Safety ideas are not acknowledged in Queensland’s RCA legislation, while quality activities frame the conduct of the RCA. This is problematic because quality improvement activities and safety agendas are different (Sheps & Cardiff, 2011) and this is central to the shared social views of the RCA because there is no accountability directed to safety principles. The challenges of quality legislative agendas rather than safety are addressed next. The avoidance of safety in the legislation is complex and complicated by an
“enabling” component (Health and Other Legislation Amendment Bill, 2007, p. 2). It is argued here that ‘enabling’ characteristics deconstruct notions to achieve system safety through processes that select some SAC 1 events to undergo RCA. In particular, a selection process is determined at a governance level and it is at this point that bureaucratic agendas introduce counterproductive safety agendas. More specifically, ‘enabling’ processes fail to address the systemic and recurring nature of harm because some SAC 1 incidents are reviewed drawing on RCA methods and some SAC 1 incidents are reviewed by other methods. The problem is that because SAC1 harm shows a pattern where human mistakes contribute to harm, the collaborative nature of harm is disregarded. As such, safety agendas that are dynamic and interactive (Weick, 1998) are ignored through enabling characteristics.
Enabling conditions silence regulatory agendas to achieve safety because the legislation “[did] not mandate that an RCA be conducted for a reportable event” (Health and Other Legislation Amendment Bill, 2007, p. 2). While a Commissioning Authority may
select SAC 1 events to undergo RCA and the enabling characteristics may be considered favourable in ways to reduce the number of RCAs conducted, enabling practices are in contrast to the social perception to review an event and this is politically influenced. By way of example, 324 Reportable events were recorded in 2010-2011 yet only 41% (Queensland Health, 2012) of these proceeded to RCA. This declining trend of completed RCAs has widened in 2014 (Queensland Government, 2013). The problem is that “safety competes with other agendas” (Tamuz & Harrison, 2006, p. 1656). This is more clearly addressed by Casler (2014) who argues that social rivalry of an organisation’s safety agenda and election agendas is a fine balance.
Activities of pubic organisations must reflect the will of the electorate and the organization must be accountable for its actions . . . in a larger sense organizations are not free to choose arbitrarily the products and service to be provided. An organization that ignores the electorate’s wishes will soon not have the political foundation needed to exist (Casler, 2014, p. 235).
Casler (2014) argues from a high reliability perspective, and notions of electoral promises that influence healthcare and re-election appear consistent. A recent example of this is electoral statements that announce to improve surgical waiting times for eligible public undergoing elective surgical procedures (Queensland Government, 2014). The point of this example is that activities of the Government to reduce surgical waiting times are socially desirable. Returning to Casler’s (2014) quote above, these actions that aim to reduce surgical waiting times, are viewed to be the will of the voting public and will encourage votes prior to an election in 2015. Conversely, and in relation to enabling characteristics, flexibility in legislative provisions that prompt a selection of services ignores the will of the public to improve patient safety and this is confusing for the electorate. While the enabling features of the legislation are mostly hidden, when patient safety issues arise, social tensions that demand to improve patient safety influence change in government. Thus, an erosion of safety (Vaughan, 2005) undermines the notion of public trust.
A further predicament in the legislation is the use of legislative language that provides a discretionary approach to safety agendas. It is common that legislative language contains words such as ‘must’, ‘shall’, and ‘will’. These terms remove the discretion to perform an act because there is no legislative option but to follow the conditions, while words like ‘may’ provide a level of discretion. This is an accepted feature of legislation and is a significant barrier that influences a lack of system safety in the RCA because first there is an option to undertake an investigation of a harm event and second central elements that comprise root cause analysis may be avoided. The point of the legislation is to provide a
State-wide approach to regulate the RCA through standardised processes (Welch & Jenson, 2007) and to reduce variation. Yet, the data revealed that the RCAs standardised processes, identification of latent system failures to construct root causes were collectively avoided. To that end, Shortell and Singer’s (2008, p. 445) publication, “Improving patient safety by taking systems seriously” is aptly entitled because not only are tenets of the culture of healthcare central here but legislative agendas in Queensland provide an optional approach to safety agendas. As such, a systems approach is silent. Importantly, there is an illusion that patient safety is a priority while a social commitment to review an event is publically addressed. The contradictory safety agenda is that legislative agendas that claim to support the interests of society to provide an investigation of harm events depart from social perspectives because there is discretion to commission an RCA and an application of healthcare’s safety agendas is concealed. A foundational flaw appears in Queensland Health’s systems approach which is the result of “slack” (Schulman, 1993, p.353). It is argued here that slack within the legislation, provides healthcare a contract of flexibility and
“freedom to manoeuvre” (Schulman, 1993, p.353) that is problematic to improve patient safety.
The paradox is that safety is deconstructed through a variety of legislative provisions comprising enabling provisions, information and disclosure conditions and a no-blame criterion. These directives establish a complex approach to the application of an RCA where the focus is finding error with no organisational accountability to improve patient safety. As such, quality frameworks have done little to improve patient safety or the recurrence of SAC 1 harm events. While some advances have been made to improve safety it is contended that overall the contributions of an RCA are negligible. While it is argued that strengthening legislation may not be an effective solution (Mascini, 2005), legislative issues that depart from safety agendas need to be addressed. Conditions in the Queensland legislation are relaxed that enable a discretionary approach to death and permanent harm events and these need to be abolished. To that end, recommendation number 1 asserts:
Recommendation 1
1. Legislative reform is critical to give patient safety precedence; to define clear safety agendas where responsibility is assigned to organisational agendas and organisational autonomy is disrupted.
a. New legislative criterion asserts a systematic process of analysis framed in new safety models
i. Establish legislation that identifies organisational accountability to the investigation of patient harm and safety improvement.
b. Abolish enabling provisions to provide social equity in the investigation of SAC 1 harm events and interrupt the culture of autonomy.
2. Prepare a Ministerial Brief to inform Queensland Parliament of the key findings of the research to progress legislative amendments and move patient safety forward.
a. Politically motivate healthcare to improve patient safety through financial incentives.
3. Develop state-wide infrastructure that commits to improving patient safety through research.