A-B-C’s of Patient Safety: Bringing Your Program to Life

1. A-B-C’s of Patient Safety:Bringing Your Program to Life Mark Daly RRT, MA (Ed.) Patient Safety Officer McGill University Health Centre Montreal, Quebec

2. Goal Share tools and techniques to help you develop or improve your patient safety program.

3. Deliverables • Definition of patient safety • Examples of national, provincial, and organizational frameworks to help move you and your champions forward • Strategies to meet potential resistance

4. Parking LotIdeas for future discussion

5. What does the phrase “Patient Safety” mean to you?

6. Pre-work Activity 1 P A T I E N T S A F E T Y

7. Pre-work Activity 1: Learning Summary • Influences • Years of service/experience • Professional affiliation • Job function • Position within the hierarchy • Teamwork • Learning environment • Respectful • Focused • Fun

8. Herding Cats

9. What is Patient Safety? “…the reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes.” The Canadian Patient Safety Dictionary, October 2003.

10. Josie King video

11. What is Sorell King asking you to do? 1. Communicate among team members (exchange of information) 2. Listen to the patient or family member (obligation to assess the relevance of the information and not dismiss it) 3. Look at the patient (not just the monitors, equipment, devices)

12. Frameworks 1. Accreditation Canada: Required Organizational Practices • Provincial legislation: Bill 113 • Organizational initiatives: The MUHC experience.

13. Accreditation Canada What is Accreditation Canada? Accreditation Canada is anational, non-profit, independentorganization whose role is tohelphealth services organizations, across Canada and internationally,examine and improve the quality of care and service they provide to their clients.

14. Qmentum process Tracer Activities REVIEWclient files and documents TALK and LISTEN individual interviews with patients and staff/ group discussions RECORDwhat is read, heard and seen OBSERVE direct observation and tours

15. “…pratique qui a été déterminée comme étant essentielle et qui doit être en place dans l’organisme pour améliorer la sécurité des patients et pour minimiser les risques.” “…an essential practice that organizations must have in place to enhance patient/client safety and minimize risk.” What is a Required Organizational Practice? Source: http://www.accreditation.ca 15

16. What is a Required Organizational Practice? • Twenty-one when introduced in 2006 • Thirty-five Required Organizational Practices related to patient safety • Mandatory for all organizations • Areas include: 1. Safety Culture 4. Workforce/Worklife 2. Communication 5. Infection Control 3. Medication Use 6. Risk Assessment

17. What is the Essence of the ROPs? Because we are Relying On you for Patient Safety 17

18. Communication/Education Strategy

19. Pre-work Activities 2 and 3 AC Patient Safety Area: Communication • Required Organizational Practice: Inform and educate patients and/or families about their role in patient safety, using both written and verbal communication • Required Organizational Practice: Employ effective mechanisms for transfer of information at interface points, including shift changes; discharge; and, patient/client movement between health care services and sectors, and implement improvements.

20. Pre-work Activities 2 and 3AC Patient Safety Area: Communication ROP exercise • Who was involved in the development of the tool? • Describe the major challenge the group faced. • Describe the major reason the initiative was successful. • How is the tool shared with the patient/family or staff?

21. Reporting adverse events and near misses:Provincial legislation Bill 113: An Act to amend the Act respecting health services and social services as regards the safe provision of health services and social services • Enacted in December 2002 • Patient’s right to be informed • Disclosure policy • Process to review accidents and develop improvement strategies • Confidentiality of the process: information is not discoverable • Mandatory risk management committee

22. Reporting adverse events and near misses:Organizational framework • Committee on Quality and Risk Management • Created in 1998 • Reports to the Board • Patient Safety Committee • Created in 2004 • Compiled an inventory of committees and functions that address risk/safety • Reviews all sentinel events • Reports to the Committee on Quality and Risk Management

23. Reporting adverse events and near misses:MUHC sentinel event policy • Implemented in 2005 • Use a standardized framework to manage the process • Ensure an objective process • Identify contributory factors • Develop an action plan to minimize the likelihood of a similar event affecting a subsequent patient • Knowledge transfer and organizational learning

24. Outcome of using a framework: Code Stroke Algorithm

25. Session 1 Review • “Patient Safety” has a variety of meanings • Sorell King asked us to: • Communicate among team members • Listen to the patient • Look at the patient • Frameworks: • Accreditation Canada: Required Organizational Practices • Provincial legislation • Organizational initiatives

26. Learning from adverse events involves implementing change Name some changes you have experienced with respect to patient safety.

27. Juggling Change START 1 END END START 2

28. Team JugglingDiscussion Questions • How did you feel after each change was introduced? • What made the process work well? • What hindered the process? • What is one lesson you learned from this exercise?

29. Sacred Cows1 Definition: “An outmoded belief, assumption, practice, policy, system, or strategy, generally invisible, that inhibits change and prevents responsiveness to new opportunities.” 1. Kriegel, R., Brandt, D. (1996). Sacred cows make the best burgers: Paradigm busting strategies for developing change-ready people and organizations. New York, NY: Warner Books, Inc.

30. Sacred Cows 1. Rounding up sacred cows 2. Developing a change ready environment 3. Turning resistance into readiness 4. Motivating people to change 5. Developing change-ready traits

31. Sacred Cows:Step 1 – Rounding up sacred cows Challenging assumptions • Why are we doing this …? • What if it did not exist? • Is someone else doing this already? • When did this practice start? • Can someone else do it better?

32. Sacred Cows:Step 2 – Developing a change ready environment Building trust Characteristics of a change ready environment: • Trust • Honesty: Can you believe what they (PSO) say? • Integrity: Do they keep their promises? • Openness: Do they share what they know? • Caring • Respect • Empathy: Standing in someone else’s shoes (situational awareness?) • Acknowledgement: Simple and sincere recognition

33. Sacred Cows:Step 3 - Turning resistance into readiness Resistance Drivers • Fear: “What if I look stupid/fail” • Feeling powerless: “No one asked me” • Inertia: “It takes too much effort” • Absence of self-interest: “WIIFM phenomenon” “People don’t resist change as much as they resist being changed.” Christopher Hegarty

34. Sacred Cows:Step 4 - Motivating people to change • Urgency: What happens if the change is NOT implemented • Inspiration: What are the possibilities, creating a shared vision • Ownership: Via participation in the definition of the problem and the solution/change to implement • Rewards and recognition: Extrinsic and intrinsic (recognition, flexibility, creativity)

35. Sacred Cows:Step 5 - Developing change-ready traits

36. Change Management Strategies:Sharing a Story

37. Change Management Strategies:Goal setting – S.M.A.R.T S Specific M Measurable A Attainable R Realistic T Timely

38. Change Management Strategies:Goal setting – S.M.A.R.T Specific • Emphasize what you want to happen • Address the following questions: • Who is involved? • What do we want to accomplish? • Where will the activity take place? • Why will this activity improve patient safety? • E.g. “I want to lose weight”

39. Change Management Strategies:Goal setting - S.M.A.R.T Measurable • Keeps you on track • Establishes a target • Provides motivation when targets are met • Quantifies the outcome • E.g. “I want to lose 20 pounds.”

40. Change Management Strategies:Goal setting - S.M.A.R.T Attainable • Can you do it? • “Small wins” • Set your team up for success by making the goal within reach • Capitalize on the synergy of an interprofessional team to ensure all aspects of the goal are considered

41. Change Management Strategies:Goal setting - S.M.A.R.T Realistic • Striking a balance between what you want to accomplish and the resources/environment currently available to help you achieve your goal.

42. Change Management Strategies:Goal setting - S.M.A.R.T Timely • Establish an end point to the activity • Helps create a sense of urgency • I want to lose weight • I want to lose 20 pounds • I want to lose 20 pounds by November 31, 2009

43. Is this goal S.M.A.R.T?

44. Pre-work Activity 4Goal Setting: Your example • Review your patient safety goal • Discuss this goal with your colleagues • Describe why the goal is S.M.A.R.T • Select one goal to share with the other participants

45. Improvement model/framework:Plan, Do, Study, Act • Developed by Dr. Walter Shewart • Modified by Dr. W. Edwards Deming • Rapid cycle test-of-change model

46. Improvement model/framework:Plan, Do, Study, Act Act Plan • Objective • Questions & predictions • (What will happen and why?) • Plan to carry out the cycle • (Who, what, where, when?) • What modifications are to be made? • Next cycle? Do Study • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data • Complete analysis of the data • Compare data to predictions • Summarize what was learned

47. O2 Ticket to Ride

48. O2 Ticket to Ride

49. Learning Summary • Definition of patient safety • Frameworks for program development • AC – Required Organizational Practices • Provincial legislation • Organizational initiatives • Frameworks for managing change • Sacred cows (challenging assumptions, sense of urgency, turning resistance into readiness) • Sharing a story • S.M.A.R.T goal setting • Improvement model/framework • PDSA rapid cycle test-of-change

50. "We cannot change the human condition, we can change the conditions under which humans work." Reason, J. (2000). Human error: Models and management. BMJ, 320, 768-770.