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
CCHSA
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 organization-
acquired 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 Centre-
wide 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