VP Lead: Marlene Smadu, Quality and Transformation

1. VP Lead: Marlene Smadu, Quality and Transformation Patient and Family Centered Care A3, Driver Diagram and Multi-year Plan Patient Safety/ Stop the Line A3 and Multi-year Plan

2. Portfolio Overview • Regional Infection Prevention and Control • Patient Safety Office—Risk, Privacy and Access to Info, Emergency Planning • Transfusion Safety • Patient Advocate Services • Kaizen Promotion Office • Clinical Quality and Professional Practice

3. Multi Year Strategic PlanVP leading on: Patient and Family Centred Care RQHR Outcome By March 31, 2017 RQHR will have created a culture of Patient and Family Centered Care that leads to zero defects, no waits and waste from the perspective of patients and families, and that incorporates the core concepts of Patient and Family Centred Care (dignity and respect, information sharing, participation and collaboration).

6. 2015-16 Multi-year Plan • Transforming the system • Supporting family presence • MDR and shift to shift at the bedside • 100% use of whiteboards • Intentional rounding • Appropriate patient centred signage • ID badges • Patient Experience Survey in RGH / PH / Rural

7. 2015-16 Multi-year Plan • Transforming the system – Cont’d • Patient and family advisory groups • Coordinating with provincial partners • Staff education on PFCC • Policy on patients/families on interview panels • Patients and families engaged in improvement / lean work

8. Patient and Family Centered Care Multi-year Plan • Successes/What is working • Completed driver diagram for this year—will focus on key drivers • Patient and family advisors educating public on HH, region orientation, board meetings, flow visioning, patient experience survey/whiteboard presentations to staff, patients on the quality and safety admin committee, patients leading gemba walks • Initiatives such as multidisciplinary rounds at the bedside, white boards, safety huddles, manager rounding, Accountable Care Unit • Consent for transfusions great improvement • Engagement of RQHR leadership in placing patients first through initiatives such as HH, Immunization, SSI prevention • Developing family friendly and evidence based PPE protocols for visitors and families of colonized isolated patients. • Beginning implementation of “real-time concern handling” with Medicine Service Line

9. Patient and Family Centered Care Multi-year Plan • Challenges/Gaps/Risks/ • Much work to spread and replicate practices redesigned by patients and frontline staff and physicians. • Lack of EHR and difficulty getting RQHR forms on physicians’ EMR, e.g. Accuro • Have not yet implemented many best practices, e.g. family presence policy, signage • What isn’t working/What can be improved • Timely disclosure to patients/families and resolution of client concerns in real time • “Concern handling is not a department – it is everyone’s responsibility” – processes need to evolve

10. Patient and Family Centered Care Multi-year Plan • Next Steps • “Full court press” on HH continues—aim 100% • Region-wide spread and replication of best practices in patient and family centred care • Continue to focus on zero defects, no waste/waits • Increased communication/education of staff, physicians, public, patients, residents, clients, families • Patient Experience Survey – medicine, critical care, surgery, rural facilities • Family presence policy

11. Patient Safety/ Stop the LineMulti-year Plan 2015-16 Provincial Outcome & Improvement Targets • To achieve a culture of safety by March 31, 2020 where there will be no harm to patients or staff • By March 2018, fully implement a provincial Safety Alert System / Stop the Line (SAS/STL) process throughout Saskatchewan • By March 31, 2018, all regions and the Cancer Agency will implement the six elements of the Safety Management System (SMS) • By March 31, 2019, all regions and the Cancer Agency receive a 75% evaluation score on the implementation of the elements of the Safety Management System • By March 2019 there will be zero shoulder and back injuries

12. Getting to Green: SAS/STL Model Implementation • Status: Spread of SAS/STL to Saskatoon City and Royal University Hospitals - in progress • Measure:Progress of Implementation and Spread of the Safety Alert System Model Line • Corrective Actions: Improvements to data base in process, increase leadership and staff focus, and investments in SAS/STL through elevation of work to 90 Day Hoshin in 2015 • PLT Action Required: Continue to support resource sharing between eHealth and SHR to continue to PDCA SHR data base Actively support SAS/STL implementation in all RHAs and Regional participation in the Safety Network to coordinate and align SAS/STL across the province

13. Patient Safety/ Stop the LineMulti-year Plan • Challenges/Gaps/Risks/ • What isn’t working/What can be improved • The region is waiting on a provincial decision regarding the purchase of an Adverse Event Management System that will be critical to the success of STL • Front line engagement has been great in some trials and a struggle in others in STL PDSA trials. This may relate to the cultural readiness of individual units in relation to the change • Psychological safety for patients/families, staff and physicians

14. Patient Safety/ Stop the LineMulti-year Plan • Successes/What is working • STL Algorithm, Roles/Responsibilities document and Tool Kit have been developed and are being used by other RHAs • STL PDSA has been completed on 4 units and 1 trial remains underway at the WRC • STL working group has patient/family representation • RQHR STL is moving forward as planned—e.g. have done design RPIW on STL re equipment and supplies • Confidential Occurrence Reporting Database is being kept current—trending occurring in real time and trials of an electronic COR are underway

15. Patient Safety/ Stop the LineMulti-year Plan Next Steps • Complete a cultural readiness survey and replication/roll-out plan prior to implementing STL throughout region • Heighten awareness of STL as a priority & continue culture change • Provide leadership on multi-year plans for the two highest COR concerns: medication errors and falls