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1
Patient Safety: New Trends and Strategies
for Implementation
Canadian College of Health Service Executives
March 2006
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Speakers
Donna Towers, CHECapital Health (Alberta)
John King, CHESt. Michael’s Hospital, Toronto
Anne McGuire, CHEIWK Health Centre, Halifax
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Outline Canadian College of Health Service
Executives
Collaboration to date on the common patient safety agenda
The executive’s role in patient safety
Practical examples Capital Health (Alberta)
St. Michael’s Hospital
IWK Health Centre
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Canadian College of Health Service Executives (CCHSE)
A professional association with 3,000 members across all sectors of health services.
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CCHSE Vision and Mission
VisionTo be the professional association of choice for Canada’s health leaders
MissionTo develop, promote, advance and recognize excellence in health leadership
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CCHSE Strategic Directions
Position the College as a ‘must belong to’ organization, responsive to its members
Raise the profile of health leaders and their contribution to public policy, the health system, and the health of Canadians
Raise the stature of the College so that it is recognized as a resource and source of solutions in addressing health leadership issues
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CCHSE Strategic Directions
Position the College as responsive to all health leaders, regardless of their professional background
Promote evidence-based practices for health leaders across the public, corporate, voluntary and university sectors
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Canadian Patient Safety Institute (CPSI)
Announced in December 2003
Located in Edmonton
Mandate: to provide leadership and coordinate the work to build a culture of patient safety and quality improvement throughout the Canadian health system
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Collaboration and Cross Representation
CCHSE is a voting member of CPSI
CPSI is a corporate member of CCHSE
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College’s Role in Patient Safety Developed a position paper for members
(2004) which states that responsibilities and accountabilities for patient safety need to be delineated in governance, management and clinical processes
Advocate effectively communicating improvements in patient safety
InternallyExternally
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Quality / Safety
Goal: Create asafer health
system
Canadian PatientSafety Institute
(CPSI)CCHSE
Culture
Accountability Measures
High Reliability/ Redesign
Communicationand Teamwork
Professional Development
ACAHO CNA RCPSC CCHSA
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Health Executive’s Role in Patient Safety
CultureAccountabilityMeasuresHigh Reliability/RedesignCommunication and Teamwork Professional Development
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CultureCritical role for leaders is to drive cultural change by demonstrating commitment to safety through:
Clearly communicating patient safety goals
Supporting resources and tools required to
achieve success
Visible commitment to openly share information
Driving patient safety education at every level and
at every opportunity
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Culture of Safety: Accreditation
Canadian Council on Health Services Accreditation (CCHSA)
Quality and patient safety are important components of CCHSA standards
Major focus areas for accreditation
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CCHSA Patient Safety Goals Create a culture of safety within the organization
Improve the effectiveness and coordination of communication among service providers and with the recipients across the continuum
Ensure the safe use of high risk medications
Create a work life and physical environment that supports the safe delivery of care/service
Reduce the risk of health service organization-acquired infections, and their impact across the continuum of care/service
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Accountability Organizations must clearly define
accountabilities for patient safety
Capital Health (Alberta): patient safety accountability resides with VP Medical and VP/CLO
Report bimonthly to the board on quality and patient safety issues
Regional Quality Council with representation from all sites and sectors – advisory to Executive Committee
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Measures
Develop reporting policies within a quality improvement framework across the organization that promote learning
Executive’s role is to ensure appropriate reporting and monitoring mechanisms are in place
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High Reliability/Redesign
Based on learnings from the aviation industry and the nuclear industry
Reliability principles: simplification standardization relation of humans to the work environment (Resar & Leonard, 2004)
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High Reliability/Redesign: KCl Appropriate monitoring from other
countries resulted in Capital Health (Alberta) taking early action in the area of potassium chloride (KCl) purchase and storage on patient units to minimize the risk of potential error of incorrect potassium chloride administration
In 2002 moved to purchase dialysate for CRRT based on environmental scanning
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must be informed participants
understand that human error is inevitable
underlying systemic factors including ongoing system change contribute to most near misses, adverse events and critical incidents
Communication and TeamworkHealth care personnel, patients and all others within the system:
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Communication and Teamwork Communication and team-building to
improve teamwork including across sites/sectors
Safer hand-offs and transitions
Openness in communication with staff, key stakeholders, patients and the general public
Sharing and dissemination of “lessons learned” about improving patient safety throughout the continuum of care
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Communication and Teamwork
Communications threaded into all areas
Transparent/open communication is essential for a culture of quality and patient safety
Behaviour change is a key indicator of effective communications
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Professional Development
Maintenance of professional competency is an important aspect of ensuring patient safety
CCHSE Certified Health Executive
CCHSE role
To continue professional development and networking in the area of patient safety and its associated techniques and theory
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Translation of National Level to the Organizational Level
Challenge for health executives is to take what is being developed at the national level and operationalize patient safety within their organizations
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St. Michael’s Hospital Safety Program and Plan
Mr. John King, CHE
Executive Vice President
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St. Michael’s Approach Strategic commitment to “adopt a
leadership role in the implementation of patient safety initiatives” (Reaching New Heights 2004)
White paper on Patient Safety (2004)
Patient Safety Plan (2005)
Corporate Objective for 2006/2007
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SMH Safety Plan is based on the Institute of Medicine (IOM) and Canadian Council on Health Services Accreditation Goals Strategies are in place under five IOM
Principles:– Leadership– Respect Human Limits in Process Design– Effective Team Functioning– Anticipate the Unexpected– A Learning Environment
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Leadership
Clear organizational leadership and professional support, including involvement of governing boards, management, and clinical leadership
– Strategic direction (2004)– EVP sponsors for all strategic safety initiatives– Safety policy– Quarterly safety reports to senior management and Board
of Directors– Accountability for all staff defined (MAC, professional
practice, performance appraisals for all staff)
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Respect Human Limits in Process Design
Job design with attention to human factors [1]
Current projects selected that affect work (individuals’) safety include:– Patient safety audits (ERM Framework)– Clinical documentation, order entry, scheduling (Gemini)– Pharmacy medication packaging and distribution
technology– Supply chain redesign in cath lab, OR and laboratory
[1] Haberstroh, Charles H. “Organization, Design Systems Analysis,” in Handbook of Organizations, J. J. March, ed. Chicago: Rand McNally, 1965.
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Effective Team Functioning
Team training for safety
– Team Safety Education Plan– Interdisciplinary collaborative practice model
(Gemini)– Critical care and perioperative services safety
strategy– Patient safety education (OHA’s “Your
Healthcare. Be Involved”)
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Anticipate the Unexpected
Continuous examination of processes of care to identify safety problems:– Failure mode analysis for selected new technologies –
collaborative work involving ORNT and simulation center (e.g. IV pumps)
– Sharps Exposure Control Program– Patient Falls Prevention Program– Wound Care Program– Patient Lifts and Transfers Program– OHA Safety Group (WSIB Workplace Safety Program)
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A Learning Environment
Communication, education and support for learning:
– Electronic Event Tracking System and Root Cause Analysis Database
– Communication of Adverse Event Policy– Quality of Care Committee under QCIPA
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Positioning Patient Safety on the Strategic Agenda
Anne McGuire, CHE
President & CEO
IWK Health Centre
34
Getting a Handle on Patient Safety Medication and non-medication occurrence
reporting (including near miss)
Committees with patient safety component:• Patient Care Committee• Drugs and Therapeutics Committee• Children’s Mortality Committee• Perinatal Peer Review Committee• Nursing Professional Practice Committee• Infection Control Committee• Professional Practice Committee• Medical Advisory Committee
35
Getting a Handle on Patient Safety MOM committees: Multidisciplinary “patient safety” teams Initiative underway for 5 years (currently 29 teams) Profile of the MOM committees has increased
significantly• Mortality review• Morbidity review• Occurrence review• Sentinel event review• Root cause analysis• Report through teams and programs to the Centre- wide
Morbidity (Patient Safety) Committee
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A Lot is Happening – No Strategic Focus!
Combination of centralized and decentralized supports
No representation at the senior executive table “Patient safety” language not used to describe
patient safety activities No single person or department leading and
coordinating all activities Not on the radar at the Board level 10 Step Program
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Step One
Organizational leader responsible for quality resources and decision support services (patient safety) to report directly to the CEO
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Step Two
Included quality/patient safety leadership on the executive team
– October 2005 Director, Quality Resources and Decision Support Services became a member of the senior management team
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Step ThreeAs part of the senior management
team reorganization, quality and patient safety was positioned as one of three communities of practice to be lead by the Director
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Step Four Centralized all supports and
programming related to patient safety under the Centralized Quality Division
– All Quality Improvement Coordinators– Infection prevention and control
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Step Five Reorganization of the Quality Division
with three new management positions:
– Manager, Quality– Manager, Patient Safety– Manager, Risk and Legal Services– Manager, Decision Support Services
(existing)
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Step Six
Patient safety positioned at the Board level
– International patient safety expertise – Updates on patient safety initiatives
included in CEO Report to the Board– Patient safety strategic focus
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Step SevenPatient safety identified as one of the
five organizational strategic themes:
– Improving the health of the population– Becoming a workplace of choice– Wise investment and efficient management of
resources – sustainability– Advancing (not creating) a culture of patient
safety (recognizing the work already underway)
– Leading in learning, discovery and innovation
44
More About the Patient Safety Strategic Theme
Goal 1: Create a climate for patient safety by ensuring that structures and processes that permit spread of best practices are consistently in place
Goal 2: Apply best practice initiatives where they are proven and appropriate to increase patient safety
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More About the Patient Safety Strategic Theme
Goal 3: Develop an environment which supports and enhances a patient safety culture
Goal 4: Live patient safety as a strategic priority– One of the measures of success for Goal 4:
“Patient safety issues are an important component of Board and Senior Management meeting agendas”
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Step Eight
Positioning patient safety on the senior executive agenda – “Real life” IWK cases presented to SMT
– Progress of patient safety initiatives reviewed:• Safer Healthcare Now!• CAPHC Patient Safety Collaborative• Pediatric Trigger Tool – CAPHC – replication of the
Baker Norton study• CPSI research participation: culture survey, indicators• Discussion of new initiatives: patient safety
leadership walkabouts, MORE OB, SBAR
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Step Nine
Communicated patient safety initiatives:
– PULSE (IWK intranet)– Leadership Forums– Town Halls– IWK website (patient safety component
under development)– Etc…
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Step Ten
Link strategies with provincial, regional and national strategies:
– Halifax Patient Safety Symposiums– Provincial Healthcare Safety Working Group– Patient Safety Advisory Group – CDHA– Safer Healthcare Now! Steering Committee– National Patient Safety Collaborative –
CAPHC– National Medbuy linkage with IHI– CCHSA patient safety standards
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In conclusion, health service executives have enhanced roles and responsibilities in patient safety that include:
CultureAccountabilityMeasuresHigh Reliability/RedesignCommunication and Teamwork Professional Development
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Conclusion
The safety of patients within the health care
system depends on all levels working
together toward the common goal of patient
safety.
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Questions?
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