Patient Safety & Health System Governance: A Review of Approaches to Governing the Physician Sector

Investigator Name: Dr. Samuel Shortt

Project Completion Date: February 2006

Research Category: Synthesis

Institution: Queen's University

Project Number: 6795-15-2003/5760004

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Summary

This project was initiated in response to a Health Canada RFA that asked:

"What are the current definitions, concepts and trends related to governance and health care quality in general, and patient safety in particular, in Canada and other countries?"

Conceptual Framework

Patient safety is the reduction and mitigation of unsafe acts within the health care system, as well as through use of best practices shown to lead to optimal patient outcomes. Quality of care may be defined as the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. The complex concept of governance may be succinctly defined as actions taken to steer society toward identified goals. It is understood as something far broader than an activity undertaken by government alone; it is now viewed as concerned with creating conditions for ordered rule and collective action, often including agents in the private and non-profit sectors. The essence is the focus on governing mechanisms that do not rest solely on the authority and sanctions of the government.

A variety of tools are available by which to implement governance. We adopted the approach suggested by Lester Salamon to evaluate the appropriateness of tool selection. He recommends the following five criteria:

1. Manageability: Is a policy approach implementable and how readily is it operated?
2. Effectiveness: Does the approach achieve its intended objectives?
3. Efficiency: How do outcomes balance against costs?
4. Equity: Is the approach fair to all those it effects?
5. Political legitimacy & feasibility: Does the approach have the required political support and will citizens view it as legitimate?

We initially conceived of those factors responsible for influencing patient safety as a series of concentric circles with the patient at the centre and then arranged according to the immediacy of contact starting with providers of all types, then organizations, and finally, the broader health care system. The research team then made an a priori list of all approaches to patient safety currently in use across all sectors and ensured completeness by comparison with an extensive compilation from the Agency for Healthcare Research and Quality in the United States. The approaches were then grouped into seven generic categories of governance processes; the relevance and comprehensiveness of these domains was confirmed by comparison to those identified by other policy commentators. When the three health system sectors and the seven generic mechanisms are combined, they create a matrix in which the twenty-one cells can be populated with examples of tools of governance. The project used the framework outlined above to describe how health system governance impacts on patient safety. However, in order to render the subject manageable within the time allotted, we confine our focus largely to the provider sector and, more specifically, to physicians. Data on the nature, domestic and international use, and evaluation of the seven approaches to provider governance was obtained from a lengthy systematic search and review of published and grey literature.

Principal Findings

Informing

Informing providers of relevant and timely information was hypothesized to be an effective process to alter their behaviour in positive ways so as to enhance patient safety. The evidence from systematic reviews establishes that the provision of point-of-care information to providers can enhance clinician performance. Though the impact on patient outcomes is more difficult to document it appears positive. Despite a number of challenges, especially achieving collaboration across all levels of government and sectors of the health system, this approach to provider governance is likely to prove modestly effective in enhancing patient safety.

Guiding

We hypothesized that authoritative guidelines could assist practitioners and institutions to provide optimal care and provide a standard against which to compare performance as a method of enhancing quality and patient safety. The major systematic reviews of clinical practice guidelines clearly confirm a modest to moderate positive effect on care process and patient outcomes. To date government has left the elaboration of guidelines to providers; however, there are opportunities for collaborative ventures. The evidence suggests guidelines are an effective governance tool for providers that will enhance quality and safety.

Educating

The study hypothesized that patient safety and quality of care could be enhanced by ensuring the provision of continuing medical education. Systematic reviews of the literature confirm that appropriately designed and implemented continuing medical education [CME] can have a positive effect on physician practices and on patient outcomes. Traditionally, government has not played an active role, preferring that CME remain the responsibility of provider organizations. However, there are clear opportunities for collaboration, suggesting the utility of CME facilitation as a governance tool to enhance patient safety.

Accrediting

Formal processes for periodic relicensing of providers and of accrediting institutions, this study hypothesized, could define the minimum levels of achievement necessary to allow individuals and organizations to provide safe health care. There is scant empirical data by which to validate this proposition. However, the Canadian experience with peer review suggests deficient practitioners can be identified successfully, while the American approach to board certification indicates practitioners achieving periodic recertification provide superior care. Creating an effective relicensure program requires a complex alliance among providers, government and the public; however, there is at present insufficient evidence to determine whether relicensure programs will prove an effective tool of provider governance to enhance patient safety.

Incentivizing

It was hypothesized that providers and institutions can be offered financial incentives to adjust behaviour so as to enhance patient safety. A review of the literature on the relationship between provider remuneration method and quality of care failed to find evidence of a consistent quality advantage for a specific payment format across most types of care. Indeed, the influence of a particular payment method appears to be highly variable according to time period, jurisdiction and organizational setting. Designing free-standing financial incentives that are correctly targeted, of sufficient magnitude, and do not have perverse results has to date proven elusive. These often-employed approaches to provider governance do not appear useful for enhancing patient safety.

Reporting

It was our hypothesis that reporting provider, organizational, or health system performance to the public and to authorities with the capacity to require action would expose inadequacies and lead to interventions to improve patient safety. Performance reporting is most extensively developed in the United States where studies suggest the public pays little heed to such reports, and physicians do not modify their clinical behaviour to address identified deficiencies. However, some organizations may respond to reports with changes that enhance quality of care. The degree to which these findings are generalizable to jurisdictions beyond the United States is unknown. The lack of evidence of an impact on quality and safety renders it at present a provider governance tool of little value.

Disciplining

It was hypothesized that disciplining individuals or institutions shown to have provided inadequate care may enhance safety by removing sources of deficient performance, acting as a deterrent to others, and creating learning experiences. Providers are subject to the disciplinary processes of their licensing bodies; however, they are also disciplined by the laws governing malpractice. Legal scholars argue that malpractice litigation is not an effective deterrent to sub-standard care and promotes harmful "defensive medicine", an approach to medical practice characterized by the ordering of clinically unnecessary tests and procedures designed to protect against possible litigation. The most frequently encountered suggestion for change is the introduction of a no-fault system as in Sweden, which is said to offer the potential for analyzing and learning from mistakes, a process that will enhance patient safety. This reform might prove to be a useful approach to provider governance; however, the present system does not improve, and may actually inhibit, efforts to enhance patient safety.

Recommendations

1. The Federal government should treat developments to governance processes to enhance patient safety in a fashion similar to its recent initiative to reduce waiting times; that is, Federal funds should be made available to provinces for initiatives addressing any of the three processes found to be modestly to moderately effective or the two processes for which effectiveness is currently unknown.
2. To remedy the deficit in empirical evidence about governance processes, increased research funding should be made available through, singly or in combination, the Canadian Patient Safety Institute, the Canadian Institutes of Health Research, Health Canada, provincial ministries of health, and provider organizations.
3. The Federal government should confirm its commitment to Canada Health Infoway, with the expressed purpose being the development of national standards and technologies for point-of-care information systems.
4. Federal assistance should be offered to provinces to implement electronic information systems in hospitals, pharmacies and community-based care venues.
5. The Federal government should collaborate with, or facilitate the work of, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada in developing effective continuing education programs based on the best available clinical practice guidelines; as a participation incentive consideration should be given to awarding physicians who successfully complete such programs some form of income tax relief.
6. The Federal government should collaborate with the Medical Council of Canada, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and provincial licensing bodies to develop valid and feasible approaches to competency evaluation.
7. The Federal government should collaborate directly with provider organizations by providing funds for clinical practice guideline development, dissemination, piloting and particularly, evaluation.
8. Provincial governments should continue to develop care models that give physicians the time and financial assistance necessary to participate in continuing educational activities.
9. Provincial governments should collaborate with their medical licensing bodies to develop and fund effective relicensure programs. Direct subsidies might be offered for program development. Individuals successfully achieving relicensure might have the cost reimbursed as in the current Ontario program to partially reimburse malpractice insurance premiums.
10. Provinces should implement electronic patient records with decision support capacity in hospitals, pharmacies and community-based care venues.
11. Provinces should identify priority areas for the introduction of clinical practice guidelines and work with the appropriate provider groups to develop, disseminate and evaluate these instruments.
12. Provincial governments should be encouraged to collaborate in reviewing the merits of no-fault approach to medical errors.

The views expressed herein do not necessarily represent the views of Health Canada

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The print version of the full report can be obtained in the language of submission from the Health Canada Library through inter-library loan.