What follows is a response to the report of the Auditor-General of Ontario, released in early December 2019. The report included a section on my favourite subject, patient safety, and I felt it was necessary to raise some of the questions that were not addressed in the report as well as indicating others that were left hanging, in suspension, unanswered. The proposed Op-Ed piece was sent to several traditional print and television media over a several week period. It was not deemed of sufficient interest to be published.
I will welcome your input – where did I go wrong? Perhaps this is truly a subject of no interest? Perhaps I have completely underestimated the importance of social media as a way of launching ideas, looking for meaningful dialogue.
The A-G’s Report on Patient Safety: A few Unanswered Questions
Ontario’s Auditor-General’s recent report included a segment on Acute-Care Hospital Patient Safety and Drug Administration. The report shines some light on the third leading cause of death for Canadians. The report is sometimes a breath of fresh air, daring to point out that the “Emperor has no Clothes”.
Only 13 of the 123 acute care hospitals in Ontario were visited. In three hospitals there were multiple walkthroughs by the auditors who also reviewed scholarly articles, statistical summaries and reports, and met with “relevant stakeholder groups”.
Some of the report’s findings were shocking – “current practices in Ontario put confidentiality about nurses’ poor performance ahead of patient safety”. The report also documented surprising inconsistencies in the application of expected quality of care standards relating to activities in multiple diverse domains.
The A-G report outlined the six criteria guiding the audit. The report indicates clearly that three of the criteria are not met while three others are fulfilled inconsistently. Of greater interest is what is missing…. some questions that deserve to be answered.
Where is the urgency?
Patient safety events rank behind cardiovascular disease and cancer as the third leading cause of death in Canada. One reasonable estimate indicates that 100 patients die every day from breakdowns in the way care is provided. This is surely unacceptable and constitutes a major public health crisis. Sadly, the report creates no sense of urgency to address this epidemic.
Where are the patients?
It seems inconceivable that a report on patient safety could be conducted without involving patients. Yet among the many “stakeholder groups” there is no mention of meeting with patients, or patient and family groups. During the walkthroughs of three hospitals there is no mention of talking with actual patients. What a shame. We have much to learn from patients. Many groups of patients (and families) that have experienced unintentional harm have developed a powerful consensus – “nothing about me, without me”.
Where is the “College of Hospitals”?
The report identifies the challenges and deficiencies of the various “Colleges” that have evolved to license professionals and to protect the public. The College of Nurses of Ontario received significant attention in the report and deficiencies impacting patient safety are clearly identified. Improvements are urgently needed but at least mechanisms exist which allow complaints to be made and concerns to be raised. The same cannot be said about hospitals.
There is a College of Physicians and Surgeons and a College of Nurses – why is there no “College of Hospitals”? Why is there no effective independent oversight of the facilities that provide care to Ontarians? If a patient or family wishes to raise a concern, to whom can they turn? Hospitals often have internal review mechanisms and staff available to receive complaints. Surely an independent body is needed to avoid any appearance of a conflict of interest (hospitals investigating themselves).
22 recommendations were shared with the Ministry of Health and the Ontario Hospital Association. We learn that “hospitals will review strategies”, or “hospitals take hand hygiene compliance very seriously”, or “the Ministry acknowledges that there may be opportunities to improve”, or “the Ministry will explore the possibility of similar requirements for hospital employees”, and on and on. There is no requirement that a single recommendation leads to concrete action.
What happened to transparency?
The report provides many examples of inadequacies in the way care is organized and delivered. Not a single hospital where “inadequacies” are occurring is identified. Why the secrecy? Do we not deserve to know which facilities are failing to meet standards? Patients and families, seeking explanations for unexpected outcomes, are wrongly told that “privacy concerns” prevent a facility from identifying specific staff. Why is it that the Transportation Safety Board can release details of serious accidents following investigations, and yet we cannot have similar transparency when it comes to healthcare?
The Auditor-General’s report is hint of a breath of fresh air containing huge gaps and disappointments. What is to come of the 22 recommendations? The one “group” with a strong interest to make healthcare safer (patients and families who have lived the impacts of unintentional harm) remains largely marginalized. As a society, we owe them better. They deserve our unreserved support and the resources needed to generate change.
December 17, 2019
Robert Robson, MDCM, FRCP (C)
Assistant Clinical Professor, Department of Family Medicine
McMaster University Faculty of Health Sciences
Healthcare System Safety and Accountability, Inc.