Norway Case Study
Global State of Patient Safety 2025 Report
6.4 Norway
Committing to systematic improvement of patient safety using multiple mechanisms of change
Contributor
Bent H酶ie
Former minister, Health and Care Services, Norway and
Current governor, County of Rogaland
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Health system |
Population |
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Publicly funded, universal |
5.5 million |
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2025 patient safety ranking: 1st |
2023 patient safety ranking: 1st |
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Summary |
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Renewed action a decade ago focused on making systematic improvements in safety and quality through greater transparency and use of data. |
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Led by the Minister of Health, new regulations and parliamentary reporting were complemented by deeper cultural and leadership development work. |
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Important lessons have been learnt about combining approaches for sustained change, and about the unintended consequences of additional rules and regulations. |
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6.4.1 Norway's healthcare system
Norway has a that provides universal coverage for its population. Healthcare is delivered through a mix of centralised services such as specialised care, and regionalised services such as primary care. of the population has private healthcare insurance, which speeds up access and provides greater choice of some services.
The Directorate of Health is responsible for implementing the national healthcare policy. The has overall responsibility for health and social services.
County-level Health and Social Services ombudsmen provide advocacy and support for patients. The Norwegian Patient Injury Compensation Board handles compensation claims for patients who have suffered harm resulting from their treatment.
6.4.2 Norway鈥檚 patient safety journey
As in many countries, work to improve patient safety and quality accelerated in Norway following the publication of in the United States and of 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:
We needed to go in a direction with more openness around quality and safety issues, we needed to try to create a learning sector, and to work systematically to improve using the data we had.
In 2017, regulations on Management and Quality Improvement in Health and Care Services were established. The regulations were designed to be 鈥渧ery easy to understand, very easy to follow up鈥�, 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, 鈥渃ontribut[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:
[鈥 We had a lot of different departments and organisations that were working on safety issues, but there was nowhere you could actually collect all the information and see it together and use it to analyse what the situation actually is.
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 鈥� 鈥渢his [limitation] must not prevent us from continuing to improve quality.鈥� 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 (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鈥檚 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鈥檚 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, has demonstrated improved perceptions of cancer care from patients, the public and GPs.
6.4.3 What has been learnt?
Replicating improvement interventions
Norway鈥檚 work to learn from Denmark鈥檚 experience in improving cancer care did not involve copying their patient pathways. Following a deep analysis of Denmark鈥檚 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:
I was very clear that we should not do that, because when you give services extra money to do something [鈥 it becomes a project, and they are used to projects coming and going. And this was not a project. It was the new way of working.
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鈥� rights 鈥� such as by enhancing the rights of children, adolescents and mental health patients 鈥� was acknowledged as the right thing to do, 鈥渢he law didn鈥檛 change the practice鈥�. Instead, it was the culture change work with clinicians 鈥� for example, using patient stories at major conferences and leadership gatherings 鈥� that helped to change the tide of opinion around openness and transparency:
I have a very strong belief that, as a politician, we often use law and regulations because [they] are the tools that we know about. But we often come up short if we only decide things through laws and regulations. So the idea was that we should have law in this area that was very easy to understand [鈥 and then base the work on culture and leadership development at the same time.
6.4.4 What next?
Deregulation of the sector
The issue of patients鈥� 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 鈥� 鈥渋t鈥檚 not feasible for services to fully know the extent of the rights available to patients.鈥�
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.
I really believe that if we don't start now with major deregulation of the sector, and shift the use of our resources from individual cases to working with the system, we can actually go into a situation where we start to lose the trust of the whole system.
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) 鈥� 鈥渂ecause the health system actually discriminates them, because they only see the addictions鈥�. Instead, a more holistic or whole-person approach would see safety and quality from the patient鈥檚 perspective, meeting all their needs, not just some of them.