The Netherlands Case Study

6.3.2 The Netherland’s patient safety journey

The use of large-scale patient safety programmes has been a defining feature of the Netherlands’ patient safety journey for more than two decades. Launched in 2003, Better Faster (2004-08) was a quality improvement collaborative involving 24 of the country’s 95 hospitals. The programme incorporated techniques from other safety-critical industries, spanning incident reporting and analysis, risk management and safety culture.

Around the same time, a former president of Shell Rein Willems was asked by the Minister of Health to conduct a review of patient safety in Dutch hospitals (2004):

In response, it was made a core requirement of the resulting national patient safety programme, Prevent Harm, Work Safely (2008-12), that hospitals implement a SMS. The SMS required hospitals to meet new requirements in areas such as leadership and management, patient participation, and risk assessment. The programme also included improvement modules across 10 clinical themes, such as wound care and treatment of sepsis.

Independent evaluation of the Better Faster and the Prevent Harm, Work Safely programmes found that the rate of preventable adverse events stayed relatively stable between 2004 and 2008 (1.9 per cent and 2 per cent of hospital admissions), and decreased by 30 per cent to 1.4 per cent in 2011/12.

This decrease equated to more than 10,000 fewer patients experiencing a preventable adverse event. The evaluation concluded that, while it was plausible for the improvement in safety to be attributable to the programmes, it may also have been due to other changes and initiatives during this time, such as the nationwide implementation and oversight of the surgical safety checklist.

More recent analysis of preventable adverse event rates highlighted a plateauing trend. It has been observed that a proliferation of self-assessment reports and improvement plans have led to an increase in bureaucracy and frustration amongst professionals, while a preoccupation with standardisation left health professionals “stuck in a forest of rules”.

The response was to develop a new patient safety programme, Time to Connect (2020-24), which built on ideas from Safety-II (see box below) to accelerate improvements. The emphasis was on “giving health professionals room to take responsibility for improving patient safety themselves".

Safety-I emphasises the importance of making the constituent parts of a system reliable, and of putting barriers in place to mitigate potential failures. Safety-II argues that safety is achieved in complex systems like healthcare by continually adapting to changing conditions and uncertainty.

Safety-II approaches seek to understand everyday work and how safety is maintained. ‘Positive deviance’ is one such approach. It recognises that solutions to common quality and safety problems can already be found within clinical communities.

Time to Connect sought specifically to reduce harm in frail elderly patients and those taking anti-coagulation medication, and to improve multi-disciplinary discussions, including with patients.

The programme embraced the principle of ‘positive deviance’ (see box above) by collecting, assessing and sharing the best examples of practice from across the country. An ambassador network was set up to create and sustain change.

Three hundred and sixty ambassadors continued to work and network, despite the programme’s official conclusion. Evaluation of the programme is ongoing.

6.3.3 What has been learnt?

Spreading safety interventions effectively

The Netherlands’ market-based health system – where providers often compete to provide services – can mean that there is a reluctance to share what is working well. Time to Connect, therefore, focused on building engagement from a wide range of providers and other stakeholders, and used literature on social movements to create viral change.

Storytelling – rather than simply sharing data – became an important way to disseminate ideas and learning. The programme also challenged beliefs that interventions could simply be copied into new sites. Instead, modifications to interventions were seen as positive sources of ongoing learning:

Operational managers played an integral, but sometimes overlooked, role in improvement efforts. They were “the heart and lungs”, providing healthcare professionals with the required confidence and support for their improvement work. Operational managers can facilitate the learning and reflection process by asking questions, creating time and space for discussion, and supporting a psychologically safe environment, which is essential for learning and experimentation.

Taking a systems perspective

Having a healthcare inspectorate that is both the system and the professional regulator has supported a more integrated approach to safety improvement: “if you can only influence one [of professionals and providers], it’s going to be more challenging”.

For example, the regulator reviews investigations conducted by providers into serious adverse events, and challenges findings that attribute cause to human error without exploring system factors. However, it is the healthcare providers, not the regulator, that are ultimately responsible for patient safety:

The Inspectorate understands that it has an important role to play in creating psychological safety in the system. It has worked hard to dispel perceptions among healthcare professionals that it is a punitive organisation, and to encourage openness when adverse events occur. The Inspectorate is also concerned about hospital groups that have seen the number of reported serious adverse events fall, suspecting that issues are going unreported.

6.3.4 What next?

Incorporating the latest safety thinking

Recent work by the Inspectorate has focused on improving the quality of recommendations made by healthcare providers following investigations into adverse events. They found that recommendations were not typically focused on improvement or on reducing the recurrence of similar events. This, together with identifying opportunities to improve providers’ SMSs, has led to the development and rollout of an eight-day safety science training programme for inspectors.

There is a reflection that the Dutch patient safety movement has been too preoccupied with safety in hospitals at the expense of other areas of care, particularly long-term care.

This was evident in the priority areas of the patient safety programmes. The Inspectorate is also examining the law around serious adverse events. The law does not recognise issues around respect or dignity, which are far more likely to occur in long-term care but which would not meet the current classification of serious harm.

Building system maturity

Time to Connect sought, for the first time, to turn ideas based around Safety-II into reality. However, it is recognised that a level of maturity amongst providers, and across the wider system, will be required to implement the ideas effectively.  There also remain several foundational aspects of patient safety – mainly associated with Safety-I principles – to be mastered first. These relate to system-level incident analysis, psychological safety, and non-judgemental dialogue within teams and with patients.

One of the most significant shifts will be an acknowledgement that new levels of safety cannot simply be achieved by adding new rules and regulations. This will require a shift in thinking and practice by the regulator, from checking for the existence of protocols and compliance with them, to looking for the ongoing presence of safety: