1 Patient Safety: New Trends and Strategies for Implementation Canadian College of Health Service Executives March 2006.

1

Patient Safety: New Trends and Strategies

for Implementation

Canadian College of Health Service Executives

March 2006

2

Speakers

Donna Towers, CHECapital Health (Alberta)

John King, CHESt. Michael’s Hospital, Toronto

Anne McGuire, CHEIWK Health Centre, Halifax

3

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

4

Canadian College of Health Service Executives (CCHSE)

A professional association with 3,000 members across all sectors of health services.

5

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

6

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

7

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

8

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

9

Collaboration and Cross Representation

CCHSE is a voting member of CPSI

CPSI is a corporate member of CCHSE

10

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

11

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

12

Health Executive’s Role in Patient Safety

CultureAccountabilityMeasuresHigh Reliability/RedesignCommunication and Teamwork Professional Development

13

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

14

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

15

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

16

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

17

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

18

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)

19

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

20

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:

21

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

22

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

23

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

24

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

25

St. Michael’s Hospital Safety Program and Plan

Mr. John King, CHE

Executive Vice President

26

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

27

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

28

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)

29

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.

30

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”)

31

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)

32

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

33

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

36

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

37

Step One

Organizational leader responsible for quality resources and decision support services (patient safety) to report directly to the CEO

38

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

39

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

40

Step Four Centralized all supports and

programming related to patient safety under the Centralized Quality Division

– All Quality Improvement Coordinators– Infection prevention and control

41

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)

42

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

43

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

45

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”

46

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

47

Step Nine

Communicated patient safety initiatives:

– PULSE (IWK intranet)– Leadership Forums– Town Halls– IWK website (patient safety component

under development)– Etc…

48

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

49

In conclusion, health service executives have enhanced roles and responsibilities in patient safety that include:

CultureAccountabilityMeasuresHigh Reliability/RedesignCommunication and Teamwork Professional Development

50

Conclusion

The safety of patients within the health care

system depends on all levels working

together toward the common goal of patient

safety.

51

Questions?