Strategic priorities in Patient Safety. Philip Hassen. IV International Conference on Patient Safety. (Madrid, Ministry of Health and Consumer Affairs, 2008)
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Strategic priorities in Patient Safety
1. Advancing Patient Safety-
Canada’s Vision for the Future
IV International Conference on Patient Safety
November 25, 2008
Philip Hassen, CEO
Canadian Patient Safety Institute
1
2. Overview
• Canadian Health System
• OECD-Comparing Spain, Canada, Other
• Background CPSI
• Concluding Remarks/Questions
2
3. Canadian
Population in
2006 was at 32.5
Million
Canadian health-
care spending for
2007 will reach
$160.1 billion.
Public-sector
health care
spending
forecast
projected to
reach 70.6%.
Private-sector
health-care
spending
forecast
projected to
reach 29.4%.
3
4. 4
Canadian Health System Key Differences
Highlighted
• one fully socialized health care system
• Federal government funds the provincial government
as long as they abide by the Canada Health Act which
explicitly prohibits end user billing for procedures
covered through the publicly funded system
• All provinces except Ontario have "mature" Regions
• These are vertically and horizontally fully integrated
health and health care under one organization
• Focuses as much on population as individual health
Canadian Government Involvement
Central structural difference is in health insurance
5. OECD Health Data 2007
3.8
3.4
2.8
4.0
0.0
1.0
2.0
3.0
4.0
adaFrance Italy United
States
OECD
Ave
Acute Care Hospital Beds
per 1000 Population
2004
3.9 4.1
6.8
5.7
0.0
2.0
4.0
6.0
8.0
anadaFrance Italy United
States
OECD
Maternal and Infant Mortality
Deaths per 1000 Live Births
2004
Canada Spain
Canada Spain
29
26
53
40
Health Employment
Health Employment
Practicing PhysiciansPracticing Nurses
Density per 1000 Population (Head Counts) Density per 1000 Population (Head Counts)
2005
16.0
4.7
15.0
0.0
9.9
France Italy United
States
OCEDAveSpain
81
Canada
55
4.0
14.0
3.5
12.0
3.0
10.0
2.5
8.0
2.0
6.0
1.5
4.0
1.0
2.0
0.5
0.0
0.0
3.4
3.8
2.4
3.0
France Italy United
States
OCEDAve
2005
Canada Spain
22
39
OECD Health Data 2007, October 2007
Not Available
5
6. OECD Health Data 2007
Health expenditure as a share of GDP, OECD countries, 2005
15.3
11.1 10.7
9.8 9.2 9 8.9 8.3 8.2
7.5
0
2
4
6
8
10
12
14
16
18
U
nited
States
France
G
erm
any
C
anadaN
etherlands
O
EC
D
Italy
U
nited
Kingdom
Spain
Ireland
%GDP
OECD Health Data 2007, July 2007
6
7. 7
• Patients for Patient Safety Patients for Patient
Safety
• Global Patient Safety Challenges:
• Clean Care is Safer Care (GPSC 1)
• Safe Surgery Saves Lives (GPSC 2)
• Reporting & Learning
• Classification
• Research
• Safety Solutions and High 5s
Alliance Programmes
8. Canadian Patient Safety Institute
Mission
To provide national leadership in building and
advancing a safer Canadian health system
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.
8
9. Patient Safety: Barriers to Action
• Access is more urgent in Canada
• Shortages of clinical professionals
• Concern about liability
• Jurisdictional conflicts
• Delays in building the Electronic Health
Record
• Culture of patient safety is lacking
9
10. 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, 3-18-2000.
% Positive Responses from: Pilots Medical
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%
10
12. Human Error – the New View
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.
Sidney Dekker (2002); The Field Guide to Human Error Investigations
12
15. Human Error – the New View
HUMAN ERRORS ARE
SYMPTOMS OF DEEPER
TROUBLE
Sidney Dekker (2002); The Field Guide to Human Error Investigations
15
16. 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
16
19. Examples of Collaboration &
Partnerships
Canadian Institute for Health Information • Hospital Standardized
Mortality Ratio (HSMR)
Institute for Safe Medication Practices • Canadian Root Cause
Canada and Saskatchewan Health Analysis Framework
Canada Health Infoway • Patient Safety and the
Electronic Health Record
Community and Hospital Infection Control • Canada’s Hand Hygiene
Association, Canadian Council on Health Campaign
.
Services Accreditation, Public Health Agency
of Canada
World Health Organization • Patients for Patient Safety
Canada; High 5s
Ministère de la santé et des services • Projet de formation sur les
facteurs humains
sociaux (Québec)
Canadian Council on Health Services • Align efforts
Accreditation, HIROC
19
20. CPSI Strategic Direction
Education
Executive Patient Safety Series
Governance for Quality and Safety
Canadian Patient Safety Officer Course
Simulation
IHI Re-broadcast
Halifax Conference
Studentships
Patient Safety Competencies
Canada’s Forum on QI and Patient Safety
.
Interventions & Programs
World Health Organization High 5’s
Patients for Patient Safety Canada
Infection Control
Hand Hygiene Campaign
Safer Healthcare Now!
Research
Home Care
Long Term Care
Mental Health Services
Emergency Medical Services
Primary Health Care
Building Capacity through Research
Tools & Resources
Event Analysis
Electronic Health Record
Canadian Disclosure Guidelines
Canadian Adverse Event Reporting and
Learning System
WHO Safe Surgery Saves Lives
Human Factors
20
21. Education
Governance for Patient Safety
• National leadership, coordination and collaboration with
current provincial/territorial and regional initiatives
• Co-commissioned research - partnership with CHSRF
• “Effective Governance for Quality and Patient Safety
in Canadian Healthcare Organizations” (Baker,
Denis, Pomey & MacIntosh Murray, 2009)
• Development of a framework and supporting tools,
resources and education to assist boards in their
understanding of and efforts to improve patient safety
2121
22. Education
Education
Simulation GOAL:
• To establish a national coordinating group
to promote and endorse simulation and
provide a foundation for collaboration (or:
“framework for the sharing of resources”)
• To facilitate the development of a national
simulation strategy for healthcare through
focused collaboration with
stakeholders
22
23. Education
Halifax Conferences
• Annual National Patient Safety Conference
Patient Safety Officer Course- One week
intense education/training session
Patient Safety Competencies
• First edition released September 25, 2008.
Activities for dissemination and stakeholder
engagement are underway
23
24. Research
• Over 60 research and demonstration
projects have been funded in the last three
years, these will form the basis for new
knowledge of Canadian patient safety
challenges and solutions
• Work Collaboratively with Other Research
Funding Groups
• Research Dollars Spent to date:
$5.8Million
24
25. Research
Building Capacity Through Research
• Development of Patient Safety background papers
to identify the current state of knowledge, future
research priorities, key issues, and strategies and
opportunities for action and improvement:
• Mental Health Emergency Medical Services
• Primary Health Care
• Home Care
• Long-Term Care
2525
26. Interventions & Programs
Patients for Patient Safety:
Why?
• More to offer than simply the ‘victims’ story of tragic
medical error.
• Consumers offer the richest resource of information
related to medical errors as many have witnessed
every detail of systems failures from beginning to end.
• Patients want to know the truth when things go wrong
and be treated with honesty and openness rather than
face a closed door of denial
26
28. Interventions & Programs
Canada’s Hand Hygiene Campaign
Hand Hygiene Campaign Goals:
• Promote the importance of hand hygiene in reducing the
occurrence of healthcare associated infections
• Respond to the needs of healthcare organizations for
capacity building and leadership development by
creating and providing them with tools to help promote
good hand hygiene
SHN MRSA Intervention Goals:
• Enable healthcare organizations and caregivers to
prevent patient harm from MRSA
• Reduce MRSA infection rates
28
29. Interventions & Programs
Canada
• 33 million people
• 10 interventions + 2
pilots
• 1035 teams enrolled
• 80% of acute care
hospitals enrolled
• All regional health
organizations outside of
Quebec enrolled
Aim
• Reduce adverse events
by 40-100% according to
intervention
www.saferhealthcarenow.ca
30. Interventions & Programs
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
Communications
Advisory Group
Atlantic
Node
Ontario
Node
Western
Node
Campaign Support
SHN National Steering Committee
Secretariat - CPSI
Patients
CCHSA CIHI
Quebec
Campaign
IHI
30
31. Interventions & Programs
SHN Interventions
Initial Interventions
• Improve Care for Acute Myocardial Infarction
• Prevention of Central Line Associated Bloodstream Infection
• Medication Reconciliation
• Rapid Response Teams
• Prevention of Surgical Site Infection
• Prevention of Ventilator-Association Pneumonia
New Interventions
• Prevention of Adverse Drug Event
in Long-Term Care
• Prevention of Harm from Falls in
Long-Term Care
• Prevention of Harm from MRSA
• Improve Care for Venous
Thromboembolism (VTE)
Pilot Projects
• Prevent Adverse Drug Events
Related to High Risk Medication
Delivery in Paediatrics
• Prevent Adverse Drug Events
Through Medication Reconciliation in
Home Care
31
32. Interventions & Programs
Safer Healthcare Now!
Teams Continue to Enroll
Total # of Enrolled Teams
Sep-05 Nov-05 Jun-06 Nov-06 Jan-07 Mar-07 Jun-07 Aug-07 Oct-07 Jan-08 Mar-08 Apr-08
May-08 Jul-08 Aug-08 Oct. 08
Safer Healthcare Now! Overview Total # Enrolled Teams
September 2005 to September 2008
118
296
443
546
579
628
695
734
789
817
860
933
962
1004
1021
1050
0
100
200
300
400
500
600
700
800
900
1000
1100
Total at September 23, 2008
33. M
onth
13
M
on
th
13
Interventions & Programs
SHN: End of Phase I – January 2007
Med Rec Results – Unintentional
discrepancies
È from 1.16 to 0.65 per patient (goal of 0.30)
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Months in SHN!
Ventilator-associated Pneumonia
Central Line-Associated Blood Stream Infections
�bloodstream infections 4.8 per 1,000 central line days
to 1.6
6
5
4
3
2
1
0
M onths in SHN!
Rapid Response Team
� in the national rate for VAP from a baseline of 19.88 per â
1,000 ventilator days to 3.76 after 13 months, (goal was 7.00)
Rate
18
16
10
14
812
10
8
6
4
2
0
6
4
2
0
national rate of Codes (occurring outside ICU)
per 1,000 discharges from 7.46 to 4.61,
Months in SHN
Months in SHN
33
34. Tools & Resources
Event Analysis
• The French adaptation for the Canadian Root Cause
Analysis Framework is completed and Failure Mode
Effect Analysis is in progress
Electronic Health Record
• Plans are underway to examine the role of EHR as it
relates to the process of medication reconciliation
Canadian Disclosure Guidelines
• Are available on the CPSI website.
34
35. Tools & Resources
Canadian Adverse Event Reporting and Learning
System (CAERLS)
• The CAERLS Consultation Paper is available on the CPSI
website. Planning for consultation meetings to be held
throughout Canada are currently underway.
WHO “Safe Surgery Saves Lives”
• An in-country working group has been assembled to adapt
the Safe Surgery Checklist for use in Canada
Human Factors
• Development of educational strategies is being
contemplated to assist organizations to better understand
this important area of patient safety
35
36. Other Challenges and Key Issues
• Develop other indicators
• Build patient safety expert capacity
• Collaborate and Increase Engagement (F/P/T,
“patient safety” agencies/organizations)
• Keep patient safety on the national agenda;
inform the public, patients, providers, policy-
and decision-makers
• Misdiagnosis
• Culture of Patient Safety
36
37. Summary
Patient Safety
• CPSI is “leading without owning” resulting in
significant and measurable patient safety
improvements by many Healthcare
organizations in just three years of operations
• Safer Healthcare Now! is a pan-Canadian success
story – “changing the face of safety in the Canadian
healthcare system”
• The success of CPSI will continue to be assessed with
the emergence of Hospital Standardized Mortality
Ratios and other measures
37
38. Commitment to Our Patients
“…there are some patients
we cannot help,
there are none
we should harm...”
Dr. Ken Stahl
38