Academic. Margot Harvie.

Looking East: How Can Alberta’s Blueprint Guide Us?

Margot Harvie RN BN MEd

Quality & Safety Education Lead

February 27, 2013

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Blueprint Project

• Vision • All those involved in

providing healthcare have a common understanding of key components of patient safety and quality and use this to continually invest in making patient care safer

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Blueprint Project

• Mission • Work collaboratively to develop a detailed

framework of learning outcomes and objectives and some priority supporting curriculum resources incorporating key messages about patient safety concepts/topics that can be used in educating all who work in the healthcare system about the principles and processes of patient safety

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Blueprint Project

• Project Partners • HQCA, Alberta Health Services, University of

Alberta, University of Calgary, University of Lethbridge, Mount Royal University, Northern Alberta Institute of Technology, Norquest College, Canadian Patient Safety Institute, BC Patient Safety and Quality Council, Manitoba Institute for Patient Safety

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Genesis of the Blueprint Project

2007 2008 2009 2010 2011 2012 2013

Patient Safety Curriculum: Gaining Consensus workshop 200 individuals providing feedback on initial model and framework

Patient Safety Curriculum Project Working Group Calgary Health Region - development of model

Blueprint Project Multi-year collaborative sponsored by the HQCA

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Healthcare System Safety Model

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Early lessons.....

• Curriculum Framework not the right terminology to use

• Simple is better!

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Patients

Personnel Environment / Equipment

Organization Regulatory Agency

Evolution of the Model

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UNSAFE ACTS

LOCAL WORKPLACE FACTORS

ORGANIZATIONAL FACTORS

LOCAL WORKPLACE FACTORS

ORGANIZATIONAL FACTORS

UNSAFE ACTS

PHYSICAL ENVIRONMENT

Crew

ORGANIZATIONAL ENVIRONMENT

REGULATORY ENVIRONMENT

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PHYSICAL ENVIRONMENT

Crew

ORGANIZATIONAL ENVIRONMENT

REGULATORY ENVIRONMENT

PHYSICAL ENVIRONMENT

Crew

ORGANIZATIONAL ENVIRONMENT

REGULATORY ENVIRONMENT

ENVIRONMENT / EQUIPMENT

PERSONNEL

THE ORGANIZATION

REGULATORY AGENCIES

PHYSICAL ENVIRONMENT

Crew

ORGANIZATIONAL ENVIRONMENT

REGULATORY ENVIRONMENT

Patient

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Health Care

Providing Receiving

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The Healthcare Encounter Safety and Quality Model

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The players The functions

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The Healthcare Encounter Safety and Quality Model

The Healthcare Encounter Safety and Quality Model

The Patient Safety Puzzle

The Patient Safety Puzzle

The Patient Safety Puzzle

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2007 2008 2009 2010 2011 2012 2013

September Principles Think Tank Meeting

May - First Steering Committee meeting

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Blueprint Project Structure

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A few things we learned...

• Individuals interested, but really needed core ‘working group’

• Collaboration takes time!

• Group writing is painful and time consuming, but very rich

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2007 2008 2009 2010 2011 2012 2013

Spring - Environmental Scan

September - Patient Safety Framework for Albertans Certificate in Patent Safety & Quality Course

June - Patient Safety Principles Document

First Event Analysis Think-tank

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Environmental Scan • Purpose • Determine extent to which systems approach

to patient safety integrated into healthcare provider education programs

• Determine what kinds of resources would be helpful in supporting integration of systems approach to patient safety

• Gather feedback about utility and content of Patient Safety Education Self-Assessment tool

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Environmental Scan • Method • Based on literature review, a draft Patient

Safety Education Self-Assessment Tool (PSESAT) was developed to assist post-secondary healthcare provider education programs in determining to what extent a systems approach to patient safety has been integrated into their curriculum

• Tool developed in collaboration with educators across Alberta

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Environmental Scan

• Tool • Three themes explored through tool items 1. Patient safety-related concepts taught in the

program with a focus on a systems orientation to patient safety

2. Leadership and organizational factors that support a systems approach to patient safety within an education program

3. Responding to close calls and adverse events involving students

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PSESAT

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Environmental Scan • Key Findings • Patient safety scale ratings were high

suggesting that patient safety is well-integrated into most programs, however it is not clear to what extent this reflects a systems oriented view of safety

• Respondents often stated that they did not completely understand the terms or concepts related to a systems approach that were embedded in the tool items

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Environmental Scan • Key Findings • A disconnect between educational programs

and clinical settings was evident which may hinder student practice of newly learned patient safety concepts

• Programs expressed interest in user-friendly resources to help them learn about the concepts of a systems approach to patient safety - case studies, interactive technology-based resources and networking opportunities

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Environmental Scan • Key Findings • Respondents recognized that the process of

completing the self-assessment tool may be its most important function

• Critically reflecting on the tool items as a group raises awareness of a systems oriented approach

• Suggestions to improve tool mainly centered on improving clarity of wording and developing a consistent rating scale

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Patient Safety Framework

Based on an understanding of what is required to make healthcare safer

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Certificate in Patient Safety & Quality

• Partnership with Office of Continuing Medical Education & Professional Practice, W21C University of Calgary & HQCA

• Third year of course - now using blended on-line and face to face format

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2007 2008 2009 2010 2011 2012 2013

May - Faculty Development Workshops

Patient Safety Conundrum Document

Completion of Patient Safety Principles Outcomes Matrix

Second Event Analysis Think-tank

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Faculty Development Workshops

• Opportunity identified in environmental scan • Help make the shift from “individual provider

responsibility for safe patient care” to an integrated “systems view of patient safety”

• Important step in addressing Strategy 5 in the Patient Safety Framework for Albertans

• about 30 participants - positive feedback

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Outcomes Matrix

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More learning

• HUGE project • Difficult to juggle big picture and deep dives • Can’t be done off the side of anyone’s desk • Lots of great ideas...

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2007 2008 2009 2010 2011 2012 2013

SSA:PSR June - Advisory Nov - Workshop

Full time Quality & Safety Education Lead hired

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SSA:PSR • Theory-based, developed

specifically for healthcare reviews

• Draws from aviation and human factors investigation techniques

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Yes - more lessons!

• Project needs more of a stakeholder group than a steering committee

• Still tons more work to do • Struggling with engagement vs getting the

work done • New process for completing learning outcomes

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2013..........

SSA:PSR February - pilot certificate course

Focus on completing learning outcomes for 21 remaining learning topics

Map learning objectives to CPSI competencies and CanMeds

Map learning topics to U of C medical school curriculum

What’s next?