already put forward a very preliminary proposal, focusing on education in quality (using patient safety as a model) thereby taking up the strands of both public education (including patient participation) and the better education of healthcare professionals in this area. Again, certain questions within the present survey touch on topics relevant to education, but a further, targeted study could lead to much greater understanding and agreement across Europe on effective mechanisms to achieve improvement using this approach.
Conclusion 3:
unless some funding is found to allow sustainability of the databases they will rapidly become obsolete. Equally, the network of contacts having now been set up (with potential for further expansion), the cost of refining survey tools and managing the databases in the medium term is relatively small compared to the initial outlay. This then offers excellent value for money as an investment and would actively support the policy direction associated with a European network for patient safety. For example, the network of contacts set in place includes competent authorities for some countries but also provides a means to establish competent authorities for some countries that have not yet identified them.
Final remarks
The targets of the mapping exercise have been met and options for further work identified. However rough and ready they may be, these results can reasonably be seen to represent a potential baseline with which future developments in patient safety across Europe can be compared.
The putting together of the Good Practice Compendium has unexpectedly proved to be probably at least as valuable as the mapping exercise and resultant database. The Compendium’s examples can provide help to other professio-
nals in other countries to avoid re-inventing the wheel. Equally, data from the mapping and the Compendium together can be used in a synergistic way to clarify what is happening in a particular country but also to explore the range of approaches available with which to implement similar initiatives. Following the comment in the previous section, there does nevertheless need to be evidence that assistance is not only available, but that it is actually used. A culture of learning from each other may prove to be as difficult to establish as a culture of safety. What matters is that there are tools to measure whether it is happening or not.
Similarly these results represent very much a first stage in identifying what can happen to the individual citizen when they become a patient in a particular health service. A report that patient safety activity is taking place or is intended does not necessarily imply that patients suffer less harm as a result, any more than an organisation signing up to a patient safety protocol necessarily means that lives will be saved.
Although other work packages of this project systematically review quality tools that can measure the outcomes of patient safety activity, few of the examples that this work package has accumulated involve the use of such tools. Evidence in the future that such measurement routinely takes place (i.e. that a quality system is really operating) would be an obvious indicator that major progress is being made.
Conclusion 4:
the completion of the mapping exercise and good practice compendium provides a foundation for more focused investigation of specific elements within the general overview. The discussion above highlights two particular issues which could form the basis for further study; whether there is transfer of expertise across country boundaries as a result of collaborative projects and whether direct benefit to citizens, as customers of healthcare services, can be identified as an outcome of such collaborative efforts.
