European Supervisory
Bodies and Patient Safety
First results presented by Sandra Eismann (CQC)
Research proposal
Objective:
The study aims to identify and compare the
overall approach European health regulators
take in regulating and assessing patient safety;
and to identify further areas for collaborations
between EPSO (European Partnership for
Supervisory Organizations in Health Services
and Social Care) members.
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EPSO working group
Jan Vesseur/ Dutch Health
Care Inspectorate
Geir Sverre Braut/ Norwegian
Board of Health Supervision
Vaida Momkuviene/
Lithuanian State Medical
Audit Inspectorate
Katja Peters/ Academy of
Public Health in Düsseldorf
Sandra Eismann/ Care
Quality Commission England
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Our early thinking ….
Possible themes to follow up in the questionnaire:
What are the different tasks supervisory bodies undertake in relation
to patient safety (e.g. system(s) for notification of events)?
What mandatory safety related reporting is in place in the different
countries, and what information is published for patients?
In the different countries, which patient safety initiatives were
evaluated and which were most effective?
Focus on hospitals and/or residential settings?
 the survey should be a starting point for future collaborations.
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Defining patient safety
Some focus on adverse events and
incident reporting
Injuries caused by medical
management as opposed to the
patient’s underlying disease process
(Mello et al. 2005)
Others include organisational
leadership, clinical engagement,
work-place safety and other, which
all contribute to patient safety
outcomes.
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Patient Safety Initiatives
Questionnaire – Part A
• What initiative or
policy for improving
patient safety in
hospitals is currently
taking place in your
country?
• What is the role of
your organisation in
the initiative?
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Responses from 15 countries/regions
•Norway
•Netherlands
•Belgium
•France
•Lithuania
•Northern Ireland
•England
•Scotland
•Slovenia
•Estonia
•Ireland
•Denmark
•Germany
•Finland
•Sweden
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Patient Safety Initiatives
Patient safety programmes aiming explicitly to reduce adverse
events or mortality rates
Scottish Patient Safety Programme aims to reduce adverse events
by 30% and mortality rates by 15%
• NHS Quality Improvement Scotland leads and co-ordinates
initiative
A programme to reduce preventable harm and death in 5 years by
50%
• Dutch Health Care Inspectorate assess progress of
implementation
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Patient Safety Initiatives
Wider quality management programmes, including patient safety:
Initiatives include creating a safety culture, reviewing governance structures,
communication and education, sharing learning, include hospital as well as
primary health services
• Lithuania: State Medical Audit Inspectorate measures implementation
• Northern Ireland: RQIA conducts reviews and reports on the quality
of care
• England: CQC used information for its own regulatory activities
• Estonia: Health Board performs surveillance and enforcement
functions
• Norwegian Board of Health Supervision integrates some initiatives
into own regulatory activities
• France: HAS oversees implementation of process
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Patient Safety Initiatives
Patients Rights/ Ombudsman
• Slovenia: HIRS deals with offences under the act
• Denmark: National Board of Health receives information from
ombudsman and undertakes disciplinary sanctions
International/bilateral initiatives
European Union Network for Patient Safety (EUNePaS), includes all
27 member states
• Health Information and Quality Authority is coordinating
agencies for Ireland
EurSafety Health-net for Patient Safety and Infection Protection
• German Dutch co-operation/ Academy of Pubic Health offers
guidance and training
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Patient Safety Initiatives
Projects on patient safety
Pilot projects around quality management and patient safety
• Belgium: incorporated in auditing activity
National project on patient safety led by SALAR in Sweden
• National Board of Health and Welfare in dialogue with SALAR
• Additionally: National Board of Health and Welfare starting
project on supervising providers in regards to infection control
Guidance issued on importance of patient record keeping
• Finland: VALVIRA issues guidance and lectures in healthcare
organisations
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Patient Safety Initiatives - Summary
1. What initiative or policy for improving patient safety in
hospitals is currently taking place in your country?
• Patient safety programmes aiming explicitly to
reduce adverse events or mortality rates
• Wider quality management programmes, including
patient safety
• Patients Rights/ Ombudsman
• Projects on patient safety
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Patient Safety Initiatives - Summary
2. What is the role of your organisation in the initiative?
Measuring progress of implementation
Including information into own regulatory
activity
Coordinating
Proving guidance and training
Leading the initiative
Following up complaints
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Focus on patient safety
Questionnaire – part B
Question 3:
When regulating/ supervising hospitals, do you focus
specifically on patient safety, or is it part of everything
that you do?
When regulating/ supervising hospitals, which areas of
patient safety do you look at?
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Focus on patient safety - summary
When regulating/ supervising hospitals, do you focus
specifically on patient safety, or is it part of everything
that you do?
We focus specifically on patient safety (5)
• Germany, Netherlands, Scotland, Northern Ireland, Sweden
Patient safety is a theme with runs through everything we do (12)
• Lithuania, Norway, Netherlands, England, Estonia, France,
Slovenia, Denmark, Sweden, Finland, Ireland, Belgium
We do not focus on patient safety (1)
• Lithuania
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Focus on patient safety - summary
When
regulating/
supervising
hospitals,
which areas of
patient safety
do you look at?
14 responses
(excluding
Denmark)
0
0.2
0.4
0.6
0.8
1
Infection control
Reporting of adverse
events
Clinical audits
Medicine
Management
Safety and suitability
of premises
Work force
Other
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Infection control
How do you supervise/ regulate hospitals’ infection
control?
• Which organisation in your country is setting
quality standards or developing guidelines in
regards to infection control?
• What are you are assessing in regards to infection
control?
• Evidence gathering and analysis
• Outcome of your activity
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Next steps
1. Draft paper
2. Circulate within working group
3. Final paper
If you have any questions, comments or would like to
see the draft paper please e-mail me:
sandra.eismann@cqc.org.uk
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