1. Solutions for Patient Safety: A model for patient safety collaboration based on High Reliability CAPHC Patient Safety Symposium October 18, 2015

2. In our own back yard: The Canadian Pediatric Adverse Events Study 3.6% of pediatric admissions in Canada involve a preventable adverse event Matlow et al, CMAJ. 2012. 4

3. “O N THE FAR SIDE OF COMPLEXITY LIES PROFOUND SIMPLICITY ” Knowledge often moves in three phases: 1.A superficial simplicity; 2.confusing complexity, as underlying, previously unidentified problems surface; 3.finally, profound simplicity. Karl Weick, Professor of Organizational Behavior and Psychology, University of Michigan. Slide courtesy K. Shojania.

4. S IMPLICITY AND C OMPLEXITY IN 15 YEARS OF P ATIENT S AFETY 1.Superficial simplicity: emulate other high risk industries – incident reporting, “systems approach,” checklists 2.confusing complexity – multiple safety targets, implementation problems, changing evidence 3.finally, profound simplicity – teamwork, communication, culture Slide courtesy K. Shojania.

5. 1. Preoccupation with failure Knowing about the last failure, looking for potential failures, regarding small errors as significant 2. Sensitivity to operations Paying attention to what’s happening on the front-line 3. Reluctance to simplify Encouraging diversity in experience, perspective, and opinion. Asking “five why’s” 4. Commitment to resilience Developing capabilities to detect, contain, and bounce-back from events that do occur 5. Deference to expertise Pushing decision making to the person with the most related knowledge and expertise, regardless of rank High Reliability Organizations (HROs) )) 7

6. Serious Safety Event: Event involving a deviation from GAPS causing moderate to severe harm © 2006, HPI, LLC Precursor event: Event that DID reach patient but resulted in minimal or temporary harm. Near Miss: Event that almost happened, but error was caught Critical Incident Serious Patient Safety Incident 12 CI SPSI SSE PRECUSOR EVENT NEAR MISS EVENT

7. HOW CAN WE GET BETTER, FASTER AT CARE WITHOUT HARM? 14

8. The Children’s Hospital’s Solutions for Patient Safety (SPS) Mission: to eliminate serious harm across all children’s hospitals in the US. How Did SPS Begin?  2005: 6 Ohio Children’s Hospitals CEOs form The Ohio Children’s Hospital Association (OCHA)  2009: Expands to all 8 Children’s Hospitals  Ohio Children’s Hospitals Solutions for Patient Safety (OCHSPS) 15

9. Taking on all sources of serious harm simultaneously: Healthcare Acquired Conditions and Serious Safety Events Adverse drug events Falls Central line infections Thromboembolism Surgical site infections Catheter-associated Urinary Tract Infection Ventilator associated pneumonia Pressure ulcers Potentially preventable Multifactorial causation  Traditional QI methods HACs SSEs Diagnostic errors Delays in definitive care Delays in recognizing deterioration Errors in medical or surgical decision-making Technical errors Slips/lapses Definitely preventable Discrete causation  Error reduction strategies  System redesign 16

10. Ohio Children’s Hospitals Results  Saved 7,700 children from harm  Avoided $11.8 million in unnecessary health care costs  2012: 25 hospitals from across the nation join a second wave to create the Children’s Hospital’s Solutions for Patient Safety (SPS) network.  2013 : SPS network adds a third wave and grows to 80 hospitals in 33 states (25% of US pediatric hospitalizations are covered by this network)  2015: Sickkids first non-US hospital to join network 17

11. Key Collaboration Philosophies:  Eliminate competition between hospitals on safety  “All teach, all learn”  Standard definitions e.g. SSER -- Serious Safety Event Rate  Creation, implementation and relentless auditing of prevention bundles for Hospital Acquired Conditions (HACs).  Data analysis and transparency across the collaborative. 22

12. Key Actions for Improvement: Articulation of safety goals in strategic plan Executive engagement in patient safety Building knowledge of patient safety science All-staff engagement in key safety behaviors and error prevention techniques Training for all leaders and all staff Perpetual effort: Relentless pursuit of elimination of preventable harm, NOT BENCHMARKING 23

13. WHAT CAN WE EXPECT? 24

14. After intervention implementation, the number of SSEs per 10,000 adjusted patient days significantly decreased from a mean of 0.9 to 0.3 (p<0.0001) Days between SSEs increased from a mean of 19.4 to 55.2 26