1. 1 The Quebec situation: a view from the trenches OCHU conference on The Epidemic of Medical Errors, June 4 th, 2012 Presented by Marc Pineault Coordinator – Quality and Risk Management St. Mary’s Hospital Center

2. 2 I have no vested financial interests in any activity that promotes patient safety The views in this presentation are my personal views and do not bind or represent my employer’s views Disclaimer

3. 3 Outline of the presentation Introduction and Quebec context Legislative measures The good The challenges Future perspectives… or what we need to win the war

4. 4 Introduction and Quebec context Quebec healthcare system in a nutshell  Regulatory framework is based on Canadian Healthcare Act – 5 conditions  The government regulates the size of the coverage basket of services (RAMQ)  Hierarchy is centralized at the MSSS level, and regional delegation through regional health boards (18)  95 CSSS (85% of which have a hospital but also include CLSC’s, LTC facilities), geographically based  CHA, Institutes, and 4 University Hospitals

5. 5 Introduction and Quebec context Quebec healthcare system in a nutshell (continued)  2000 private clinics and family medicine groups  Over 3000 community organizations  Long-term care facilities  Rehabilitation centers  Youth protection  Private institutions (private long-term care, community pharmacies, non-institutionalized resources, etc.)

6. 6 The Quebec Context In the world, To Err is Human Australian study UK study The Quebec stories and study

7. 7 Legislative measures adopted in 2003 Became mandatory to: Disclose accidents to patients and family Have a Board of Directors by-law for disclosure Define support measures for patients and family Report incidents/accidents Put in place measures to prevent recurrence

8. 8 Legislative measures adopted in 2003 Create a risk management committee Create a local registry of incidents/accidents Follow an accreditation process (since 2011, mandatory to be accredited) Transmit a summary of the report to authorities (since 2011, made public) Annual report must contain risk management activities conducted during the year

9. 9 Legislative measures adopted in 2003 In addition to a local registry, a national registry was to be put in place This took over 8 years to accomplish!!! And what did we learn? You’ll soon see…

10. 10 The good Improvements were observed in increased transparency: With victims and families through the disclosure process (CMPA, CPSI guidelines, etc.) Through the development of a structured reporting system In institutions, through the accreditation process, the reporting of results, and the obligation to report on risk management activities in the annual report Disclaimer: none of these claims are necessarily scientifically-based but are based on experience

11. 11 The good (continued) Focus on patient safety has increased in health institutions through the local registry, through the activities of the risk management committees, and through the accreditation process that focuses on patient safety The increase in expertise on patient safety within health institutions has also increased the responsiveness of organizations to correct and prevent adverse events Disclaimer: none of these claims are necessarily scientifically-based but are based on experience

12. 12 The good (continued) Some tools to support institutions: Training for risk management committees Purchase and adaptation of the Australian human factors and patient safety program called ErroMed ©

13. 13 The good (continued) Infection control: Mandatory reporting and public disclosure of infection rates for C-diff since 2005. Standardized ratio of infection control personnel per hospital bed established Effort put into guidelines and methods of prevention

14. 14 The challenges Disclosure: despite efforts, telling patients that something went wrong remains taboo in many areas and with many professionals Accreditation process: the cycle has been increased to 4-years, posing a risk that institutions will not pay attention to patient safety issues during 2 of the 4 years in the interval between visits Expertise in patient safety within institutions has not been recognized by the Ministry (i.e. risk managers and patient safety officers)

15. 15 The challenges (continued) Reporting system: The focus on reporting and the birth of the national registry has put emphasis on the management of reporting forms, and less on prevention

16. 16 The challenges (continued) “National” registry: 179,011 events were reported in 6 months 10% were incidents, 65% were accidents, and 25% were undetermined Falls and medication were the 2 highest reported events 1/5 events required only monitoring 1/10 events required non-specialized interventions 2/100 events required specialized interventions 4/1000 events required increased level of care or increased the length of stay

17. 17 The challenges (continued) “National” registry: But what does this mean? Validity of the data 25% undetermined severity! Rates? What do institutions report? What’s the purpose vs what was the legislator’s intent 10 years ago?

18. 18 The challenges (continued) Tools to increase patient safety: Risk management committee training quickly outdated and was finally upgraded in 2011; many senior trainers dropped off Human factors training program was not sufficiently supported and has lost momentum through high turnover at the MSSS level

19. 19 The challenges (continued) Infection control: Efforts seem to not be heard by some professionals Uneven attention to the risks involved Inter-institution transfers seem to remove ownership of problem Disclaimer: none of these claims are necessarily scientifically-based but are based on experience

20. 20 Future perspectives: what the Ministry is hinting Continue presenting numbers; no communicated plan as to how to improve the report Based on the frequency, create “expert groups” to find solutions Human factors is still in limbo, after 7 years, decisions based on erroneous information from the Regional Health Authorities

21. 21 Support for training in Human Factors and patient safety Data that is meaningful Recognition that some issues are solvable at the Ministry level; but that most are at the institution level Future perspectives: what the Ministry is hinting

22. 22 Future perspectives: what the true stakeholders need To stop looking at humans as being the problem; to err is human; to implement a culture of why’s not who’s Transforming Dr Seuss’s Whoville into Whyville Empower the front liners to be able to implement change instead of implementing more centralized control

23. 23 Thank you for your attention Merci beaucoup de votre écoute