Quality & Patient Safety TOH

1. Quality & Patient Safety TOH Linda Hunter Director, Quality and Patient Safety 2011

2. Deep River & District Hospital Ottawa Area Hospitals - The Ottawa Hospital - Royal Ottawa Pembroke General Hospital - CHEO - Montfort - Bruyere Continuing Care Hawkesbury & District General Hospital - Queensway-Carleton Hospital St. Francis Memrial Hospital Renfrew Victoria Hospital Arnprior & District Memorial Hospital Glengarry Memorial Hospital Almonte General Hospital Winchester District Memorial Hospital Carleton Place & District Hospital Cornwall General Hospital Kemptville District Hospital Hotel Dieu Hospital Perth & Smith's Falls District Hospital Champlain LHIN

3. The Ottawa HospitalFacts and Figures Capacity • ~$1B Operating Budget • 1,172 Inpatient Beds • 12,000 Staff • 1,200 Physicians Activity • 46,000 Admissions • 49,000 Surgical Cases • 127,000 ED Visits

4. Patient Volumes

5. To provide each patient with the world class care, exceptional service and compassion that we would want for our loved ones Vision To Become a Top 10% Performer in Quality and Patient Safety in North America • Access • Wait Times: • DI, Hip/Knee, Cancer & ED Effectiveness Re-admission rates Surg. Site Infections Efficiency ALOS-ELOS CPWC • Safety • HSMR • Hospital Infections: • MRSA, VRE & C-Difficile Satisfaction Overall Pain Transition Outcomes Culture Create a culture of compassionate people, world-class care Service Excellence Performance Measurement Physician Engagement & Accountability Milestones & Tactics Patient Experience Enabling environments Clinical transformations Staff Engagement Our Patients Quality Plan Research Plan Our Staff Human Resources Plan Our Finances Operating Plan Our Environment Capital Plan Information Services Plan Our Partners Communication & Community Outreach Plan Commitment to Quality Working Together Respect for the Individual Compassion Values

6. Quality and Performance Measurement • Define • Align • Prioritize • Measure • Report

7. Definition of Quality • Providing the patient with appropriate consistent health care in a clean and safe environment in which the patient is treated with respect. • - TOH Board, January 2003, reconfirmed 2008

8. Defining the Quadrants OHQC: Attributes of a High-Performing Health System, Ontario Health Quality Council HQCA: Quality Matrix for Health, Health Quality Council of Alberta

9. Alignment With: • TOH Strategic Direction • Best Practice • Legislation • Accreditation Recommendations • Ministry of Health Mandated Requirements • Future Trends • Others?

10. Corporate Quality Plan Prioritization • Corporate in scope • Aligns with TOH mission and vision • Aligns with at least one of the following: • Addresses issues occurring frequently or to a high volume of patients • Addresses high risk for patient safety issues • Addresses accreditation or regulatory requirements • High probability of impact on outcomes/process measurement/indicators

11. Reporting • Scorecard • Workplan • Colour coded – green, yellow, red • Trend charts • Others …to different end stakeholder groups

12. The Ottawa Hospital Corporate Quality Plan Balanced Scorecard • Access • Emergency Offload (Q) • 90th percentile CTAS 1 • 90th percentile CTAS 2-5 • Emergency Access Times (Q) • % admitted ED LOS < 8 hrs • % non-admit waiting < 8 hrs for CTAS 1&2 • % non-admit wait < 6 hrs, CTAS 3 • % non-admit wait < 4 hrs, CTAS 4&5 • Number of cancer surgeries (Q) • Number of knee surgeries (Q) • Number of hip surgeries (Q) • Number of cataract procedures (Q) • Number of hours MRI delivered (Q) • Number of hours CT delivered (Q) • Safety • Ventilator Associated Pneumonia rate (Q) • Central Line Infection rate (Q) • Surgical Site Infection rate (Q) • Hand Hygiene compliance rate (Q) • Hip fractures receiving surgery < 48 hours (Q) • C Difficile rate (Q) • MRSA rate (Q) • VRE rate (Q) • HSMR (Q) • - Data currently available A - Reported annually Q - Reported quarterly Appropriate • Satisfaction • NRC-Picker Pt Satisfaction Results (Q) • Medicine • Surgery • Obstetrics and Gynecology • Emergency Department • Same Day Surgery • Rehabilitation • Ambulatory Care • Effective Ottawa Model for Diabetes(Q) • Inpatient satisfaction with pain control (Q) • Medicine • Surgery • Obstetrics and Gynecology • Emergency Department • Rehabilitation • Efficient • Cost per weighted case (A) • % clinical pathways revised (Q) • # new clinical pathways / program (Q)

13. Infection Control Dashboard

14. Hand Hygiene by Unit – Selection Criteria

15. Statistics Table by Campus

17. Indicator Assumptions Selection criteria for indicators: • Data is available • Data is timely • Indicator is valid and reliable • Indicator is actionable • Impact on high volume, high cost and high risk Focus on the vital few versus the trivial many

18. Mandatory Indicators For accreditation: • Percentage of patients receiving medication reconciliation at admission • MRSA infection rate • C. Diff infection rate • Rate of post surgical infections • Rate of timely administration of prophylactic antibiotic Submitted quarterly in each three year cycle For MOH Public Reporting: • CLI rate • VAP rate • MRSA • C. Diff • VRE • SSI antibx • HH compliance • HSMR • SSCL Submitted quarterly to annually

19. 2010/2011 Public Reporting Indicators Updated Jan 2011

20. Reporting: Infection Rates

21. Reporting: Central Line Infection – Line Insertions

22. Reporting: Ventilator Associated Pneumonia

23. Patient Safety Indicators on the Infonet

24. Quality Monitoring • Insanity is doing the same thing over and over again and expecting a different result. • -Albert Einstein • It’s not the data. • It’s what you do with it.

25. Model of a work system UW-Madison Systems Engineering Initiative for Patient Safety (SEIPS) Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P. Alvarado, C. J., Smith, M., and Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Healthcare, 15(Suppl I), i50-i58.

26. Definitions • Patient safety is defined as 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. • Patient Safety Culture is defined as a commitment to applying core patient safety knowledge, skills, and attitudes to everyday work. (CPSI, 2008)

27. CPSI – The Safety Competencies Framework which includes 6 core domains that provide for safer patient care: Domain 1: Contribute to a Culture of Patient Safety Domain 2: Work in Teams for Patient Safety Domain 3: Communicate Effectively for Patient Safety Domain 4: Manage Safety Risks Domain 5: Optimize Human and Environmental Factors Domain 6: Recognize, Respond to and Disclose Adverse Events Visit CPSI – Safety Competencies www.safetycomp.ca for complete framework information.

28. Fostering Patient Safety Culture at TOH Need: • A vision of where we want to go • Senior leadership buy-in • Actions to get us there • Passionate clinicians and support staff • Accountabilities defined • An action plan to move forward

29. Patient Safety Culture Surveys at TOH The Survey on Patient Safety Culture (AHRQ) was launched in August 2006, and offered to all staff, physicians and volunteers at TOH. A second survey, the Patient Safety Culture in Healthcare Organizations Survey, a tool developed by Stanford and modified by York University and supported by AC was run on four TOH inpatient units the following year. Further surveys were done in 2010 and 2011. There were six survey items where the large majority of staff members responded the same way in both surveys. (i.e. there was very little variation in responses); these include: • Asking for help is a sign of incompetence (93% disagree) • If I make mistake, and nobody notices, I do not tell anyone (95% disagree) • I will suffer negative consequence if I report a patient safety problem (86% disagree; 9% neutral) • I engage in unsafe practices in order to get the job done (95% disagree) • I report the errors I make (86% often/always; 11% occasionally) • I learn from errors made by my colleagues (81% often/always; 16% occasionally)

30. Develop a Culture of Safety • Relay safety reports at shift changes • Create an adverse event respond team • Re-enact adverse events • Appoint a patient safety champion for every area/unit • Simulate possible adverse events • Involve patients in safety initiatives • Create a reporting system (PSLS) • Designate a patient safety officer • Conduct safety briefings • Provide feedback to frontline staff • Conduct patient safety walkabouts (rounds)

31. Comparison of Patient Safety Culture Surveys Survey on Patient Safety Culture (n 738) Both sets of survey results reflect staff with direct patient interaction only. Patient Safety Culture in Healthcare Organizations Survey(n 109)

32. Required Organizational Practices

33. Response Analysis Detection Adverse Event Reporting • Focus on how we can prevent and intercept errors • Statistical data that can be analyzed to determine trends • Understand and improve practices that promote a safe care environment for patients

34. Definitions A reportable incident is … any unusual occurrence that is inconsistent with the routine care of a patient; or that adversely affects patients, volunteers, visitors or hospital property; or an unexpected negative treatment outcome. e.g. falls, med errors, equipment problems, lab incidents Injury does not have to occur for an event to be reportable (“near misses”)

35. More definitions As defined in TOH Critical Incident Review Policy and in accordance with the Public Hospitals Act a “Critical Incident” means any unintended event that occurs when a patient receives treatment in the hospital: (a) that results in death, or serious disability, injury or harm to the patient, and (b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing the treatment. As defined in TOH Patient / Visitor Incident Reporting Policy a “Serious Incident”is one that results in a fracture, haemorrhage, aspiration, serious drug variance/reaction or death, transfer to a critical care area, increased length of stay or admission to hospital.

36. Patient Safety Learning System (PSLS)

37. Disclosure Disclosure is a professional, ethical, moral and legislative requirement “Disclosure” refers to the communication of information regarding an adverse event, adverse outcome or critical incident. Public Hospitals Act directs that the disclosure conversation must include: (a) the material facts of what occurred with respect to the critical incident; (b) the consequences for the patient of the critical incident, as they become known; and (c) the actions taken and recommended to be taken to address the consequences to the patient of the critical incident, including any health care or treatment that is advisable. Documentation of the disclosure discussion is also a legislative requirement. TOH Disclosure Toolkit available

38. Goals of Root Cause Analysis (RCA) To find out: • What happened • Why it happened • What can be done to reduce the likelihood of a recurrence? Resources: CPSI RCA Toolkit & TOH RCA Lite Toolkit

39. Steps of a RCA • Determine the team • Organize the meeting • Gather information and the facts of the incident • Who, What, Where, When but not the Why • At the meeting • Review the information gathered and determine what did happen compared with what should have happened • Determine contributing factors and root causes • Keep asking “why” until the contributing factors and root causes are found • Develop actions and determine performance measurements • Implement the actions • Measure and evaluate the effectiveness of the actions

40. Common Root Causes Rules, Policies, Procedures, Protocols and Processes: • Lack of awareness of what protocols, policies and procedures are available • Lack of standardization of processes Communication Issues: • Breakdown in communication primarily at the point of transition, both internally and externally • Lack of information in the patient health record Equipment Issues: • Lack of available equipment (department specific requirements) Staff Factors (Knowledge, skill) • Incomplete & inaccurate documentation across all disciplines • Lack of ongoing education related to policies, procedures and protocols

41. CPSI/TOH Patient Safety Culture Project

42. Questions?