Transcript Document
A-B-C’s of Patient Safety:
Bringing Your Program to Life
Mark Daly RRT, MA (Ed.)
Patient Safety Officer
McGill University Health Centre
Montreal, Quebec
Goal
Share tools and techniques to help you
develop or improve your patient safety
program.
Deliverables
Definition of patient safety
Examples of national, provincial, and
organizational frameworks to help move you
and your champions forward
Strategies to meet potential resistance
Parking Lot
Ideas for future discussion
What does the phrase
“Patient Safety”
mean to you?
Pre-work Activity 1
P
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Pre-work Activity 1: Learning Summary
1.
2.
3.
Influences
a. Years of service/experience
b. Professional affiliation
c. Job function
d. Position within the hierarchy
Teamwork
Learning environment
a. Respectful
b. Focused
c. Fun
Herding Cats
What is Patient Safety?
“…the reduction and mitigation of unsafe acts within
the healthcare system, as well as through the use
of best practices shown to lead to
optimal patient outcomes.”
The Canadian Patient Safety Dictionary, October 2003.
Josie King video
What is Sorell King asking you to do?
1.Communicate among team members
(exchange of information)
2.Listen to the patient or family member
(obligation to assess the relevance of the
information and not dismiss it)
3.Look at the patient
(not just the monitors, equipment, devices)
Frameworks
1. Accreditation Canada:
Required Organizational Practices
2. Provincial legislation:
Bill 113
3. Organizational initiatives:
The MUHC experience.
Accreditation Canada
What is Accreditation Canada?
Accreditation Canada is a national, nonprofit, independent organization whose role
is to help health services organizations,
across Canada and internationally, examine
and improve the quality of care and service
they provide to their clients.
Qmentum process Tracer Activities
REVIEW
client files and
documents
TALK and LISTEN
individual
interviews with
patients and staff/
group discussions
RECORD
what is read,
heard and
seen
OBSERVE
direct observation
and tours
What is a Required Organizational Practice?
“…pratique qui a été déterminée comme étant
essentielle et qui doit être en place dans
l’organisme pour améliorer la sécurité des
patients et pour minimiser les risques.”
“…an essential practice that organizations must
have in place to enhance patient/client safety
and minimize risk.”
Source:
http://www.accreditation.ca
15
What is a Required Organizational Practice?
Twenty-one when introduced in 2006
Thirty-five Required Organizational Practices related to
patient safety
Mandatory for all organizations
Areas include:
1. Safety Culture
2. Communication
3. Medication Use
4. Workforce/Worklife
5. Infection Control
6. Risk Assessment
What is the Essence of the ROPs?
Because we are
Relying
On you for
Patient
Safety
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Communication/Education Strategy
Pre-work Activities 2 and 3
AC Patient Safety Area: Communication
1. Required Organizational Practice:
Inform and educate patients and/or families about
their role in patient safety, using both written and
verbal communication
2. Required Organizational Practice:
Employ effective mechanisms for transfer of
information at interface points, including shift
changes; discharge; and, patient/client movement
between health care services and sectors, and
implement improvements.
Pre-work Activities 2 and 3
AC Patient Safety Area: Communication
ROP exercise
1. Who was involved in the development
of the tool?
2. Describe the major challenge the
group faced.
3. Describe the major reason the
initiative was successful.
4. How is the tool shared with the
patient/family or staff?
Reporting adverse events and near misses:
Provincial legislation
Bill 113: An Act to amend the Act respecting health
services and social services as regards the safe
provision of health services and social services
Enacted in December 2002
Patient’s right to be informed
Disclosure policy
Process to review accidents and develop
improvement strategies
Confidentiality of the process: information is not
discoverable
Mandatory risk management committee
Reporting adverse events and near misses:
Organizational framework
1. Committee on Quality and Risk Management
Created in 1998
Reports to the Board
1. Patient Safety Committee
Created in 2004
Compiled an inventory of committees and functions
that address risk/safety
Reviews all sentinel events
Reports to the Committee on Quality and Risk
Management
Reporting adverse events and near misses:
MUHC sentinel event policy
Implemented in 2005
Use a standardized framework to manage the
process
Ensure an objective process
Identify contributory factors
Develop an action plan to minimize the likelihood of a
similar event affecting a subsequent patient
Knowledge transfer and organizational learning
Outcome of using a framework:
Code Stroke Algorithm
Session 1 Review
“Patient Safety” has a variety of meanings
Sorell King asked us to:
Communicate among team members
Listen to the patient
Look at the patient
Frameworks:
Accreditation Canada:
Required Organizational Practices
Provincial legislation
Organizational initiatives
Learning from adverse events involves
implementing change
Name some changes you have
experienced with respect to
patient safety.
Juggling Change
START 1
END
END
START 2
Team Juggling
Discussion Questions
1. How did you feel after each change was
introduced?
2. What made the process work well?
3. What hindered the process?
4. What is one lesson you learned from this
exercise?
Sacred Cows1
Definition:
“An outmoded belief, assumption, practice,
policy, system, or strategy, generally invisible,
that inhibits change and prevents
responsiveness to new opportunities.”
1.
Kriegel, R., Brandt, D. (1996). Sacred cows make the best burgers: Paradigm busting strategies
for developing change-ready people and organizations. New York, NY: Warner Books, Inc.
Sacred Cows
1. Rounding up sacred cows
2. Developing a change ready environment
3. Turning resistance into readiness
4. Motivating people to change
5. Developing change-ready traits
Sacred Cows:
Step 1 – Rounding up sacred cows
Challenging assumptions
Why are we doing this …?
What if it did not exist?
Is someone else doing this already?
When did this practice start?
Can someone else do it better?
Sacred Cows:
Step 2 – Developing a change ready environment
Building trust
Characteristics of a change ready environment:
Trust
Honesty: Can you believe what they (PSO) say?
Integrity: Do they keep their promises?
Openness: Do they share what they know?
Caring
Respect
Empathy: Standing in someone else’s shoes
(situational awareness?)
Acknowledgement: Simple and sincere recognition
Sacred Cows:
Step 3 - Turning resistance into readiness
Resistance Drivers
Fear: “What if I look stupid/fail”
Feeling powerless: “No one asked me”
Inertia: “It takes too much effort”
Absence of self-interest: “WIIFM phenomenon”
“People don’t resist change as much as they resist
being changed.” Christopher Hegarty
Sacred Cows:
Step 4 - Motivating people to change
Urgency: What happens if the change is NOT
implemented
Inspiration: What are the possibilities, creating a
shared vision
Ownership: Via participation in the definition of the
problem and the solution/change to implement
Rewards and recognition: Extrinsic and intrinsic
(recognition, flexibility, creativity)
Sacred Cows:
Step 5 - Developing change-ready traits
1. Resourcefulness
5. Adaptability
2. Optimism
6. Confidence
3. Adventuresomeness
7. Tolerance for
ambiguity
4. Drive
Change Management Strategies:
Sharing a Story
Change Management Strategies:
Goal setting – S.M.A.R.T
S
M
A
R
T
Specific
Measurable
Attainable
Realistic
Timely
Change Management Strategies:
Goal setting – S.M.A.R.T
Specific
Emphasize what you want to happen
Address the following questions:
Who is involved?
What do we want to accomplish?
Where will the activity take place?
Why will this activity improve patient
safety?
E.g. “I want to lose weight”
Change Management Strategies:
Goal setting - S.M.A.R.T
Measurable
Keeps you on track
Establishes a target
Provides motivation when targets are met
Quantifies the outcome
E.g. “I want to lose 20 pounds.”
Change Management Strategies:
Goal setting - S.M.A.R.T
Attainable
Can you do it?
“Small wins”
Set your team up for success by making
the goal within reach
Capitalize on the synergy of an
interprofessional team to ensure all
aspects of the goal are considered
Change Management Strategies:
Goal setting - S.M.A.R.T
Realistic
Striking a balance between what you
want to accomplish and the
resources/environment currently
available to help you achieve your goal.
Change Management Strategies:
Goal setting - S.M.A.R.T
Timely
Establish an end point to the activity
Helps create a sense of urgency
I want to lose weight
I want to lose 20 pounds
I want to lose 20 pounds by November 31, 2009
Is this goal S.M.A.R.T?
Pre-work Activity 4
Goal Setting: Your example
Review your patient safety goal
Discuss this goal with your colleagues
Describe why the goal is S.M.A.R.T
Select one goal to share with the other
participants
Improvement model/framework:
Plan, Do, Study, Act
• Developed by Dr. Walter Shewart
• Modified by Dr. W. Edwards Deming
• Rapid cycle test-of-change model
Improvement model/framework:
Plan, Do, Study, Act
Act
What modifications are to
be made?
Next cycle?
Study
Complete analysis of the data
Compare data to predictions
Summarize what was learned
Plan
Objective
Questions & predictions
(What will happen and why?)
Plan to carry out the cycle
(Who, what, where, when?)
Do
Carry out the plan
Document problems and
unexpected observations
Begin analysis of the data
O2 Ticket to Ride
O2 Ticket to Ride
Learning Summary
1.
2.
3.
4.
Definition of patient safety
Frameworks for program development
a. AC – Required Organizational Practices
b. Provincial legislation
c. Organizational initiatives
Frameworks for managing change
a. Sacred cows (challenging assumptions, sense of
urgency, turning resistance into readiness)
b. Sharing a story
c. S.M.A.R.T goal setting
Improvement model/framework
a. PDSA rapid cycle test-of-change
"We cannot change the human condition,
we can change the conditions under
which humans work."
Reason, J. (2000). Human error: Models and management.
BMJ, 320, 768-770.
McGill University Health Centre
Quality, Patient Safety, Performance Improvement
Questions and Comments?
Mark Daly
Patient Safety Officer
514-934-1934 local 35662
[email protected]
Supplemental Reading List
• Bagian, J.P. (2001). Developing and deploying a patient safety program
in a large health care delivery system: You can't fix what you don't
know about. Journal on Quality Improvement, Joint Commission on
Accreditation of Healthcare Organizations, 27:10, 522-532.
• Daly, M. (2006). The McGill University Health Centre policy on sentinel
events: Using a standardized framework to manage sentinel events,
facilitate learning and improve patient safety. Healthcare Quarterly:
Patient Safety Papers, 9, 28-34.
• Patient safety program manual. (2006). Retrieved July 1, 2007, from
http://www.dhs.ca.gov/lnc/download/PSPM/PatientSafetyProgramManu
al09-20-2006.pdf
• Stevens, P., Matlow, A., & Laxer, R. (2005). Building from a blueprint for
patient safety at the Hospital for Sick Children. Healthcare Quarterly:
Patient Safety Papers, 8, 132-139.
• Zimmerman, R., Christoffersen, E., Shaver, J., & Smith, T. (2006). A
framework for local accountability for patient safety. Healthcare
Quarterly: Patient Safety Papers, 9, 65-68.