Strategic priorities in Patient Safety

Advancing Patient Safety-Canada’s Vision for the Future

IV International Conference on Patient Safety November 25, 2008

Philip Hassen, CEO Canadian Patient Safety Institute

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Overview

• Canadian Health System • OECD-Comparing Spain, Canada, Other

• Background CPSI • Concluding Remarks/Questions

2

Canadian Population in 2006 was at 32.5 Million

Canadian health-care spending for 2007 will reach $160.1 billion.

Public-sector health care spending forecast projected to reach 70.6%.

Private-sector health-care spending forecast projected to reach 29.4%.

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Canadian Health System Key Differences Highlighted

• one fully socialized health care system • Federal government funds the provincial government

as long as they abide by the Canada Health Act whichexplicitly prohibits end user billing for procedures covered through the publicly funded system

• All provinces except Ontario have "mature" Regions • These are vertically and horizontally fully integrated

health and health care under one organization • Focuses as much on population as individual health

Canadian Government Involvement

Central structural difference is in health insurance

OECD Health Data 2007 3.8

3.4 2.8

4.0

0.0

1.0

2.0

3.0

4.0

ada France Italy Uni ted States

OE C D Ave

Acute Care Hospital Beds per 1000 Population

2004

3.9 4.1

6.8 5.7

0.0 2.0 4.0 6.0 8.0

anadaFrance Italy United States

OECD

Maternal and Infant Mortality Deaths per 1000 Live Births

2004

Canada Spain

Canada Spain

29 26 53

40

Health Employment Health Employment Practicing Physicians Practicing Nurses

Density per 1000 Population (Head Counts) Density per 1000 Population (Head Counts)

2005

16.0

4.7

15.0

0.0

9.9

France Italy United States

OCED Ave Spain

81

Canada

55

4.0 14.0 3.5 12.0 3.0 10.0 2.5 8.0 2.0 6.0 1.5 4.0 1.0 2.0 0.5 0.0 0.0

3.4 3.8

2.4

3.0

France Italy United States

OCED Ave

2005

Canada Spain

22

39

OECD Health Data 2007, October 2007 Not Available

5

OECD Health Data 2007 Health expenditure as a share of GDP, OECD countries, 2005

15.3

11.1 10.7 9.8 9.2 9 8.9 8.3 8.2 7.5

0 2 4 6 8

10 12 14 16 18

United

States

Fran

ce

German

y Can

ada

Netherl

ands

OECD

Italy

United

Kingdo

m Spa

in Ire

land

%GDP

OECD Health Data 2007, July 2007

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• Patients for Patient Safety Patients for Patient Safety

• Global Patient Safety Challenges: • Clean Care is Safer Care (GPSC 1) • Safe Surgery Saves Lives (GPSC 2)

• Reporting & Learning • Classification • Research • Safety Solutions and High 5s

Alliance Programmes

Canadian Patient Safety Institute Mission

To provide national leadership in building and

advancing a safer Canadian health system

Vision We envision a Canadian health system where:

• Patients, providers, governments and others work together to build and advance a safer health system;

• Providers take pride in their ability to deliver the safest and highest quality of care possible; and

• Every Canadian in need of healthcare can be confident that the care they receive is the safest in the world.

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Patient Safety: Barriers to Action

• Access is more urgent in Canada

• Shortages of clinical professionals

• Concern about liability

• Jurisdictional conflicts

• Delays in building the Electronic Health Record

• Culture of patient safety is lacking

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A Culture of Safety 31,033 Pilots, Surgeons, Nurses and Residents Surveyed*

*Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: crosssectional surveys. BrMedJour, 3-18-2000.

% Positive Responses from: Pilots Medical Is there a negative impact of fatigue on your performance?

74% 30%

Do you reject advice from juniors? 3% 45%

Is error analysis system-wide? 100% 30%

Do you think you make mistakes? 100% 30%

Easy to discuss/report mistakes? 100% 56%

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Human Error – the New View

The point of an investigation is not to find where people went wrong.

It is to understand why their assessments and actions made sense at the time.

Sidney Dekker (2002); The Field Guide to Human Error Investigations

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Human Error – the New View

HUMAN ERRORS ARE SYMPTOMS OF DEEPER

TROUBLE

Sidney Dekker (2002); The Field Guide to Human Error Investigations

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A Systems Approach “The systems approach is not about

changing the human condition but

rather the conditions under

which humans work.”

J.T. Reason, 2001

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. Tools &

Resources Interventions & Programs

ResearchEducation

.

Influence Change

Measure & Evaluate

Communicate

Build Capacity

Engage Stakeholders

Understand the Issues

Examples of Collaboration & Partnerships

Canadian Institute for Health Information • Hospital Standardized Mortality Ratio (HSMR)

Institute for Safe Medication Practices • Canadian Root Cause

Canada and Saskatchewan Health Analysis Framework

Canada Health Infoway • Patient Safety and the Electronic Health Record

Community and Hospital Infection Control • Canada’s Hand Hygiene Association, Canadian Council on Health Campaign

.Services Accreditation, Public Health Agency of Canada

World Health Organization • Patients for Patient Safety Canada; High 5s

Ministère de la santé et des services • Projet de formation sur les facteurs humains sociaux (Québec)

Canadian Council on Health Services • Align efforts

Accreditation, HIROC

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CPSI Strategic Direction Education

Executive Patient Safety Series

Governance for Quality and Safety

Canadian Patient Safety Officer Course

Simulation

IHI Re-broadcast

Halifax Conference

Studentships

Patient Safety Competencies

Canada’s Forum on QI and Patient Safety.

Interventions & Programs World Health Organization High 5’s

Patients for Patient Safety Canada

Infection Control Hand Hygiene Campaign

Safer Healthcare Now!

Research Home Care

Long Term Care

Mental Health Services

Emergency Medical Services

Primary Health Care

Building Capacity through Research

Tools & Resources

Event Analysis

Electronic Health Record

Canadian Disclosure Guidelines

Canadian Adverse Event Reporting and

Learning System WHO Safe Surgery Saves Lives

Human Factors 20

Education

Governance for Patient Safety

• National leadership, coordination and collaboration with current provincial/territorial and regional initiatives

• Co-commissioned research - partnership with CHSRF

• “Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations” (Baker, Denis, Pomey & MacIntosh Murray, 2009)

• Development of a framework and supporting tools, resources and education to assist boards in their understanding of and efforts to improve patient safety

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Education

Education

Simulation GOAL: • To establish a national coordinating group

to promote and endorse simulation andprovide a foundation for collaboration (or:“framework for the sharing of resources”)

• To facilitate the development of a national simulation strategy for healthcare throughfocused collaboration with stakeholders

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Education

Halifax Conferences • Annual National Patient Safety Conference

Patient Safety Officer Course- One week intense education/training session

Patient Safety Competencies • First edition released September 25, 2008.

Activities for dissemination and stakeholder engagement are underway

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Research

• Over 60 research and demonstration projects have been funded in the last three years, these will form the basis for new knowledge of Canadian patient safety challenges and solutions

• Work Collaboratively with Other Research Funding Groups

• Research Dollars Spent to date: $5.8Million

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Research

Building Capacity Through Research

• Development of Patient Safety background papers to identify the current state of knowledge, future research priorities, key issues, and strategies and opportunities for action and improvement:

• Mental Health Emergency Medical Services

• Primary Health Care

• Home Care

• Long-Term Care

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Interventions & Programs

Patients for Patient Safety:

Why?

• More to offer than simply the ‘victims’ story of tragic medical error.

• Consumers offer the richest resource of information related to medical errors as many have witnessedevery detail of systems failures from beginning to end.

• Patients want to know the truth when things go wrongand be treated with honesty and openness rather than face a closed door of denial

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Health-care providers’ compliance with hand hygiene practices is less than 40% on average

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Interventions & Programs

Canada’s Hand Hygiene Campaign

Hand Hygiene Campaign Goals: • Promote the importance of hand hygiene in reducing the

occurrence of healthcare associated infections • Respond to the needs of healthcare organizations for

capacity building and leadership development by creating and providing them with tools to help promote good hand hygiene

SHN MRSA Intervention Goals: • Enable healthcare organizations and caregivers to

prevent patient harm from MRSA • Reduce MRSA infection rates

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Interventions & Programs

Canada

• 33 million people • 10 interventions + 2

pilots • 1035 teams enrolled • 80% of acute care

hospitals enrolled • All regional health

organizations outside of Quebec enrolled

Aim • Reduce adverse events

by 40-100% according to intervention

www.saferhealthcarenow.ca

Interventions & Programs

Campaign Structure

Partner Network

Peer Support Network

CAPHC

Measurement Working Group & CMT Education & Resource

Working Group

Clinical Support

Canadian ICU Collaborative

ISMP Canada

Operations

Teams

Other Canadian Faculty

Communications Advisory Group

Atlantic Node

Ontario Node

Western Node

Campaign Support SHN National Steering Committee

Secretariat - CPSI

Patients

CCHSA CIHI

Quebec Campaign

IHI

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Interventions & Programs

SHN Interventions Initial Interventions • Improve Care for Acute Myocardial Infarction • Prevention of Central Line Associated Bloodstream Infection • Medication Reconciliation • Rapid Response Teams • Prevention of Surgical Site Infection • Prevention of Ventilator-Association Pneumonia

New Interventions • Prevention of Adverse Drug Event

in Long-Term Care • Prevention of Harm from Falls in

Long-Term Care • Prevention of Harm from MRSA • Improve Care for Venous

Thromboembolism (VTE)

Pilot Projects • Prevent Adverse Drug Events

Related to High Risk Medication Delivery in Paediatrics

• Prevent Adverse Drug Events Through Medication Reconciliation in Home Care

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Interventions & Programs

Safer Healthcare Now! Teams Continue to Enroll

Total # of Enrolled Teams

Sep-05 Nov-05 Jun-06 Nov-06 Jan-07 Mar-07 Jun-07 Aug-07 Oct-07 Jan-08 Mar-08 Apr-08

May-08 Jul-08 Aug-08 Oct. 08

Safer Healthcare Now! Overview Total # Enrolled Teams September 2005 to September 2008

118

296

443

546 579 628

695 734

789 817 860

933 962 1004 1021

1050

0

100

200

300

400

500

600

700

800

900

1000

1100

Total at September 23, 2008

Month

13

Month

13

Interventions & Programs

SHN: End of Phase I – January 2007

Med Rec Results – Unintentional

discrepancies

È from 1.16 to 0.65 per patient (goal of 0.30)

1.4 1.2

1

0.8 0.6 0.4 0.2

0

Months in SHN!

Ventilator-associated Pneumonia

Central Line-Associated Blood Stream Infections �bloodstream infections 4.8 per 1,000 central line days

to 1.6

6

5

4

3

2

1

0

M o nt hs in SHN !

Rapid Response Team � in the national rate for VAP from a baseline of 19.88 per â 1,000 ventilator days to 3.76 after 13 months, (goal was 7.00)

Rat

e

18

16 10 14

812

10

8

6

4

2

0

6 4 2 0

national rate of Codes (occurring outside ICU) per 1,000 discharges from 7.46 to 4.61,

Months in SHN

Months in SHN

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Tools & Resources Event Analysis

• The French adaptation for the Canadian Root Cause Analysis Framework is completed and Failure Mode Effect Analysis is in progress

Electronic Health Record • Plans are underway to examine the role of EHR as it

relates to the process of medication reconciliation

Canadian Disclosure Guidelines • Are available on the CPSI website.

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Tools & Resources Canadian Adverse Event Reporting and Learning

System (CAERLS) • The CAERLS Consultation Paper is available on the CPSI

website. Planning for consultation meetings to be held throughout Canada are currently underway.

WHO “Safe Surgery Saves Lives” • An in-country working group has been assembled to adapt

the Safe Surgery Checklist for use in Canada

Human Factors • Development of educational strategies is being

contemplated to assist organizations to better understand this important area of patient safety

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Other Challenges and Key Issues

• Develop other indicators • Build patient safety expert capacity • Collaborate and Increase Engagement (F/P/T,

“patient safety” agencies/organizations) • Keep patient safety on the national agenda;

inform the public, patients, providers, policy-and decision-makers

• Misdiagnosis • Culture of Patient Safety

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Summary

Patient Safety

• CPSI is “leading without owning” resulting in significant and measurable patient safety improvements by many Healthcare organizations in just three years of operations

• Safer Healthcare Now! is a pan-Canadian success story – “changing the face of safety in the Canadian healthcare system”

• The success of CPSI will continue to be assessed with the emergence of Hospital Standardized Mortality Ratios and other measures

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Commitment to Our Patients

“…there are some patients

we cannot help,

there are none

we should harm...”

Dr. Ken Stahl

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