Patient Safety:
New Trends and Strategies
for Implementation
Canadian College of Health
Service Executives
March 2006
1
Speakers
Donna Towers, CHE
Capital Health (Alberta)
John King, CHE
St. Michael’s Hospital, Toronto
Anne McGuire, CHE
IWK Health Centre, Halifax
2
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
3
Canadian College of Health Service
Executives (CCHSE)
A professional association with 3,000
members across all sectors of health
services.
4
CCHSE Vision and Mission
Vision
To be the professional association of
choice for Canada’s health leaders
Mission
To develop, promote, advance and
recognize excellence in health
leadership
5
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
6
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
7
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
8
Collaboration and Cross
Representation
 CCHSE is a voting member of CPSI
 CPSI is a corporate member of CCHSE
9
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
Internally
Externally
10
C a n a d ia n P a tie n t
S a fe ty In s titu te
CCHSE
AC AHO
CNA
RCPSC
CCHSA
(C P S I)
Q u a lity / S a fe ty
G o a l: C re ate a
s a fer h ea lth
s ys te m
C u ltu re
C o m m u n ic a tio n
a n d T e a m w o rk
A c c o u n ta b ility
M e a s u re
s
H ig h R e lia b ility
/ R e d e sig n
P ro fe ss io n a l D e ve lo p m e n t
11
Health Executive’s Role
in Patient Safety
Culture
Accountability
Measures
High Reliability/Redesign
Communication and Teamwork
Professional Development
12
Culture
Critical 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
13
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
14
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 organizationacquired infections, and their impact across the
continuum of care/service
15
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
16
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
17
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)
18
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
19
Communication and Teamwork
Health care personnel, patients and all others
within the system:
 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
20
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
21
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
22
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
23
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
24
St. Michael’s Hospital Safety
Program and Plan
Mr. John King, CHE
Executive Vice President
25
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
26
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
27
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)
28
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.
29
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”)
30
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)
31
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
32
Positioning Patient Safety
on the Strategic Agenda
Anne McGuire, CHE
President & CEO
IWK Health Centre
33
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
34
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 Centrewide Morbidity (Patient Safety) Committee
35
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
36
Step One
 Organizational leader responsible for
quality resources and decision
support services (patient safety) to
report directly to the CEO
37
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
38
Step Three
As 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
39
Step Four
 Centralized all supports and
programming related to patient
safety under the Centralized Quality
Division
– All Quality Improvement Coordinators
– Infection prevention and control
40
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)
41
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
42
Step Seven
Patient 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
43
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
44
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”
45
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
46
Step Nine
 Communicated patient safety
initiatives:
– PULSE (IWK intranet)
– Leadership Forums
– Town Halls
– IWK website (patient safety component
under development)
– Etc…
47
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
48
In conclusion, health service executives have
enhanced roles and responsibilities in patient
safety that include:
 Culture





Accountability
Measures
High Reliability/Redesign
Communication and Teamwork
Professional Development
49
Conclusion
The safety of patients within the health care
system depends on all levels working
together toward the common goal of patient
safety.
50
Questions?
51
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