Patient Safety: New Trends and Strategies for Implementation

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Patient Safety New Trends and
Strategies for Implementation Canadian College
of Health Service Executives March 2006
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• Speakers
• Donna Towers, CHE
• Capital Health (Alberta)
• John King, CHE
• St. Michaels Hospital, Toronto
• Anne McGuire, CHE
• IWK Health Centre, Halifax

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• Outline
• Canadian College of Health Service Executives
• Collaboration to date on the common patient
  safety agenda
• The executives role in patient safety
• Practical examples
• Capital Health (Alberta)
• St. Michaels Hospital
• IWK Health Centre

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Canadian College of Health Service Executives
(CCHSE) A professional association with
3,000 members across all sectors of health
services.
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CCHSE Vision and Mission Vision To be the
professional association of choice for Canadas
health leaders Mission To develop, promote,
advance and recognize excellence in health
leadership
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• 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

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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

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• 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

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Collaboration and Cross Representation

• CCHSE is a voting member of CPSI
• CPSI is a corporate member of CCHSE

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• Colleges 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

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CCHSA
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• Health Executives Role
• in Patient Safety
• Culture
• Accountability
• Measures
• High Reliability/Redesign
• Communication and Teamwork
• Professional Development

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• 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

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• 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

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• 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

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• 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

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• Measures

• Develop reporting policies within a quality
  improvement framework across the organization
  that promote learning
• Executives role is to ensure appropriate
  reporting and monitoring mechanisms are in place

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• 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)

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• 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

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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

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• 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

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• 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

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• 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

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• 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

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St. Michaels Hospital Safety Program and Plan

• Mr. John King, CHE
• Executive Vice President

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St. Michaels 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

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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

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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)

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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.

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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 (OHAs Your Healthcare.
  Be Involved)

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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)

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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

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Positioning Patient Safety on the Strategic Agenda

• Anne McGuire, CHE
• President CEO
• IWK Health Centre

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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
• Childrens Mortality Committee
• Perinatal Peer Review Committee
• Nursing Professional Practice Committee
• Infection Control Committee
• Professional Practice Committee
• Medical Advisory Committee

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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

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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

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Step One

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

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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

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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

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Step Four

• Centralized all supports and programming related
  to patient safety under the Centralized Quality
  Division
• All Quality Improvement Coordinators
• Infection prevention and control

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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)

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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

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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

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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

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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

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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

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Step Nine

• Communicated patient safety initiatives
• PULSE (IWK intranet)
• Leadership Forums
• Town Halls
• IWK website (patient safety component under
  development)
• Etc

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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

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• 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

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Conclusion The safety of patients within the
health care system depends on all levels working
together toward the common goal of patient
safety.
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Questions?