Norway Case Study

6.4.2 Norway’s patient safety journey

As in many countries, work to improve patient safety and quality accelerated in Norway following the publication of To Err is Human in the United States and of An Organisation with a Memory in the UK at the turn of the 21st century.

However, following the appointment of a new Minister for Health in 2013, the systematic improvement of safety and quality became a key priority. The guiding principle was to use data to guide and evaluate improvement efforts and increase transparency around safety and quality performance:

In 2017, regulations on Management and Quality Improvement in Health and Care Services were established. The regulations were designed to be “very easy to understand, very easy to follow up”, and applicable to leaders at every level of the health system. The regulations directed organisation and system leaders on how to collect and use data for the purposes of improvement, evaluate the results, and continue the improvement cycle.

Openness has been an important principle of the Norwegian health system for years. Since 2012, for example, the Norwegian Directorate of Health has held statutory responsibility for developing, maintaining and disseminating national quality indicators for health and care.

Performance on these indicators was  published in an annual white paper (2013-2020) focusing on the safety and quality of the healthcare system.

These white papers served as annual reports to the Norwegian Parliament, highlighting areas of progress, as well as risks and challenges, “contribut[ing] to greater transparency and a better basis for continued efforts to improve quality and increase patient safety".

They also served an important purpose in consolidating, for the first time, safety and quality data into a single, accessible source:

Data and intelligence for the white papers were drawn from a wide range of sources, including ombudsman reports, financial compensation reports, investigation reports, international benchmarking data, and other local, regional and national level sources.

While it was acknowledged that they could not provide a comprehensive picture of safety and quality, work continued to improve the range of intelligence available – “this [limitation] must not prevent us from continuing to improve quality.” The white papers also supported greater alignment of the system, enabling a shared understanding of progress made and the direction of travel.

In 2019, the Norwegian Healthcare Investigation Board (Ukom) was established to conduct independent, expert investigations into safety issues and concerns. Investigations focus on systems and processes and identify factors that could contribute to patient harm. Ukom’s primary goal is to facilitate learning and to improve the system, without attributing blame or liability. Ukom and its counterpart in England (HSSIB) have become models for conducting such system-wide investigations.

Norway has also modelled how to identify, replicate and scale safety and quality improvement interventions. For example, despite performing well in objective assessments and international benchmarks of healthcare quality, complaints were made to the Minister about the quality of cancer care. Concerns centred on delays from the patient’s first contact with primary care, through diagnosis to the onset of treatment, and on the quality of communication during this time. By replicating a Danish model to redesign the cancer patient pathway, independent evaluation has demonstrated improved perceptions of cancer care from patients, the public and GPs.

6.4.3 What has been learnt?

Replicating improvement interventions

Norway’s work to learn from Denmark’s experience in improving cancer care did not involve copying their patient pathways. Following a deep analysis of Denmark’s work, Norway understood that it was not the pathways themselves, but the process of patients and clinicians working together to co-design the pathways, that made them meaningful, sustainable and relevant to each local context. It was made clear to regions that there would be no money in the initial phase to conduct this work, as the Government did not want it to be seen as a time-limited exercise:

Beyond laws and regulations

There was a realisation that, while laws and regulations played an important role, lasting change would only come about when combined with other levers and initiatives. This approach helped to sustain the focus on quality and safety, while new regulations led to deeper work on culture and leadership. 

Similarly, while work to improve the legislation on patients’ rights – such as by enhancing the rights of children, adolescents and mental health patients – was acknowledged as the right thing to do, “the law didn’t change the practice”. Instead, it was the culture change work with clinicians – for example, using patient stories at major conferences and leadership gatherings – that helped to change the tide of opinion around openness and transparency:

6.4.4 What next?

Deregulation of the sector

The issue of patients’ rights offers important insight on how regulations are being perceived to impede progress. Norway has seen welcome developments in this area over the past 30 years, but there are concerns that the regulations have gone from being too weak to too complicated following years of accumulated legislation – “it’s not feasible for services to fully know the extent of the rights available to patients.”

Such concerns also extend to the system of regulation, where efforts to promote systems-thinking can be undermined by a plethora of regulations that require disciplinary action on professionals. Instead, individualised approaches should be reserved only for those cases where practitioners wilfully or recklessly breach rules, or negligently cause harm.

Taking a whole-person approach

One area that has been identified as a neglected safety issue affects people with addiction and other psychiatric conditions. Life expectancy for people with severe mental illness (SMI) is 20 years lower than for those without them. However, the cause of premature death is typically for issues unrelated to their psychiatric state, such as heart disease and diabetes.

The evidence suggests that people with SMI do not receive, or are unable to access, to same level of care and treatment as the general population (see Section 5.3.1) – “because the health system actually discriminates them, because they only see the addictions”. Instead, a more holistic or whole-person approach would see safety and quality from the patient’s perspective, meeting all their needs, not just some of them.