1 Introduction
1.2 The Norwegian healthcare context
Norway is a parliamentary democracy, divided into three administrative levels: the state, 11 counties and 356 municipalities (Kartverket, 2021;
Ringard et al., 2013). The Norwegian healthcare system is semi-decentralised. The parliament is the national decision-making body. In the specialised healthcare services the responsibility is held by the state, administered by the four Regional Health Authorities, which govern the hospital trusts. The municipal healthcare services have no direct steering line from the national authorities. Therefore, Norwegian municipalities have freedom in the organising of their primary care services. The municipalities are responsible for the provision of all primary care services, including rehabilitation, physiotherapy and nursing homes, midwife, homecare, and after-hours emergency services. They are also responsible for public health and preventive measures (Ringard et al., 2013; Saunes et al., 2017). This thesis focuses on nursing homes and homecare services, as part of the primary care services.
Nursing homes provide 24-hour care, treatment or rehabilitation that is more intensive than patients can receive at home. Nursing homes can have several departments such as long-term care, sheltered care for dementia, rehabilitation and short-term care. The nursing homes employ interdisciplinary professionals such as physiotherapists, occupational therapists, chaplains and general practitioners who hold full-time positions or make visits. Homecare services provide healthcare services in the patient’s home, usually assisting with personal hygiene,
administration of medication, wound and palliative care (Ringard et al., 2013).
The organisational structure of the Norwegian healthcare system is built on the principle of equal access to services for all inhabitants, regardless of their social or economic status, country of origin and geographical location. This long-standing feature of the Norwegian welfare system has been enshrined in national healthcare legislation and strategic documents (Ringard et al., 2013; Saunes et al., 2017). Although everyone formally has an equal right to healthcare, there are variations in the real access to healthcare services as a result of geographical differences, organisation, size and diversity in settlement (Health and care services act, 2011; NOU, 2018). Local needs and conditions are taken into account in the assessment and prioritisation when municipalities offer healthcare services (NOU, 2018).
The Coordination Reform and the municipality’s responsibility
The Coordination Reform from 2012 gives the municipality increased responsibility for meeting patients’ needs for coordinated healthcare services, and the municipalities are obligated to co-finance the secondary healthcare service and are economically responsible for patients considered ready for discharge from the hospitals (Health and Care Service Act, 2011; Innst. 212 S 2009-2010; Meld. St. 47 2008-2009).
The reform was established to ensure patient treatment at the lowest level possible and for healthcare services to be provided closer to where the patients live (Grimsmo et al., 2015). This led to an increase in patients who were ready for discharge and the patients were often sicker and needed more complex treatment and where little flexibility was shown in relation to the municipalities' need for time to plan (Gautun & Syse, 2013; Gautun & Syse, 2017; Glette et al., 2018). In this way, the Coordination Reform put pressure on the nursing homes and homecare services with demands for increased competence and was expected to improve patient safety.
Increased attention on quality and safety in the Norwegian healthcare context
Since 2010, there have been patient safety campaign, programmes and action plans towards quality and safety improvement in Norway (Helsedirektoratet, 2005; Helsedirektoratet, 2017; Helsedirektoratet, 2019; Kunnskapssenteret, 2014a; Kunnskapssenteret 2014b; Meld. St.
10 2012-2013; Meld. St. 11 2014-2015; Meld. St. 26 2014-2015; Meld.
Meld. St. 13 2016–2017; St. 11 2018 –2019; Meld. St. 9 2019-2020;
Meld. St. 11 2020-2021). The specialised healthcare service has been required to participate in these campaigns and programmes, while the participation of municipalities is voluntary. In the municipalities, the Centres for Development of Institutional and Homecare Services (USHT) have played a central role in the dissemination of patient safety campaign work, but it has been up to the individual municipality to decide on its own involvement (Kunnskapssenteret, 2014a;
Kunnskapssenteret 2014b; Forås & Andreassen, 2020). Efforts have been directed towards better coordination of healthcare services, and increased attention to quality and patient safety (Meld. St 47 2008-2009;
Meld. St. 10 2012-2013; Meld. St. 11 2014-2015; NOU, 2018). The increased attention to quality and safety is seen from white papers and actions plans at the national level and includes systematic leadership involvement in quality and safety improvement, a new management regulation (2017) (Forskrift om ledelse og kvalitetsforbedring i helse- og omsorgstjenesten, 2017) and the establishment of The Norwegian Health Investigation Board (2019) (UKOM, 2019).
Reporting systems, quality indicators, and regulatory demands
One thousand of the most severe adverse events were mandatorily reported to the Norwegian Board of Health Supervision in 2020 (Andresen, 2020). Of these events, 700 were from hospitals and 150 from primary care. This used to be a reporting system for hospitals only, but from 2019 it has been mandatory for the municipalities, which are
responsible for providing primary care (nursing homes, homecare, general practitioners). The Norwegian Board of Health Supervision argues there is a large degree of underreporting from the municipalities as this is a new system (Andresen, 2020).
The Norwegian compensation system for patient injuries is an agency under the Ministry of Health and Care Services. It processes compensation claims from patients who believe they have suffered an injury after treatment or failure in the healthcare service. Moreover, several cases with serious consequences for the patient in hospitals, have not been found again in the error reporting system. The Norwegian compensation system describes that the local error reporting system does not provide an accurate picture of the type of injuries that most patients sustain. This makes it difficult to learn from the adverse events and prevent them from recurring, and compromises patient safety (Norwegian Patient Injury Compensation, 2021).
A management regulation on quality improvement from 2017 is based on four elements that are important in a management system: planning, implementing, evaluating, correcting and clarifying the manager's responsibility for quality and safety improvement work (Plan, Do, Study, Act, or PDSA) (Forskrift om ledelse og kvalitetsforbedring i helse- og omsorgstjenesten, 2017). This regulation elaborates on the requirements and responsibility for managers to understand quality and safety challenges and risks and to ensure systematic improvement work. The management regulation is important for managers to provide professionally sound healthcare services and work on quality and safety improvement (Forskrift om ledelse og kvalitetsforbedring i helse- og omsorgstjenesten, 2017; Øyri et al., 2021; Øyri et al., 2020a; Øyri et al., 2020b). This holds managers in nursing home and homecare services accountable for quality and safety improvement (Meld. St. 11 2020–
2021). Crucial in this regard is thus, the competencies of managers within nursing homes and homecare services and their interactions with
municipal and other actors in establishing and implementing a quality and safety agenda within their own organisations, as well as to build improvement capacity.
In terms of national quality indicators, there are fewer quality indicators in nursing home and homecare settings than in the specialised healthcare services (Meld. St. 9 2019–2020). The policymakers and health authorities (e.g., Directorate of Health, Ministry of Health and Care Services, Norwegian Institute of Public Health) have tried to reduce the gap with increased focus on indicators such as hospital readmission rates, waiting time for a nursing home placement, waiting time for homecare services, nutrition, competence level (proportion of employees with education in municipal health care services), dental services last 12 months, hours of doctor per resident in nursing homes, and activities for residents with dementia or disability (Helsedirektoratet, n.d.; Meld. St.
9, 2019–2020).
An important first step in preventing harm in primary care is to understand how often patient safety incidents occur, what type of incidents occur, and what impact they have (Rubin & Meyer, 2021;
Panesar et al., 2016). In Norway, we do not have such a system; this responsibility rests with the healthcare organisations and services themselves.