Developing a culture of safety: regulation or education? To help, or at least to do no harm

Abstract

A culture of safety is important for protecting patients from harm. Developing a culture of safety entails changing health professionals’ attitudes and behaviour from reticence and defensiveness about medical error and injury to openness and learning. It is not easy to change people’s attitudes, but both regulatory and educational means have proved effective in the past. This thesis assesses two potentially positive influences on the development of a culture of safety in New Zealand health care settings: New Zealand’s distinct medical regulatory structure and a patient safety educational tool. Instead of the more typical tort-based malpractice system, New Zealand has a no-fault accident compensation scheme, which bars suing for compensatory damages, and separate medical professional accountability processes. In 2005, ‘no-fault’ compensation reforms shifted the focus of the compensation scheme from identifying fault to rehabilitation and injury prevention. This thesis focuses on professional attitudes and diverse evidence about patient safety in primary care. It is therefore not suitable for hypothesis testing but is amenable to a qualitative and discursive assessment of, firstly, the punitive nature of New Zealand’s medical regulatory system; secondly, changes in both punishment and medical professional accountability following the 2005 no-fault compensation reforms; thirdly, the patient safety data generated under the reformed compensation scheme; fourthly, whether these data can be analysed to identify learning for patient safety; and, fifthly, whether a UK safety culture educational tool could be adapted to the New Zealand general practice context and used to improve safety culture. Findings suggest that because punishment lies in both the process and the penalty, New Zealand’s medical regulatory system may not be perceived as less punitive than a malpractice system. Punitive outcomes for doctors decreased following the no-fault reforms but patient complaints increased, making the environment not less punitive (subjectively) overall. The increase in patient complaints reflects increased demand for accountability, but following the no-fault reforms medical professional accountability decreased, as indicated by fewer doctors being referred by ACC to the Medical Council, fewer complaints being investigated by the Health and Disability Commissioner, and fewer doctors being held to account by either the performance review or disciplinary processes. It is not possible to say from this analysis whether doctors are adequately held to account under New Zealand’s current medical regulatory structure. More patient safety data are generated under the reformed compensation scheme, suggesting that the reforms have engendered openness about medical injury. These data are generated without relying on health professionals to report incidents and although they lack information about injury preventability, they may be analysed to identify lessons for patient safety. Analysis of treatment injury claims and ACC harm reports data confirms medication as the major threat to patient safety in primary care, but most medication events from this no-fault compensation perspective are not associated with error. This suggests that to improve patient safety in primary care, we may need to look beyond reducing medication error to reducing medication treatment overall (where possible). Provider feedback about ACC reported events yielded helpful suggestions for improving patient safety but also revealed a continuing tendency, in some organisations, to focus on individual blame. The UK safety culture tool seemed to adapt well to the New Zealand general practice context and its use is supported by New Zealand’s medical regulatory structure. The tool educates practice personnel about the dimensions of patient safety culture and facilitates communication about patient safety issues. The influence of New Zealand’s distinct medical regulatory structure on health care ethics and practice is not yet fully understood, but findings from this project suggest that the no-fault accident compensation scheme engenders openness about medical injury and creates novel opportunities for learning to improve patient safety.