178. Out of the three levels of alignment, the first explores whether the functions are interlinked across domains. For example, are national standards linked to the development of a set of safety indicators that are frequently collected and used for either internal improvement or external accreditation, inspection or audits of patient safety processes or outcomes?
179. Whether alignment exists, and across which domains, was measured by the following modalities and corresponding scores: yes (score=1), to a certain extent (score=0,5) and no (score=0). With a maximum attainable score of 10, Denmark is the only country among the survey responders with a maximum score. Norway and the Netherlands both reported alignment of functions corresponding to a score of 9. While the Netherlands report no alignment between functions in systems for measurement and monitoring and capacity building (2&4), Norway has fully aligned functions across all domains, but functions are aligned only to a certain extent between key accountabilities and systems for measurement and monitoring as well as capacity-building (2&3 and 3&4) (Figure 4.4).The majority of responding countries, however, report to have functions aligned across domains to a certain extent, for example Canada, Ireland, Slovenia and Luxembourg. Poor alignment is indicated by Switzerland, Estonia and Czech Republic, and the respondents highlight fragmentation of system governance and service delivery as the main reasons for limited or lacking alignment of different governance functions.
Figure 4.4. Alignment of patient safety governance functions in OECD countries
Note: 25 respondents
Source: 2019 OECD Patient Safety Governance Survey
Functions that clearly define roles and responsibilities are the corner stone of governance models in OECD countries
180. Functions ensuring clearly defined roles and responsibilities are most frequently aligned with other functions. Half of the responding countries have fully aligned functions ensuring clearly defined roles and responsibilities with involvement of key stakeholders, followed by key accountabilities and systems for measuring and monitoring (Figure 4.5). Alignments most frequently exist to a certain extent between systems for measuring and monitoring progress, capacity building and key accountabilities as well as involvement of key stakeholders.
0 1 2 3 4 5 6 7 8 9 10
Figure 4.5. Frequency of alignment of functions
Note: Scores calculated by assigning 2 points to functions that are fully aligned, 1 points to functions that are partly aligned, 0 points to no alignment. Max possible score indicating for alignment for all responding countries is 48.
1: Clearly defined roles and responsibilities; 2. Systems for measuring and monitoring patient safety; 3. Key accountabilities; 4. Capacity-building;
5. Involvement of key stakeholders.
25 country responses.
Source: 2019 OECD Patient Safety Governance Survey
181. Particularly strong alignments are found between the domains clearly defined roles and responsibilities and systems for monitoring and measuring patient safety. In Austria, for example, one of the leading principles of Health Care Reform (Zielsteuerung-Gesundheit) is to ensure alignment of the national legislation, through the Federal Health Care Quality Act and Quality Strategy and functions under measurement and monitoring. Similar strong links are reported from Australia, Canada and Sweden where national safety standards are closely linked systems for measurement and monitoring of safety and performance indicators.
182. Governance functions in the domain of clearly defined roles and responsibilities at the system level are also often strongly aligned with internal monitoring of patient safety indicators for continuous improvement and external accreditation or inspection of patient safety processes and outcomes. In Japan, for example, the risk management structure for patient safety is clearly defined in the Medical Care Act and the implementation of the risk management is monitored through on-site inspection. In Norway, the alignment of these functions extends across different levels of care. Every year the Ministry of Health and Care Services defines the goals for reduction of adverse events in letter of intent sent to the regional health authorities. The national system for measurement and training of reviewer teams are set up in all hospitals throughout the country. National-level quality and safety indicators are published in a White Paper and presented to the parliament as well as made available to the general public. In England, the National Quality Board provides a forum where the key NHS oversight organisations come together regionally and nationally to share intelligence, agree action and monitor overall assurance on quality and safety. It publishes national guidance where appropriate, for example on safe staffing and learning from deaths. At the regional level, the NHS England and NHS Improvement integrated regional teams play a key role in monitoring the quality, including safety, of services in the region.
0 5 10 15 20 25 30 35 40
2&4 3&4 1&4 4&5 3&5 2&3 2&5 1&2 1&3 1&5
Capacity-building functions implemented to ensure right skills and competencies are less frequently aligned with other domains
183. This report previously established that capacity-building to ensure right skills and competences are among the most frequently implemented functions across surveyed countries. Nevertheless, incorporating safety in curricula of students, ongoing training of professionals and promoting patient safety culture at the management level are the functions least likely to be aligned with other functions. The survey results further indicate that where there is alignment between capacity-building and other functions, the links are relatively weak. Poor alignment is exacerbated by unclear roles and responsibilities or lack of accountability structures ensuring compliance with capacity building functions. Norway is one of the countries where bridging the gap between the health system and the educational institutions in charge of developing curricula is listed as one of the key challenges. To meet this challenge, four ministries including the Ministry of Health and Care Services and the Ministry of Education and Research joined forces in restructuring the National Curriculum Regulations for Health and Welfare Educational (RETHOS). The aim of RETHOS is to develop curricula that reflect the health care needs and feed into the continuous work on quality and safety improvement. Israel also reports that integrating safety in education programmes and overall governance model remain underdeveloped, while the German government is actively engaging with stakeholders at state and university level to incorporate international best practices in planning and training courses.
184. Links between functions involvement of stakeholders, both political leadership as well as patients, appears to be of weaker character. Even in the presence of strong legislation and policy support to include patients and the public in monitoring and developing safety and quality metrics, there is room for improvement in many countries. Involvement of political leadership remains a challenge in many health systems, particularly in those where functions for measuring and monitoring safety are not aligned to inform government and formal decision-makers about the status of safety within the health system.