Building a Safer System Together: The Role of the Canadian Patient Safety Institute

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Building a Safer System Together The Role of
the Canadian Patient Safety Institute
Presentation to CAPHC November 7, 2004 John Wade,
MD, FRCPC Chair, Board of Directors
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PRESENTATION OVERVIEW

• Understanding and defining patient safety and
  adverse events
• Background/What we now know
• Baker, R. Norton, P. et al. (2004)
• Forster, J. et al. (2004)
• Canadian Safety Patient Institute
• Mandate and vision
• Workplan
• Future Challenges

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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 (Bad outcomes from care)
• 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

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Swiss-cheese Model
Reason, J. (2000) Human error models and
management. BMJ 320 (7237) 768-70
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Patient Safety History

• Pioneering work
• Snow to Beecher, Manitoba Outcome Study,
  Anesthesia
• System-wide/national reviews
• Harvard study
• UK, Australia, NZ
• Baker Norton

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Patient Safety Status in Canada

• 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 - 24,000 preventable AE deaths
• 1.1 million additional hospital days
• Comparable to similar health systems
• Ottawa Hospital Patient Safety Study (Forster, J.
  et al. 2004)
• 61 of adverse events occurred before index
  hospitalization
• Health Care in Canada 2004 Focus on Safe Care
• (Canadian Institute for Health Information)

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Baker Norton Findings Procedures or events to
which AEs were related, by service most
responsible for delivery of care at time of AE
i Physician reviewers could attribute events to
more than one type of procedure ii AEs not
covered in previous categories i.e. burns,
falls iii System events include AEs that cannot
be attributed to an individual or specific
sources e.g. communication, reporting, lack of
equipment
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Types of Adverse Events
Sharp End Immediate Cause(s)
Sharp End Examples Medication AEs,
Nosocomial Infections
Patient / Health Care Provider / Team / Task and
Environmental Factors
Contributing Factors
Blunt End Underlying Cause(s)
Blunt End Examples Communications Culture
Physical Environment Policies /
Procedures
Management/ Organizational/ Regulatory Factors
Root Cause(s)
Adapted from the NHS Report Doing Less Harm,
2001
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What Needs To Be Done

• Further research
• Types of AEs and contributing factors
• Acute care and beyond
• Greatest gains will come from
• Modifying work environments
• Creating better defenses
• Need
• Leadership to encourage reporting
• Continue to monitor incidences
• Apply new technologies
• Improve communication and coordination
• Ways to monitor for continuous improvement
• Baker, R. Norton, P. et al. (2004)

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Canadian Patient Safety Institute

• Governance
• Mission
• Mandate
• Business Plan

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Board of Directors

• Non-governmental Directors
• John Wade, Chair
• Wendy Nicklin
• James Nininger
• Brian Postl
• Denis Roy
• Bonnie Salsman
• Provincial/Territorial Directors
• Patricia Petryshen
• David Rippey
• George Tilley

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Governance

• Not-for-profit corporation
• Separate legal entity
• Arms length independence consistent
• with mandate and guiding principles
• Fully transparent and accountable

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Limits

• CPSI will not have a role in
• Overseeing, managing or prescribing practices for
  delivering health care
• Regulating the health professions
• Approving devices, drugs, technologies or
  interventions

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

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Mandate

• Provide leadership on patient safety issues
• Advise governments, stakeholders and public on
  effective strategies
• Foster information sharing
• Influence culture change
• Support systems change
• Collaborate with stakeholders in an ongoing
  dialogue on patient safety

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What does the Institute mean for the Canadian
health-care system?
Measurement and Evaluation
Legal/Regulatory
System Changes to Create a Culture of Safety
Education and Professional Development
Information and Communication
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Strategic Business Plan

• Theme 1 Define Patient Safety Issues
• Theme 2 Identify Leading Practices and
  Effective Interventions
• Theme 3 Champion Change

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Theme One Define Patient Safety Issues

• Highlights
• Provincial/Territorial Consultation Workshops
  across Canada
• Obtain feedback on strategic business plan
• Learn about local patient safety issues and
  initiatives
• Obtain feedback on recommended priorities for the
  Institute.

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Theme One Define Patient Safety Issues

• Highlights (continued)
• Sponsor an annual national conference to discuss
  major patient safety issues and the progress made
  in addressing them
• Platinum sponsor of Halifax 4
• Create a national storehouse of patient safety
  information, beginning with environmental scan
  and identification of patient safety indicators

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Theme Two Identify Leading Practices and
Effective Interventions

• Highlights
• Increase scope and scale of research
• Promote access to tools for root cause analyses
  and case studies
• Support learning opportunities
• Develop a standardized and validated patient
  safety curriculum
• Safety champions
• Leadership development
• Simulation-based, multi-disciplinary training

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Theme Three Champion Change

• Highlights
• Support innovation and technology
• Example Canadian Medication Incident Reporting
  and Prevention System
• Develop legislative model
• Example Saskatchewan critical incident
  legislation and root cause analysis framework.
• Increase public awareness
• Develop national policy guidelines regarding
  disclosure and patient/provider communications

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Taking Action

• Management team
• Don Schurman, Interim CEO
• Judith Dyck, Consulting Director of
  Communications
• Joseph Gebran, Director of Corporate Services
• Carolyn Hoffman, Director of Operations -Ontario
  to B.C.
• Pierrette Leonard, Director of Operations
  Quebec and Eastern Canada

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Taking Action (continued)

• Stakeholder Advisory Network
• Establish network of advisory committees,
  including
• Education/Professional Development
• Health System Innovation
• Legal/Regulatory
• Research/Evaluation
• Information/Communication
• Emphasis on web-based communication
• www.cpsi-icsp.ca

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The Challenge

• Pediatric health centres and CPSI
• Key partners in defining the issues and
  collaborating on improvement strategies
• Build on the expertise and capacity within your
  member organizations to identify and implement
  leading practices and share outcomes
• Within organizations
• Ensure all members of the health team are
  involved
• Nurture strong and knowledgeable leadership for
  improving patient safety

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Contact Information

• Canadian Patient Safety Institute
• Phone [phone] or
• Toll free [phone]
• Fax [phone]
• Email info_at_cpsi-icsp.ca
• www.cpsi-icsp.ca
• The Canadian Patient Safety Institute would like
  to acknowledge funding support from Health
  Canada. The views expressed here do not
  necessarily represent the views of Health Canada.