189. The second level of alignment refers to the governance functions’ alignment across levels of care.
While functions aligned across domains contribute to building a governance model, dynamic governance models strive to align functions across different levels of care. Respondents were asked to assess the extent to which governance functions extended across system to organisational and clinical level within their health system. The responses point towards generally strong governance models, but some health systems identify a clear need for improvement (Figure 4.7). Similar to other assessment exercises in this
survey, the responses indicate a clear divide between health systems with a more national approach to system governance and those characterised by system fragmentation and care delivery.
Figure 4.7. Experts’ assessment of alignment of governance functions across levels of care
1 1 1
2
5
3 3
4 4
1
1 2 3 4 5 6 7 8 9 10
Number of countries
As s igned s core assessing the s trength of alignment of functions a cross levels of care
Note: 25 responding countries. Score of 0 corresponds to major room for improvement. Score of 10 corresponds to no room for improvement.
Source:2019 OECD Patient Safety Governance Survey
190. Health systems reporting the highest ability to achieve cross-level governance are those having implemented most of the governance functions in Table 4.1, for example Denmark, Netherlands, Norway and Japan. Another characteristic of these health systems is the defined, system-level strategic vision for safety. The recently published NHS Patient Safety Strategy provides a single aligned vision for patient safety in the NHS across all levels of the system (Box 4.4). Similarly in Wales, safety legislation is supported by the national performance oversight and safety surveillance, supported by national independent inspectorate and patient voice body. In Scotland, the data collection develops an understanding and awareness at the clinical level which further identifies areas for improvement, capacity-building. At the organisational level, the cultural focus on openness and learning support continuous development of safety improvement strategies and maintains the momentum.
Box 4.4. NHS Patient Safety Strategy provides a single, aligned vision for patient safety in NHS England
Cross-level alignment promoted by linking inspection against national standards and stakeholder involvement
The Care Quality Commission (CQC) provides a common thread through its inspection of providers against national standards, supported by the operational activities of NHS England and NHS Improvement and supported by relevant stakeholder organisations. A single oversight framework is in place across NHS England and NHS Improvement, aligned with CQC standards and penetrating through regional teams into the operation of providers and their sub-organisational divisions and units.
Greater coherence and alignment across the system has emanated from the reforms implemented as a result of the Mid Staffordshire Inquiry.
This promotes a focus on the systems approach to patient safety, supported by strong safety cultures, and supports work on further understanding where care is safe and not safe and why. Full involvement of clinicians, managers, patients and the public is key, supported by appropriate training, education and knowledge sharing, and using a consistent approach to tackling key safety concerns using the principles of safety science and quality improvement methodologies.
The NHS Patient Safety Strategy – Safer Culture, Safer Systems, Safer Patients
The new strategy of the NHS focuses on improving patient safety systems and patient safety culture, taking a macro approach to patient safety governance. The strategy outlines three aims – insight, involvement and improvement, respectively referring to improving the understanding of safety by drawing intelligence from sources of patient safety information, equipping patients, staff and partners wits skills an opportunities to improve patient safety throughout the whole system, and designing and supporting programmes that deliver effective and sustainable change in the most important areas.
Among other insight activities, the NHS intends to promote culture measurement, use digital technologies for designing a learning system, and share insights from litigation for harm prevention.
Involvement policies include creating the first system-wide and consistent patient safety syllabus, training and education framework for the NHS as well as ensuring learning from what goes well.
Improvement dimension focuses on delivering programmes on neonatal safety, medication safety, mental health safety and supporting research and innovation for patient safety improvement.
Source: Expert consultations and (NHS England and NHS Improvement, 2019[154])
191. The feasibility of achieving across-level alignment and taking a system-wide approach to safety governance depends on the system governance structure. Health systems considering cross-level alignment as a weakness often have a high degree of decentralisation with insurance-based coverage, e.g. Austria, Belgium, the Czech Republic and Estonia. In Germany, the decentralised structure combined with high numbers of autonomous healthcare-providing organisations complicates alignment of safety governance functions across levels of care. A complex governance model also reduces cross-level alignment in Canada, with health system governance is the responsibility of the thirteen territories and provinces. Large variations are observed at the province level where the same legislation guiding practice both poor and strong performance can be seen when it comes to patient safety governance and patient safety outcomes.
192. Having already identified the room for improvement, Ireland and Luxembourg are actively implementing measures to improve cross-level alignment. Ireland has already implemented its national
monitoring system of hospital and community services, which has impacted the development of safety processes. In Luxembourg, increased transparency around safety activities and patient safety outcomes as well as accountability of healthcare providers is expected to strengthen safety governance.