We must continue seeking the most effective set of indicators if we are to obtain a more accurate picture of patient safety, writes Lord Ara Darzi
How do you know your local hospital or GP surgery is safe? It turns out there are multiple ways – depending where in the world you live. While health organisations in many countries record errors, monitor staff reports and gather patient complaints, there is no consistency among them. Without consistency, there can be no common understanding of what it means to say a healthcare organisation is safe.
This is not mere semantics. One in 10 patients are harmed when receiving hospital care, seven to 10 per cent of patients acquire a healthcare-associated infection and there are 400,000 deaths a year in the US alone from potentially avoidable errors. We cannot begin to reduce this toll if we cannot agree how to measure it.
A study of 34 hospitals in the US found only 14 per cent of incidents were captured by incident reporting systems. In the UK a similar review found only 5 per cent of incidents were reported
Assessing whether a healthcare organisation provides safe care is not a simple task. There is a patchwork of measures. Most hospitals rely on staff reporting incidents where things go wrong. These can provide useful patterns but they are beset by problems of under-reporting.
A study of 34 hospitals in the US found only 14 per cent of incidents were captured by incident reporting systems. In the UK a similar review found only 5 per cent of incidents were reported.
In April 2015, the Institute of Global Health Innovation launched a survey of measures of patient safety used by health providers in seven countries (India, Spain, New Zealand, Hong Kong, Scotland, Canada, Australia) and by one national commissioning body (NHS England). They are members of the Leading Health Systems network, established by the institute in 2009 to share insights, experience and expertise.
The results were presented in a report by an international team of experts, which is being launched at the World Innovation Summit for Health (WISH) in Doha today and tomorrow.
They showed that all countries relied on administrative data. Staff reported information – such as that gathered through incident reporting systems – also played a critical role.
Patient involvement in patient safety is universally encouraged yet patient feedback as a means of measuring safety is not encouraged
Patient reported information was used less. An exception was the Department of Health and Human Services in Victoria, Australia, which asked patients to report if they had seen hospital staff washing their hands, whether hand washing gels were available for patients and visitors and how clean their hospital room was.
There is a conflict here. Patient involvement in patient safety is universally encouraged yet patient feedback as a means of measuring safety is not encouraged. There are concerns about involving patients directly in this way, in case it causes tensions with healthcare workers. But it should be researched.
Many organisations rely on auditing medical records and case reports. Greater Glasgow NHS Health Board, for example, uses them to create monthly infection control reports, and Vancouver Coastal Health, the publicly funded regional health authority in British Columbia, uses the same source for infection control surveillance.
Apollo Hospitals in India, a chain of private hospitals, uses a combination of administrative data and case reviews to provide 20 indicators across five areas ranging from clinical handover to medication safety. Medical directors and chief executives at each location are expected to review and act on the information to improve safety where problems are identified.
In addition to this sort of qualitative information, the range of quantitative measures used to record levels of harm varied widely. Osakidetza, the publicly funded health service in the Basque region of Spain, had 25 measures of structure and process (eg percentage of surgeries with surgical checklist, staff participating in hand hygiene training) while Counties Manukau Health, one of 20 district health boards in New Zealand, had just two (high risk patients with electronic medical records completed within 48 hours of admission, and pharmacy errors).
Measures of structural characteristics were the least common in the survey. Yet organisational culture is a vital factor in determining the success of any intervention. Process measures were more common.
Outcome measures were the most common in the survey – ranging from 21 in Osakidetza to 11 in the Greater Glasgow NHS Health Board – probably because they are more objective and associated with patient harm. Typically they are driven by local priorities. For example DHHS in Victoria is required to report on a set of sentinel events established at national level.
Tracking a core set of indicators from year to year helps systems identify problems. Measuring preventable deaths should be a universal priority
NHS England uses 38 main measures in total, reflecting structure, culture and outcomes. It has a broad set of indicators because it serves as a commissioner for care across the whole of England.
What should health systems measure? There is no gold standard and no universally adopted methodology, at least not yet. Comparing performance across countries is challenging.
However, tracking a core set of indicators from year to year helps systems identify problems. Measuring preventable deaths should be a universal priority.
Obtaining an accurate picture of patient safety is an essential building block of providing safe care and we must generate more evidence of the most effective set of indicators. Health systems should monitor a standard set of core indicators – including deaths from poor care – to track internal progress, and embed an effective incident reporting system. Trained analysts are needed to monitor the data and identify problems, provide feedback to staff and foster a no blame culture.
This may reveal a darker reality than providers want to see. But we must not turn away. We cannot improve what we cannot measure.
Lord Darzi is a surgeon and executive chair of the World Innovation Summit for Health (WISH), an initiative of the Qatar Foundation.