Saturday, August 22, 2009

Patient safety -- Canada and France

Patient safety is a key issue in managing and assessing a regional or national health system. There are very sizable variations in patient safety statistics across hospitals, with significantly higher rates of infection and mortality in some institutions than others. Why is this? And what can be done in order to improve the safety performance of low-safety institutions, and to improve the overall safety performance of the hospital environment nationally?

Previous posts have made the point that safety is the net effect of a complex system within a hospital or chemical plant, including institutions, rules, practices, training, supervision, and day-to-day behavior by staff and supervisors (post, post). And experts on hospital safety agree that improvements in safety require careful analysis of patient processes in order to redesign processes so as to make infections, falls, improper medications, and unnecessary mortality less likely. Institutional design and workplace culture have to change if safety performance is to improve consistently and sustainably. (Here is a posting providing a bit more discussion of the institutions of a hospital; post.)

But here is an important question: what are the features of the social and legal environment that will make it most likely that hospital administrators will commit themselves to a thorough-going culture and management of safety? What incentives or constraints need to exist to offset the impulses of cost-cutting and status quo management that threaten to undermine patient safety? What will drive the institutional change in a health system that improving patient safety requires?

Several measures seem clear. One is state regulation of hospitals. This exists in every state; but the effectiveness of regulatory regimes varies widely across context. So understanding the dynamics of regulation and enforcement is a crucial step to improving hospital quality and patient safety. The oversight of rigorous hospital accreditation agencies is another important factor for improvement. For example, the Joint Commission accredits thousands of hospitals in the United States (web page) through dozens of accreditation and certification programs. Patient safety is the highest priority underlying Joint Commission standards of accreditation. So regulation and the formulation of standards are part of the answer. But a particularly important policy tool for improving safety performance is the mandatory collection and publication of safety statistics, so that potential patients can decide between hospitals on the basis of their safety performance. Publicity and transparency are crucial parts of good management behavior; and secrecy is a refuge of poor performance in areas of public concern such as safety, corruption, or rule-setting. (See an earlier post on the relationship between publicity and corruption.)

But here we have a little bit of a conundrum: achieving mandatory publication of safety statistics is politically difficult, because hospitals have a business interest in keeping these data private. So there was a lot of resistance to mandatory reporting of basic patient safety data in the US over the past twenty years. Fortunately, the public interest in having these data readily available has largely prevailed, and hospitals are now required to publish a broader and broader range of data on patient safety, including hospital-induced infection rates, ventilator-induced pneumonias, patient falls, and mortality rates. Here is a useful tool from USA Today that lets the public and the patient gather information about his/her hospital options and how these compare with other hospitals regionally and nationally. This is an effective accountability mechanism that inevitably drives hospitals towards better performance.

Canada has been very active in this area. Here is a website published by the Ontario Ministry of Health and Long-Term Care. The province requires hospitals to report a number of factors that are good indicators of patient safety: several kinds of hospital-born infections; central-line primary bloodstream infection and ventilator-associated pneumonia; surgical-site infection prevention activity; and hospital-standardized mortality ratio. The user can explore the site and find that there are in fact wide variations across hospitals in the province. This is likely to change patient choice; but it also serves as an instant guide for regulatory agencies and local hospital administrators as they attempt to focus attention on poor management practices and institutional arrangements. (It would be helpful for the purpose of comparison if the data could be easily downloaded into a spreadsheet.)

On first principles, it seems likely that any country that has a hospital system in which the safety performance of each hospital is kept secret will also show a wide distribution of patient safety outcomes across institutions, and will have an overall safety record that is much lower than it could be. This is because secrecy gives hospital administrators the ability to conceal the risks their institutions impose on patients through bad practices. So publicity and regular publication of patient safety information seems to be a necessary precondition to maintaining a high-safety hospital system.

But here is the crucial point: many countries continue to permit secrecy when it comes to hospital safety. In particular, this seems to be true in France. It seems that the French medical and hospital system continues to display a very high degree of secrecy and opacity when it comes to patient safety. In fact, anecdotal information about French hospitals suggests a wide range of levels of hospital-born infections in different hospitals. Hospital-born infections (infections nosocomiales) are an important and rising cause of patient illness and morbidity. And there are well-known practices and technologies that substantially reduce the incidence of these infections. But the implementation of these practices requires strong commitment and dedication at the unit level; and this degree of commitment is unlikely to occur in an environment of secrecy.

In fact, I have not been able to discover any of the tools that are now available for measuring patient safety in hospitals in North America in application to hospitals in France. But without this regular reporting, there is no mechanism through which institutions with bad safety performance can be "ratcheted" up into better practices and better safety outcomes. The impression that is given in the French medical system is that the doctors and the medical authorities are sacrosanct; patients are not expected to question their judgment, and the state appears not to require institutions to report and publish fundamental safety information. Patients have very little power and the media so far seem to have paid little attention to the issues of patient safety in French hospitals. This 2007 article in LePoint seems to be a first for France in that it provides quantitative rankings of a large number of hospitals in their treatment of a number of diseases. But it does not provide the kinds of safety information -- infections, falls, pneumonias -- that are core measures of patient safety.

There is a French state agency, OFFICE NATIONAL D'INDEMNISATION DES ACCIDENTS MÉDICAUX (ONIAM), that provides compensation to patients who can demonstrate that their injuries are the result of hospital-induced causes, including especially hospital-associated infections. But it appears that this agency is restricted to after-the-fact recognition of hospital errors rather than pro-active programs designed to reduce hospital errors. And here is a French government web site devoted to the issue of hospital infections. It announces a multi-pronged strategy for controlling the problem of infections nosocomiales, including the establishment of a national program of surveillance of the rates of these infections. So far, however, I have not been able to locate web resources that would provide hospital-level data about infection rates.

So I am offering a hypothesis that I would be very happy to find to be refuted: that the French medical establishment continues to be bureaucratically administered with very little public exposure of actual performance when it comes to patient safety. And without this system of publicity, it seems very likely that there are wide and tragic variations across French hospitals with regard to patient safety.

Are there French medical sociologists and public health researchers who are working on the issue of patient safety in French hospitals? Can good contemporary French sociologists like Céline Béraud, Baptiste Coulmont, and Philippe Masson offer some guidance on this topic (post)? If readers are aware of databases and patient safety research programs in France that are relevant to these topics, I would be very happy to hear about them.

Update: Baptiste Coulmont (blog) passes on this link to Réseau d'alerte d'investigations et de surveillance des infections nosocomia (RAISIN) within the Institut de veille sanitaire. The site provides research reports and regional assessments of nosocomia incidence. It does not appear to provide data at the level of the specific hospitals and medical centers. Baptiste refers also to work by Jean Peneff, a French medical sociologist and author of La France malade de ses médecins. Here is a link to a subsequent research report by Peneff. Thanks, Baptiste.


Coulmont said...

"French medical sociologists and public health researchers who are working on the issue of patient safety..."
It is unfortunately not my field... You may find something in Peneff's "La France malade de ses médecins" or his previous work on French E.R.
There's also a Surveillance Network of Hospital infections : RAISIN
see also

I'm sure that fellow blogger and PhD student François Briatte ( and ) will comment here. If something has been written in French, he has already read it.

Dan Little said...

Baptiste -- thanks for your references about this topic. The link I googled for some of Peneff's work is a good exposure to his research and thinking -- very useful. (The link is included in the "update" in the post.) This is maybe another good example of a case where it's important to gain more exposure to sociology research across the communities of France and the US.

Fr. said...

I read the post on the day Daniel published it online, but did not comment as I could not really contribute anything useful. My field of inquiry does not really touch upon patient safety, except through excessive irradiation during radiotherapy sessions; on that precise aspect of patient safety, a lot remains to be done, as shown by a recent case (if memory serves) where 20+ patients in the South of France got excessive doses from equipment that had been badly set up by the radio technician.

I can say, however, that Daniel's hypothesis seems very plausible to me: "the French medical establishment continues to be bureaucratically administered with very little public exposure of actual performance when it comes to patient safety."

Of course, French officials would contend that overseeing of medical work has dramatically increased and that France is enforcing what is perceived as harsh quality & safety on its medical professions. In comparative perspective, however, France might still be underperforming on patient safety, and its policies are surely less visible than UK ones, for instance (I am not suggesting the UK should be used as an absolute benchmark).

Perhaps you could link the state of pateitn safety, both in legislation and in regulatory practices, to the unfolding of health-related scandals, many of which triggered or renewed interest in patient information and safety. The UK scandals (Bristol Inquiry, Harold Shipman, etc.) do not present the same media/public profile as blood contamination and hemophilia in France. All these episodes are documented, but I have spotted only a few comparisons.

Finally, you might want to check Eurohealth for comparative reports, and the IJQHC for articles (OECD indicators; and a French case study).

That's a long comment, apologies. Second apology, my ignorance of North American policies is appalling, and I am not able to comment on either Canada or the US… but enjoyed Daniel's notes very much.

Dan Little said...

Fr., Thanks for the useful comments and references. Both articles from International Journal for Quality in Health Care are very relevant and I will read them. The 21 indicators of patient safety in hospitals listed in the "Indicators" paper seem largely similar to those that are tracked in US hospitals. The next step is being able to track individual hospitals according to their performance on these indicators; this seems not to be available in France. The "Accreditation" paper is useful as well, in that it gives a flavor for the standards of quality that are now used in accrediting / regulating French hospitals.

Toronto Real Estate said...

In 2005 the US government passed the "The Patient Safety and Quality Improvement Act". The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients. By far this is the choice on how to assure better patient safety. The French system, as many other in Europe, are too secretive about patient safety. Why? I believe it's because the results of the statistics would be catastrophic in comparison with for example US hospitals. So why would the French government voluntarily bash its hospitals in front of the whole world? Thanks you for the articles, interesting reading indeed.

Take care, Elli

Anonymous said...

From Barbara ...

Healthcare-associated infections (HAIs) are a global crisis affecting both patients and healthcare workers. 1.4 million people worldwide suffer from infections acquired in the hospital and HAIs represent an estimated annual impact of $6.7 billion to healthcare facilities.

Here is a useful site that readers are welcome to check out and grab resources from:

3D Ultrasounds said...

Thank you a lot for your great article. I have been looking for such message for a really long time. Not all your content is completely clear to me, but it is definitely interesting and worth reading.