PATIENT SAFETY through COMMUNICATION March 11, 2008.

PATIENT SAFETYthrough

COMMUNICATION

March 11, 2008

BACKGROUND on MIPS:BACKGROUND on MIPS: Independent, non-profit corporation Independent, non-profit corporation Created in May 2004Created in May 2004 Governed by 12 member board:Governed by 12 member board:

Majority (7) elected by our membership and 5 Majority (7) elected by our membership and 5 appointed by Minister of Healthappointed by Minister of Health

Board – citizens, providers, administratorsBoard – citizens, providers, administrators

MISSION

To promote patient safety and quality health care for Manitobans

Objective 1

Promote patient safety activities in Manitoba health care system.

Objective 2

Identify emerging patient safety & quality care issues.

Objective 3

Promote “best practices” in patient safety.

Objective 4

Raise awareness of patient safety issues.

MIPS PATIENT ADVISORY COMMITTEEMIPS PATIENT ADVISORY COMMITTEE

““MPAC”MPAC”

MPAC

Provide a voice for patients/families interested in patient safety & its promotion in healthcare settings

Do activities to promote MIPS mission & objectives

Create long-term strategies for patient & family involvement in MB Health care system

Canadian Adverse Events Study (2004):

The results suggest that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about:

7. 5% (185,000) of adult hospital admissions (acute care) resulted in an adverse event

Of these, 37% (70,000) were considered preventable, and

9000-24000 died.

FACTSFACTS

Safety in Long-Term Care Settings (2008)Wagner & Rust

Accidental injury - most common adverse event among nursing home residents with dementia & psychosis

Falls - most frequently reported adverse event in LTC settings

Medications- 42% of all adverse drug events preventable

FACTSFACTS

“Patient safety is everyone’s responsibility.”

PATIENT SAFETY IS A COMMON GOAL

Reduce preventable harm to patients Provide the safest quality care possible

DO I PROMOTE PATIENT SAFETY?

Ask yourself: Do I value resident safety?

Do I communicate effectively with residents & their families?

Do I do all that I can to promote patient safety in my organization?

ACTION CHECKLIST(Reality Check)

Do I:

1. Communicate in respectful open, honest manner daily?

2. Communicate regularly with families & HC team?

3. Provide families with timely health information?

4. Use plain language and visual clues when discussing the patient with families?

5. Regularly ask families to clarify what was discussed?

ACTION CHECKLIST

DO I:

6. Encourage families to ask questions?

7. Discuss patient safety with families & HC team?

8. Look for latent safety threats every day?

9. Report/disclose any errors or potential errors that may impact on patients?

DO I PROMOTE PATIENT SAFETY??

BUILDING BLOCKS TO

PATIENT SAFETY

BUILDING BLOCKS TO PATIENT SAFETY

CommunicationCommunication

COMMUNICATION

Why is it important?

Bridge between HC providers, patients/ families & rest of HC team to achieve patient safety & quality care.

Communication Root cause of 70% of sentinel events reported to

the Joint Commission, US.

WHAT TYPE OF COMMUNICATION IS NEEDED ?

Verbal & Non-Verbal Respectful Honest Mutually trusting Accepting Empathetic

COMMUNICATION

Interdisciplinary Engage family Care planning Reporting/disclosing incidents Medication safety Critical to culture of safety Timely shared

BUILDING BLOCKS TO PATIENT SAFETY

CommunicationCommunication

ActionAction

What can you-Health Care Provider- do?What can you-Health Care Provider- do?

ACTIONS OF HEALTH CARE PROVIDERS

1. Open two-way communication

2. Ongoing involvement

3. Ongoing sharing

4. Teamwork

5. Advocate for Culture of Patient Safety

ACTION

1. OPEN TWO-WAY COMMUNICATION:

• Talk with families/care givers.

• Listen to families/care givers.

• Talk with HC team.

• Listen to HC team.

ACTION

2. ONGOING INVOLVEMENT:

• Families/care givers in health decisions

• Health care team

• Upper management

ACTION

3. ONGOING SHARING of:

• Patient information

• Importance of patient safety

• Latent threats to patient safety

• Reporting/disclosure of adverse events

With:

• Families/care givers • Rest of HC team

ACTION4. TEAMWORK:

• Effectively collaborate with others

• Give and receive feedback on performance

• “No Blame” approach to incident reporting & analysis

ACTION5. ADVOCATE - CULTURE of PATIENT SAFETY

• Be a site “champion”

• Stay positive

• Involve families in important decisions

• Be persistent

BUILDING BLOCKS TO PATIENT SAFETY

Communication

Action

Support

SUPPORT:

1. Is there a patient safety culture? Is patient safety:

A top priority in your organization & among leaders?

Viewed as a positive concept? The focus of attention for all organizational

activities?

SUPPORT:

2. Is there a collaborative environment?

“Blame-free reporting system” Proactive approach (errors/problems anticipated) Share information (3 Cs) Accountability - safety is everyone’s responsibility Monitoring of situations & actions taken

SUPPORT:

3. Are families/care givers involved in process of patient safety improvement?

4. Is there a clear organizational policy?

5. Are there adequate resources to respond to identified concerns?

SUPPORT:

For residents,

Balance

Patient Safety Quality of Life/Independence

TOOL for FAMILIES & HC PROVIDERS

Is It … Safe to Ask?

ISTA

It’s Safe to Ask Offers information and tips

for providers and patients/families to:

Enhance clear communication

Make care a more positive experience

Increase health literacy

Help reduce adverse events

It’s Safe to Ask (ISTA) Target Groups:

1. Public Groups in Manitoba (such as elderly, low literacy, people with disabilities)

1. Health care providers

It’s Safe to Ask

1. What is my health problem?

2. What do I need to do?

3. Why do I need to do this?

What are the values behind in ISTA?

1. Know your rights as patients/families.

Personal Health Information Act (PHIA) Right of patient to receive healthcare instructions

and information in a way they/care givers can understand. (Standards for PCH #1 Pte Bill of Rights)

2. Ask questions.

What is MPAC telling families/care givers?

Communicate with HC providers: Ask questions

Learn some medical terminology

Seek credible resources

Gain support

Material translated into: Amharic English

Arabic French

Chinese Cree

Ojibway Oji-Cree

Eritrean German

Korean Punjabi

Russian Spanish

Tagalog 15 languages!15 languages!

PHASE 2, ISTA

Medication CardMedication Card

Patient Safety is achievable!Everyone must be willing to:

Communicate

Act

Support

Look for Look for windows of windows of opportunityopportunity

FAMILY STORIES

www.mbips.ca

www.safetoask.ca

COMING TOGETHER IS A BEGINNING.COMING TOGETHER IS A BEGINNING.

KEEPING TOGETHER IS PROGRESS.KEEPING TOGETHER IS PROGRESS.

WORKING TOGETHER IS SUCCESS.WORKING TOGETHER IS SUCCESS.

Henry FordHenry Ford