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Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer Patient Safety Past, Present, Future.

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Presentation on theme: "Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer Patient Safety Past, Present, Future."— Presentation transcript:

1 Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer Patient Safety Past, Present, Future

2 2 Presentation Overview Introduction to Patient Safety and CPSI Nature of the Problem Evolution of Patient Safety Systems Approach vs. Medical/Community Approach Current Activities and Goals Conclusion

3 3 To provide national leadership in building and advancing a safer Canadian health system Mission 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.

4 4 Definitions Patient Safety: The reduction and mitigation of unsafe acts within the health- care system, as well as through the use of best practices shown to lead to optimal patient outcomes. Canadian Patient Safety Dictionary, 2003 Adverse Event: An adverse event is an unintended injury or complication which results in disability, death or prolonged hospital stay, and is caused by health-care management. Wilson et al

5 5 ‘Will we put the methods of science to work in the evaluation of our practices, or must we admit that no matter how much we read, study, practice and take pains, when it comes to a show-down of the results of our treatment, no one could tell the difference between what we have accomplished and results of some genial charlatan…?” Codman, 1915 Evolution of Patient Safety

6 6 What Patient Safety Is and Is Not It is not what most of us were thinking about 10 years ago It is not what ‘we have always done’ It is the most significant change in the healthcare system in over a century It is a new applied science It has forever changed the face of modern healthcare

7 7 Francoeur Committee (Quebec 2001) / Blais et al Study (GRIS, Quebec 2004) Building a Safer System: A National Integrated Strategy for Improving Patient Safety in Canadian Health Care (2002) Adverse Events in Canadian Hospitals (Baker, R. & Norton, P. et al. (2004)) –Incidence rate of 7.5% in hospitals (2000) –70,000 preventable adverse events (est.) –9, ,000 preventable AE deaths in Canada (2000) What We Know

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9 9 Canadian Institute for Health Information (2004) One in nine adults contract infection in hospital. One in nine patients receive wrong medication or wrong dose. More deaths after experiencing adverse events in hospital than deaths from breast cancer, motor vehicle and HIV combined.

10 Harvard Medical Practice Study 1995 Quality in Australian Health Care Study 1996Annenberg conferences begin 1999 Colorado / Utah Study 1999IOM Report: To Err is Human 2000BMA/BMJ London Conference on Medical Error 2000 SAEM: San Francisco Conference on EM Error 2001 British study ______________________________________________ Halifax Symposia on Medical Error 2001 RCPSC National Steering Committee on Patient Safety 2002 RCPSC Report: Building a Safer System 2004 Canadian Patient Safety Institute th Canadian Symposium on Patient Safety (Vancouver) Milestones of the Modern Era

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12 12 Adverse Events Delayed or missed diagnosesDelayed or missed diagnoses Medication errorsMedication errors Wrong side surgeryWrong side surgery Wrong patient surgeryWrong patient surgery Equipment failureEquipment failure Patient identityPatient identity Transfusion errorsTransfusion errors Mislabeled specimenMislabeled specimen Patient fallsPatient falls Time delay errorsTime delay errors Laboratory errorsLaboratory errors Radiology errorsRadiology errors Procedural errorProcedural error Lost, delayed, or failures to follow up reportsLost, delayed, or failures to follow up reports Retention of foreign object following surgeryRetention of foreign object following surgery Contamination of drugs, equipmentContamination of drugs, equipment Intravascular air embolismIntravascular air embolism Failure to treat neonatal hyperbilirubinemiaFailure to treat neonatal hyperbilirubinemia Stage lll or lV pressure ulcers acquired after admissionStage lll or lV pressure ulcers acquired after admission Wrong gas deliveryWrong gas delivery Deaths associated with restraints or bedrailsDeaths associated with restraints or bedrails Sexual or physical assaultSexual or physical assault

13 13 Why Do Adverse Events Happen? In any system or organization that involves humans, error is inevitable because there is a wide variation in performance both within and between peopleIn any system or organization that involves humans, error is inevitable because there is a wide variation in performance both within and between people Evidence is accumulating that some human dispositions towards error are hard-wiredEvidence is accumulating that some human dispositions towards error are hard-wired Only a small proportion of error is egregiousOnly a small proportion of error is egregious Ambient conditions and systemic design increase the likelihood of errorAmbient conditions and systemic design increase the likelihood of error Error has been described as the ‘essential friction’ within all systemsError has been described as the ‘essential friction’ within all systems

14 14 Sources of System Error Overall cultureOverall culture Education/Training/ExperienceEducation/Training/Experience System design / HFESystem design / HFE Resource availabilityResource availability Demand/VolumeDemand/Volume Throughput ImpedanceThroughput Impedance Shift-work/schedulesShift-work/schedules Adverse Events

15 15 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: cross sectional surveys. BrMedJour, % Positive Responses from:PilotsMedical 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%

16 16 1,000, ,000 10, DEFECTS 50% 31% 7% 1% 0.02% % SIGMA PPM Low Back TX Post Heart Attack Medications Mammography Screening Tax Advice (phone-in) (140,000 PPM) Medication Accuracy in General Airline Baggage Handling Domestic Airline Flight Fatality Rate (0.43 PPM) Sigma Scale of Measure Difficulty with Referral Comparative Reliability Between Industries Source: Institute for Healthcare Improvement

17 Imagine: $15 billion in annual purchases hand-written on slips of paper The Canadian prescription drug industry 1 billion service events scheduled manually over the phone Annual diagnostic test events in Canada An industry that does not increase productivity The healthcare industry in Canada comprises almost 10% of the economy A service industry that injured 7.5% of its customers through preventable errors (30% of injuries resulting in permanent impairment, 5-10% resulting in death) Hospital care in Canada

18 18 THEN WE HAVE HUMAN FACTORS

19 19 Human Factors “Health care is the only industry that does not believe that fatigue diminishes performance.” Lucian Leape

20 20 Human Factors Fatigue 24 hours without sleep is equivalent to a blood alcohol level of 0.10 – a 30% decrease in cognitive processing Nurses are 3 times more likely to make mistakes after 12 hours on the job Interns made 30% more errors in ICU patients when on traditional 24 hour call schedules The best countermeasure for fatigue is teamwork –more people in the movie 3 major disasters related to night time workers: Exxon Valdez, Chernobyl, and Three Mile Island. Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

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22 22 Association Between Evening Admissions and Higher Mortality Rates in the Pediatric Intensive Care Unit Yeseli Arias, Doublas S. Taylor, and James P. Marcin Pediatrics 2004; 113:

23 23 Human Factors Multitasking, Interruptions, Distractions Humans are poor multi-taskers Drivers on cell phones have 50% more accidents, 25% of traffic accidents are “distracted drivers” Interruptions and distractions increase error rates Humans need very formal cues to get back on task when interrupted and distracted Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

24 24 Human Factors Inherent Human Limitations Limited memory capacity – 5-7 pieces of information in short term memory Negative effects of stress – error rates –Tunnel vision Negative influence of fatigue and other physiological factors Limited ability to multitask – cell phones and driving Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

25 Difficulty recognizing errors Lack of information systems to identify errors Relationship of trust with providers Access is more urgent in Canada Leadership turnover Fragmentation of care delivery hampers systems thinking Patient Safety: Barriers to Action

26 Poor capital investment framework favours short term needs Shortages of clinical professionals Concern about liability Jurisdictional conflicts Simplistic approach to building the EHR Culture of patient safety is lacking

27 27 Systems Approach to Patient Safety Measurement and Evaluation Legal/Regulatory Education and Professional Development Information and Communication System Changes to Create a Culture of Safety EHR

28 28 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

29 29 Reason’s Swiss Cheese Model

30 30 CPSI Strategies and Activities Adverse Event Reporting and Learning System Root Cause Analysis National Disclosure Guidelines Safer Healthcare Now!

31 31 Development of a Canadian Adverse Events Reporting and Learning System (CAERLS) A major initiative in the 2006/07 CPSI Action Plan is to explore the development of a Canadian Adverse Event Reporting & Learning System to enable a patient safety knowledge base, create a repository and facilitate knowledge transfer to inspire innovation and safety improvement. Activity to date includes: 1.The synthesis of findings on adverse event reporting and learning systems related to: international site visits an extensive literature search and review a comprehensive review of applicable Canadian legislation and policy. 2.Development and circulation of a consultation paper outlining recommended options for a non-punitive national adverse event reporting and learning system so that the information can be sorted, integrated, evaluated and acted upon in a highly coordinated and timely manner.

32 32 The Canadian Root Cause Analysis Framework What is Root Cause Analysis? An analytic tool that can be used to perform a comprehensive, system-system based review of critical incidents. 1 History In January of 2005 CPSI partnered with ISMP Canada and Saskatchewan Health, to begin work on the development of the Framework. Goals of the partnership To standardize information and processes related to RCA in Canada. To utilize those with known expertise in use of the process and knowledge transfer of the tool to assist with the development of the framework. 1 Hoffman, C., Beard P., Greenall,J., U,D., & White, J. (2006). Canadian Root Cause Analysis Framework. Edmonton AB: Canadian Patient Safety Institute

33 33 National Guidelines for Disclosure of Adverse Events National Working Group Project Charter – full endorsement Background Document Literature Search and Review Final Draft – Feb 2007 Nationwide Consultation – Mar – April 2007 Nationwide Endorsement – May – Aug 2007 Publication and Distribution – October 2007 (Halifax 7)

34 34 Safer Healthcare Now! Interventions 1.Deploying rapid response teams 2.Improved care for acute myocardial infarction 3.Prevention of adverse drug effects 4.Prevention of central line-associated bloodstream infection 5.Prevention of surgical site infection 6.Prevention of ventilator associated Pneumonia Retrieved from or Toll free#:

35 35 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 Communication Working Group Atlantic Node Ontario Node Western Node Campaign Support SHN National Steering Committee Secretariat - CPSI Patients CCHSA CIHI Quebe c Node IHI

36 36 WestOntarioAtlanticQuebecTotal Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)] *As of January, 2007

37 37 Teams Continue to Enroll

38 38 Ventilator Associated Pneumonia (VAP) Calgary Health Region

39 39 Ventilator Associated Pneumonia (VAP) St. Paul’s Hospital (SK)  229 days since last reported VAP

40 40 Preventing Central Line Infections National Nosocomial Infections Surveillance System (NNIS) Rate

41 41 Rapid Response Team University of Alberta # CardiacICU Arrests ALOS Pre-implementation 7 (4.0 per 100 separations) 10.2 Post-implementation 1 (0.8 per 100 separations) 6.4 Total # calls 24 Source: ICU Collaborative

42 42 CPSI Strategies and Activities Research Professional Development Simulation National Hand Hygiene Campaign Patient Safety Competencies Project Executive Patient Safety Series Canadian Patient Safety Officer Course

43 43 Research –With CIHR, CHSRF and safety leaders safety research priorities –Launched 2005 CPSI grants competition 327 registered projects 125 full applications received 57 peer-reviewed 28 funded ($1.9M) –Co-funded with CHSRF two REISS programs Pediatric and Adult Acute Care, Family Medicine –Two Projects Funded with CIHR CPSI Strategies and Activities

44 44 Research /07 –Launched 2006/07 CPSI grants competition 64 full applications received 35 peer-reviewed 15 funded ($1.4M) –Launched with CIHR a Patient Safety Priority Announcement Grants Fellowships –Partner in the “Listening for Direction” health services research priority setting initiative with CHSRF, CIHR, CADTH, CH, CIHI, Health Canada, Statistics Canada –Partnered with CIHR, CADTH, CIHI, Statistics Canada, CHSRF to study post marketing surveillance and effectiveness CPSI Strategies and Activities

45 45 CPSI Strategies and Activities Professional Development - Leading the Safety Process In partnership with the CMA and the CMPA, CPSI is developing a workshop in which participants will learn: –the key best practice approaches to patient safety –how to build a culture of safety & reporting while maintaining professional accountability –how to disclose adverse events to patients –Participants will also practice the effective communication skills and techniques when confronted with critical incidents

46 46 CPSI Strategies and Activities Simulation in Canada Goal: To facilitate the development of a national simulation s trategy for healthcare Objectives To create a national vehicle for the promotion and endorsement of simulation including an infrastructure for collaboration To endorse team – focused simulation education Phases Phase 1: Endorse and Support Phase 2:Educate Phase 3:Evaluate

47 47 CPSI Strategies and Activities National Hand Hygiene Campaign The Canadian Patient Safety Institute, the Canadian Council for Health Services Accreditation, the Public Health Agency of Canada and the Community and Hospital Infection Control Association are working together to support, supplement and integrate existing hand hygiene initiatives locally, regionally and provincially, by developing and implementing a hand hygiene campaign across Canada. Campaign Goal: To promote the importance of hand hygiene in reducing the spread of healthcare associated infections in Canada Campaign Objective: To respond to the needs of healthcare organizations for capacity building, leadership development, and/or the production of tools to help promote hand hygiene

48 48 CPSI Strategies and Activities Patient Safety Competencies Project Objectives: Identify the key knowledge, skills and attitudes related to patient safety competencies for all healthcare workers Develop a simple, flexible framework that will act as a benchmark for training, educating and assessing healthcare professionals in patient safety Help make patient safety competencies easy for everyone to understand and apply

49 49 CPSI Strategies and Activities Executive Patient Safety Series Objectives: Describe how you can better fulfill your responsibilities and accountabilities for patient safety at the Board/Executive level; Understand the methods to effect a cultural shift in your organization to improve patient safety; Create and share safety practices that can be adapted and established in your organization; and Position safety in the context of quality in your organization.

50 50 CPSI Strategies and Activities Canadian Patient Safety Officer Course With the help of faculty experts, this course will be delivered through interactive workshops, networking and presentations by patient safety leaders for healthcare professionals and leaders involved in patient safety (patient safety officers, clinical managers and physicians) Overall objectives: Provide the skills to create, implement, and maintain a vigorous and focused patient safety program Help develop detailed, customized patient safety strategies and implementation plans Dates: September 24-28, 2007 Location: The Kingbridge Centre, Toronto, Ontario

51 51 Other Important Tools Resource Crew Management Briefings S-B-A-R –Situation –Background –Assessment –Recommendation

52 52 Is It Getting Better? Patient Safety

53 53 What is HSMR? HSMR track changes in hospital mortality rates in order to: –Reduce avoidable deaths in hospitals –Improve quality of care Developed in the UK in mid-1990s by Sir Brian Jarman of Imperial College Used in hospitals worldwide (i.e. UK, Sweden, Holland and US)

54 54 HSMR is easy to interpret Equal to 100 –No difference between facility’s mortality rate and average rate More than 100 –Facility’s mortality rate is higher than the average rate Less than 100 –Facility’s mortality rate is lower than the average rate

55 55 Much has Been Done … Trend in Age-Adjusted 30-Day In-Hospital Death Rate Excludes NL, QC, BC

56 56 What Does Average Mean? (Results from Baker/Norton) Extra hospital days associated with adverse events Deaths among patients with preventable adverse events

57 57 Efforts to Date (Preliminary based on data as of March 2006) > 3,200 more lives saved between Apr 04-Dec 05 vs. 03/04

58 58 But Variations Persist Distribution of HSMR for facilities with at least 2000 discharges, FY 2004/05 – Adapted international method

59 59 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. Human Error – the New View Sidney Dekker (2002); The Field Guide to Human Error Investigations

60 60 HUMAN ERRORS ARE SYMPTOMS OF DEEPER TROUBLE Human Error – the New View Sidney Dekker (2002); The Field Guide to Human Error Investigations

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63 63 Conclusion Accept that accidents are inevitable and failure will occur Accept that impact of failure can be minimized Promote a safety culture Listen to and support front-line workers Establish a framework that recognizes costs of failure and benefits of reliability Involve managers in communicating overall picture Safe and Reliable Organizations

64 64 Train managers to recognize and respond to system abnormalities Become adaptive – learn quickly and efficiently from adverse events Make knowledge about problems available throughout organization Design redundancy to create more opportunity to detect and correct Avoid shaming, blaming and organizational hubris Don’t micro-manage – allow decision migration - Croskerry, EPSS Nov 2006 Conclusion Safe and Reliable Organizations

65 65 Seven Steps to Patient Safety 1.Lead and support your staff 2.Foster a culture of safety 3.Promote reporting 4.Involve patients and the public 5.Implement solutions to reduce / avoid harm 6.Learn and share safety solutions 7.Integrate your safety management activity Adapted from: National Patient Safety Agency for the National Health Service “Seven Steps to Patient Safety – An Overview Guide for NHS Staff” Conclusion

66 66 “Culture is the vessel for crossing the chasm of quality.” - Peter Provost, MD, PhD Johns Hopkins University Medical School This image is in the public domain because its copyright has expired in the United States and those countries with a copyright term of life of the author plus 100 years or less. Focusing on a Culture of Safety “Charon on The River Styx” by Gustave Doré, 1861

67 67 “Culture eats strategy for lunch over & over again” Marc Bard

68 High Reliability Organizations are Pre-occupied with the Possibility of Failure “…there are some patients we cannot help, there are none we cannot harm...” Arthur Bloomfield, M.D. Quality of Healthcare in America Project Dr. Ken Stahl


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