In January 2007, as part of the Government's commitment to ensuring patient safety and quality in our health service, I established a Commission on Patient Safety and Quality Assurance to develop clear and practical recommendations to ensure that quality and safety of care for patients is paramount within the healthcare system. The Commission's Report — ‘Building a Culture of Patient Safety' was published in August 2008. The Commission's recommendations will be considered by me and my Department and proposals on implementation will be submitted to Government in the near future. This is the first report of its kind and it makes far reaching recommendations which when implemented will impact very positively on patients and their families.
The implementation plan endorsed by the Commission recommends the immediate establishment of an Implementation Steering Group (ISG) with clear and regular reporting obligations to the Minister for Health and Children regarding progress on the implementation of the recommendations of the Report. This also requires the establishment of expert sub-groups comprised of representatives of relevant stakeholders, each of which will be required to report to the ISG on the practical and detailed implementation of the recommendations within their remit. The advantages of this model are that it immediately builds on the structures already in place and can deliver results quickly.
The most significant recommendation of the report is the introduction of a licensing system for all health services whether they are delivered publicly or privately and such a system would of course require legislation which will be extremely complex and take some time to develop. Other recommendations in the report which would require legislation include a mandatory system of adverse event reporting and legal protection for information collected through such a system. Similar protection is also suggested for information provided in the context of a process of open disclosure or clinical or other patient safety audit.