How public hospitals respond to and use a national serious and sentinel events report: A qualitative study in New Zealand

Introduction

Annually, over 200,000 people enter New Zealand (NZ) public hospitals in the hope they will receive life-improving treatments. ¹ For the most part, timely and appropriate care is given, but around 12% of patients can expect to be harmed in the process of care sometimes resulting in serious disability or even death. ² New Zealand is not alone in this. The 1995 Quality of Australia Health Care Study found that 16.6% of admissions resulted in preventable adverse events. ³ Adverse events in British hospitals have shown that 10.8% of patients experience an adverse event when receiving medical treatment. ⁴

Since 2008, NZ has produced an annual Serious and Sentinel Event (SSE) report. While the collating and dissemination by a government-funded agency of SSEs in a national report is unusual internationally, such reporting to a central agency is routine and via a range of mechanisms in other high-income countries. ⁵ For example, in Britain, serious events are reported to the National Reporting and Learning System (NRLS) an aim of which is to facilitate analysis of risk, to drive learning and improve patient safety. Since 2010, it has been mandatory to report all serious patient safety incidents which come via the NRLS to the Care Quality Commission (CQC) as part of the CQC registration process. ⁶ Australia has its Australian Incident Management System, while in the USA the Joint Commission on Accreditation of Healthcare Organisations is the key agency involved in incident reporting.^7,8

Responsibility for New Zealand's SSE report presently resides with the Health Quality and Safety Commission (HQSC) which has developed policy requiring each of NZ's 20 District Health Boards, ^a which govern and operate public hospitals, to report all SSEs. ⁹ However, historically this has been difficult to monitor because adverse event reporting was voluntary in the NZ health system. The aim of the SSE report is to shine light on serious errors in the effort to improve healthcare quality and safety and stimulate learning across the NZ health sector. The SSE report provides information on falls, clinical management and medication errors. These incidents are represented as a percentage of all patients. Until 2010, the report included out-patient suicides, but the HQSC now considers these events to be different from other SSEs reported, because the report is focused on incidents that have an identifiable cause and are for the most part preventable. ⁹ Once an adverse event has been identified and reported within the hospital, the severity assessment code (SAC) is then used to rate the severity of the event on a scale of 1–4. ⁹ It is mandatory for all SAC rated 1 or 2 events to be reported to the HQSC within 14 working days. ⁹ The hospital is then required to undertake a root cause analysis to identify the events that led to the event happening.^10,11 The completed report must be reported to the HQSC with recommendations to prevent such incidents from reoccurring. ¹¹ The report previously provided an additional file, which contained as detailed as possible information on each identified SAC1 and 2 event. ⁹ However, since the release of the 2011–2012 report, each hospital district now provides this information themselves on their website.

Adverse events do not inevitably signal poor quality of care, nor does their absence necessarily indicate good quality of care. ¹² Often the occurrence of adverse events boils down to faults in management systems within the organisation and more often than not similar incidents are occurring at other hospital organisations. It might be assumed that the SSE report serves as a means to improve hospital systems and that having comparative data would help hospital districts to learn from each other. Yet, little is known about whether an SSE report actually stimulates change and is a useful exercise, both within NZ and in the international context. This article, therefore, reports on a study designed to assess this question.

Methods

Results

Twenty-six individuals from the 20 different hospital organisations were interviewed. Interviews ranged from 30 to 90 minutes with the average interview being 47 minutes. There were 18 different job titles amongst interviewees. Twelve reported straight to the Chief Executive, one was the Chief Executive and the remaining 13 reported to superiors, one or two levels below the Chief Executive. Interviewees had been in their current positions from 3 months up to 11 years. Interviewees generally had a nursing, medical or allied health background but two had come from the quality and patient safety industry.

Discussion

This study found that, rather than having a transformational impact on NZ's healthcare system and providers, the response to an annual SSE report was limited bringing into question its use as a quality improvement tool. This counters assertions made in the literature around the need for wider dissemination of information on adverse events.^17–19 Our findings also indicated that more could be done by NZ's hospital districts in using information from the SSE report which would be to their own and their patients' benefit.

As described in this article, the use of the SSE report elicited mixed views from our research participants. While many saw a limited impact, there were some positives including that it had raised the profile of adverse events in showing these were important and not taboo with significant implications for the individual patients harmed in the process of care. Respondents had indicated that the report helped boost transparency including opening up discussions at national meetings and other forums and facilitating a degree of cross-sectoral learning and reflection on incidents. This said, a surprising finding was that that a majority of hospital districts said they were unable to use information in the SSE report from their counterparts as it lacked the depth required for sufficient lesson-drawing and response generation. A number also said that it was an annual report and that quality improvement is on going. Again, this is not ideal and counters one of the objectives of the report, which is to allow for shared and continuous learning. ⁹

What would be required for the SSE report to have more impact and to produce the transformational change intended of it? First, the place of quality improvement staff in the organisation and structure of the hospital or any health organisation is vital. ²⁰ The participants in this study all felt that the executive level should have a major focus on quality and patient safety. In many hospital districts, this was the case, but in some the position of quality and safety in the organisational hierarchy was still lower than evidence suggested it should be.^20–22 This meant reduced capacity for information transfer from the hospital frontlines to the executive level and vice versa, and reduced potential for SSE report impact and response.

Second, culture is a major driver of quality improvement and improved patient safety.^23–26 The literature affirms that to become safer, hospitals need to build cultures of quality and safety that are committed to respect, clear communication, full disclosure, apology, support, resolution and learning for staff, patients and families when harm has occurred.^23–27 In 2000, Leape and Berwick (2000) identified that building a culture of safety that involves learning, trust, curiosity, systems thinking and executive responsibility would be difficult. Results from our study confirm that multiple hospital districts were struggling to develop an ‘ideal culture’, but a small number were more developed. Reasons for this could be due to the size of the organisation, the allocations of resources within and, very importantly, leadership. According to Leape and Berwick, changing even a few practices and policies necessitates that all personnel share one vision and take personal responsibility for safety, which requires vision and leadership. ²⁷

Third, feeding into culture is the provision of education and training opportunities for continuous professional development.^28,29 In the 2010–2011 SSE report, the HQSC commented on how hospital districts provided education and training to their employees. ⁹ From the participants of this study, it was found that some organisations have more advanced opportunities for professional development than others. Basic orientation training into the organisation for new employees was the only formal training provided by some hospitals. Others provided periodic opportunities for staff to voluntarily attend seminars. Resource issues again influenced a hospital's ability to provide professional development to its staff, suggesting that it would be beneficial for a national approach to training in quality and patient safety.

Of course, a further explanation and intertwined with the aforementioned three points, is provided by the voluminous literature around organisational learning and capacity to absorb knowledge from external sources.^30–33 Studies have variously found that organisational response to external quality improvement initiatives or data can be characterised by conflict and tension and is often haphazard and inadequate. ³⁴ The general explanations for this include the basic commitment within the organisation to resourcing an appropriate response, leadership around this, and presence of organisational objectives which conflict with the demands for response to externally generated information. When multiple organisations across a health system are involved, the absorption and response challenges are exacerbated. ³⁵ Thus, any preconception that information from a national report, as discussed in this article, will result in system-wide change may be naïve. Theories of implementation in complex adaptive systems, which portray change as circuitous and contextual,^36,37 may assist and help with the practical process of garnering an appropriate response in cases such as New Zealand's SSE report.

Conclusion

The main finding of this study is that an annual SSE report has a limited role in improving quality and patient safety in the NZ context. The report has been of value to the public by increasing community awareness of what is occurring in our public hospitals. It has also provided a bridge for national groups to talk about and discuss systems improvement in varying contexts. Very importantly, this study provides a contribution to the literature in which there is limited understanding of how healthcare organisations use national information about SSEs and about the possible impact of such reporting on healthcare improvement.