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Quality Improvement and Reporting of Medical Errors

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... of the individual will add value to the quality of the system Barriers to Healthcare Renewal There is no standardized privacy and confidentiality legislation ... – PowerPoint PPT presentation

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Title: Quality Improvement and Reporting of Medical Errors


1
Quality Improvement and Reporting of Medical
Errors
Expect the Unexpected Are We Clearly Prepared?
  • Sharon Saberton, Registrar, College of Medical
    Radiation Technologists, Ontario
  • David Swankin, President and CEO, Citizen
    Advocacy Center, Washington, DC.
  • Debbie Tarshis, Lawyer, WeirFoulds LLP, Toronto,
    Ontario

Council on Licensure, Enforcement and Regulation
2006 Annual Conference
Alexandria, Virginia
2
Agenda
  • Legal Framework for moving to a culture of safety
    through quality improvement and reporting of
    medical errors
  • The current process in Ontario and a different
    model for consideration
  • Linking the individuals performance and the
    system as a whole

3
Why Patient Safety
  • U.S. Institute of Medicine estimated that 44,000
    to 98,000 people die in hospitals each year as a
    result of adverse events
  • NHS study in Britain found that adverse events
    occurred in 10 of hospital admissions, at a cost
    of 2 billion annually in additional hospital
    stays

4
Why Patient Safety
  • 2004 Canadian study estimated that in 2000, of
    the almost 2.5 million annual admissions to
    hospitals in Canada, about 185,000 were
    associated with an adverse event, of which close
    to 70,000 were potentially preventable

5
Systems Approach to Patient Safety
  • Majority of adverse events do not result from
    recklessness on part of health practitioner, but
    from basic flaws in way health system is
    organized
  • Individual practitioner not a potential culprit
    to be blamed and punished but one participant
    interacting with many others in a highly complex
    environment

6
Systems Approach to Patient Safety
  • Analysis of adverse events
  • do not limit to occurrences at sharp end, where
    practitioners interact with patients and each
    other in process of delivering care
  • must include considerations of role played by
    blunt or remote end of system (regulators,
    administrators, policy makers and technology
    suppliers) who shape environment in which
    practitioners work

7
Common Themes of Patient Safety Analysis
  • Essential to find out about errors and injuries
    to patients
  • To undertake systemic analysis of what has gone
    wrong
  • Develop effective strategies to prevent, reduce
    and ameliorate harm
  • Disseminate lessons learned more widely through
    health system for implementation elsewhere

8
Common Themes of Patient Safety Analysis
  • Disclosure will be chilled if risk of negative
    repercussions
  • Prospect of legal liability for negligence is
    major impediment to openly disclosing errors and
    systemic analysis
  • Recovery of damages conditional on finding of
    fault

9
Common Themes of Patient Safety Analysis
  • Information gathered and activities undertaken as
    part of quality assurance or patient safety
    initiatives should be insulated from disclosure
    or use in civil litigation and other types of
    legal proceedings
  • Culture of blame and shame must be changed to
    culture of openness, problem-solving and safety

10
Reporting and Investigation of Critical Incidents
  • Should reporting and investigation be mandatory?
  • Canadian jurisdictions that have adopted
    mandatory reporting
  • Saskatchewan
  • Manitoba (not yet in force)
  • Quebec
  • Alberta

11
...Reporting and Investigation of Critical
Incidents
  • Define critical incident ie. what must be
    reported and investigated
  • What institutions have obligation to report and
    investigate
  • To whom must report be made
  • Regional authorities? Government?
  • Nature of information that is shared

12
Healthcare Quality Improvement Legislation
  • To create a confidential environment where
  • designated persons can collect, analyze and share
    information
  • data and opinions associated with discussions are
    protected from disclosure in legal proceedings

13
Healthcare Quality Improvement Legislation
  • All Canadian jurisdictions have some form of
    protection for quality of care information but
    legislation varies in
  • What type of health care body can establish
    committee
  • Whose communications are protected
  • What communications and information are protected
  • What committees are protected
  • What is the subject of communication at issue
  • Who is seeking quality assurance records

14
Legislation on Privacy and Confidentiality of
Personal Health Information
  • Need to be able to collect, analyze and share
    information
  • Need to protect the privacy and confidentiality
    of individuals
  • Standardize privacy and confidentiality
    legislation
  • To facilitate access to patient-safety data while
    respecting privacy of patients

15
Role of Professional Regulatory Bodies
  • How best to advance patient safety goals in ways
    that are consistent with regulators obligations
    to protect public and ensure practitioners
    provide safe, quality care?
  • Should regulatory body be involved at the review
    stage of a specific patient case?

16
Role of Professional Regulatory Bodies
  • Would collaborative review facilitate a
    multi-disciplinary determination of contributing
    factors and one set of recommendations to enhance
    individual and/or system performance?
  • How can regulatory Colleges encourage
    practitioners to move from a culture of blame
    and shame to a culture of patient safety?

17
Role of Professional Regulatory Bodies
  • Greater focus on practitioners improvement
    through education and remediation rather than
    blame and punishment
  • Changes to standards of practice and codes of
    ethics regarding reporting of hazardous
    situations, adverse events or near misses

18
Role of Professional Regulatory Bodies
  • Regulatory bodies as recipients of information
    regarding lessons to be learned from adverse
    events or near misses
  • Regulatory bodies as organizations to disseminate
    lessons learned to practitioners

19
Regulated Health Professions Act, 1991 (RHPA)
  • The intent of the RHPA is to protect the public
    interest, and to ensure that individuals have
    access to quality service by health professionals
    of their choice

20
RHPA
  • Provides a complaints procedure which aims at
    ensuring that a thorough investigation of a
    complaint is conducted
  • If the Complaints Committee determines that an
    accusation of professional misconduct should be
    referred to the Discipline Committee, a hearing
    is held before a panel of the Discipline
    Committee

21
RHPA
  • Mandatory Reporting is considered an essential
    professional obligation and ensures that
    instances of professional misconduct,
    professional incompetence or sexual abuse or
    concerns regarding incapacity are brought to the
    attention of the College

22
RHPA
  • These processes are based on the behaviour of the
    individual and are often termed the bad apple
    approach

23
RHPA Quality Assurance Program
  • Quality Assurance programs are mandated in
  • the legislation. The goals of Quality Assurance
  • Programs are to
  • Assure the public of the quality of regulated
    health professionals by maintaining members
    performance at a level consistent with the
    Standards of Practice
  • Promote continuing competence among members

24
RHPA - Quality Assurance Program
  • Focuses on the performance of the individual
  • Does not link to the system as a whole
  • Based on the belief that quality improvement of
    the individual will add value to the quality of
    the system

25
Barriers to Healthcare Renewal
  • There is no standardized privacy and
    confidentiality legislation to facilitate access
    to patient-safety data while respecting privacy
    of patients
  • Legislative and regulatory framework has created
    boundaries that prevents disclosure of quality
    assurance information to the health care system

26
The Two Solitudes
  • Quality improvement of the system
  • Quality improvement of the individual

27
A Different Model - Teamwork
  • Many reports in Canada are calling for improved
    collaboration as a key strategy in healthcare
    renewal
  • A healthcare system that supports effective
    teamwork can improve the quality of patient care,
    enhance patient safety and reduce workload issues
    that cause burnout among healthcare professionals

28
Structures Necessary to Support Teamwork
  • Team objectives
  • Roles and responsibilities of team members
  • Mechanisms for exchanging information
  • Co-ordination mechanisms for team activities and
    staffing

29
Organizational Factors Necessary to Support
Teamwork
  • A clear organizational philosophy that values
    teamwork
  • Management structure
  • Resources
  • Education
  • Feedback

30
System Factors Necessary to Support Teamwork
  • Consistent government policies and approaches
  • Health human resource planning
  • Regulatory/legislative frameworks that do not
    create barriers
  • Models of funding and remuneration that encourage
    collaboration

31
Some Successful Canadian Initiatives
  • Teaching hospitals exploring new practice models
  • Aboriginal communities
  • Remote primary care centres serving specific
    populations
  • Disease based groups such as seniors, diabetic
    care and individuals requiring mental health
    services

32
Moving Forward to Effective Teamwork Can We Do
It?
33
Nobody wants to continue with the Blame and
Shame Game BUT Looking ONLY at system
safety flaws is not sufficient
34
Concentrating exclusively on systems is an
initial over-reaction to the data on medial
errors.
  • -Dr. R. Salvata, University of Washington

35
I dont see safety failures overall as a
dichotomy---either as systems problems or as
performance problems. Performance problems are
systems problems, too.
  • -Dr. Lucian Leape,
  • Harvard School of Public Health

36
Finding and Fixing competency problems of
individual health care professional can and
should also lead to system improvements.
37
Commercial airline pilots are required to
demonstrate their current competence
yearly. That is NOT the case with health care
professionals.
38
Hospital credentialing and privileging programs
today are inadequate.
39
JCAHO is just now beginning to require stronger
credentialing and privileging programs as part of
their accreditation standards, BUT
40
Ability to rely on JCAHO accreditation still is a
long way off.
41
The time has come to require all health care
professionals to periodically demonstrate their
current competence as a condition of re-licensure.
42
Mandatory continuing education is NOT the answer.
43
CACs Framework for State Legislature Action
  1. Eliminate continuing education requirements
  2. Mandate that as a condition of relicensure,
    licensees participate in continuing professional
    development programs approved by their respective
    health care boards

44
CACs Framework for State Legislature Action
  1. Mandate that continuing professional development
    programs include (a) assessment (b) development,
    execution, and documentation of a learning plan
    based on the assessment and (c) periodic
    demonstrations of continuing competence

45
CACs Framework for State Legislature Action
  1. Provide licensure boards with the flexibility to
    try different approaches to foster continued
    competence
  2. Ensure that the boards assessments of continuing
    competence address knowledge, skills, attitudes,
    judgment, abilities, experience, and ethics
    necessary for safe and competent practice in the
    setting and role of an individuals practice at
    the time of relicensure

46
CACs Framework for State Legislature Action
  1. Require that boards evaluate their approaches to
    gathering evidence on the effectiveness of
    methods used for periodic assessment
  2. Authorize licensure boards to grant deemed status
    to continuing competence programs administered by
    voluntary credentialing and specialty boards, or
    by hospitals and other health care delivery
    institutions, when the private programs meet
    board-established standards

47
Questions for Discussion
  1. Reporting and investigation of critical incidents
  2. Should reporting and investigation be mandatory?
  3. What institutions have obligation to report and
    investigate?
  4. To whom must the report be made Regional
    authorities? Government?
  5. What is the nature of information that is shared?

48
Questions for Discussion
  • Role of professional regulatory bodies
  • How best to advance patient safety goals in ways
    that are consistent with regulators obligations
    to protect public and ensure practitioners
    provide safe, quality care?
  • Should regulatory body be involved at the review
    stage of a specific patient case?
  • Would collaborative review facilitate a
    multi-disciplinary determination of contributing
    factors and one set of recommendations to enhance
    individual and/or system performance?

49
Questions for Discussion
  1. Will moving forward to effective teamwork
    improve both the quality of the system and the
    individual?
  2. What strategies can be implemented to move from a
    culture of blame and shame to a culture of
    patient safety?

50
Speaker Contact Information
Sharon Saberton College of Medical Radiation
Technologists of Ontario 170 Bloor Street West,
Suite 1001 Toronto, ON M5S 1T9 Phone
1-800-563-5847 Fax 416-975-4355 E-mail
ssaberton_at_cmrto.org Website www.cmrto.org
51
Speaker Contact Information
David Swankin Citizen Advocacy Center 1400 16th
Avenue NW, Suite 101 Washington, DC 20036 Phone
202-462-1174 Fax 202-265-6564 E-mail
davidswankin_at_cacenter.org
52
Speaker Contact Information
Debbie Tarshis WeirFoulds LLP Suite 1600,
Exchange Tower, P.O. Box 480 130 King Street
West Toronto, ON M5X 1J5 Phone (416) 947-5037
Fax (416) 365-1876 Email dtarshis_at_weirfoulds.com
Website www.weirfoulds.com
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