WELCOME INFORMATION AND ORIENTATION SESSION MARCH 14, 2005

1. WELCOME INFORMATION AND ORIENTATION SESSION MARCH 14, 2005

2. MISSION To promote patient safety and quality health care for Manitobans

3. OBJECTIVES • Promote, coordinate, facilitate, participate in, and/or stimulate research, activities and initiatives to enhance patient safety in the Manitoba health care system • Identify and monitor emerging issues related to patient safety and quality care

4. OBJECTIVES (cont.) • Promote best practices related to patient safety and quality care • Raise awareness of patient safety issues

5. SOME ACTIVITIES…. • Create inventory of patient safety initiatives • Host a conference to share best practices • Capture Manitobans’ experiences with adverse events • Develop communication strategy • Develop future leaders

6. PATIENT SAFETY: DEFINITION • The reduction of preventable harm to patients • Reduction • Preventable • Harm • (prevention, detection, mitigation) • concept of “Getting to Zero”

7. PATIENT SAFETY 101 • Is there a problem? • Are there solutions? • How do we get there?

8. PS 101: THE PROBLEM Let’s study the problem: • Moser (1956, NEJM) Diseases of Medical Progress • Beecher and Todd (1954) Anesthesia versus Polio • CFMIS (1974) 22,000 hospitalizations, 4.75% with preventable adverse event • HMPS (1984, New York State) 30,000 hospitalizations, 3.75%

9. PS 101: THE PROBLEM • Colorado/Utah (1992) 15,000 records, 2.9% • Australia (1995) 15,000 records, 16.6% had adverse event • U.K, Denmark, New Zealand studies showed similar results

10. PS 101: THE PROBLEM • Institute of Medicine (1999) To Err is Human • 44,000-98,000 preventable deaths in hospitalized patients each year in US • 90,000 deaths/year from nosocomial infections (CDC, 2002)

11. PS 101: THE PROBLEM • 218,000 deaths/year from preventable ADE’s (2004) • 21 preventable deaths/hour in US (2005, IHI)

12. PS 101: WHAT ABOUT CANADA? Baker and Norton (2004, CMAJ) Canadian Adverse Event Study • 3,700 charts of patients hospitalized in 2000 reviewed • 7.5% of patients experienced an adverse event • 1.6% of hospitalized patients experienced an adverse event and died • 500 bed hospital will have almost 100 preventable adverse events/ month

13. PS 101: SOLUTIONS • Step one in a twelve point program (AA): • Admit there is a problem! • Accept that human error is inevitable

14. PS 101: SOLUTIONS • Adopt a systems perspective: • Most harm results from a series of errors that are the inevitable result of the way we have designed complex processes in healthcare

15. PS 101: SOLUTIONS • Clinical solutions • 100K Lives campaign (IHI) • Ventilator bundle for VAP • Clinical Pharmacist in Anticoagulation clinic • Surgical site infections • Rapid Response Teams • Central line catheter infection • Peri-operative cardiac prophylaxis

16. PS 101: GETTING THERE FROM HERE 1. Culture change 2. Adopt process improvement methods 3. Partnering with patients/families

17. PS 101: GETTING THERE • Culture change in the healthcare system • Creating a culture of safety • Reporting culture (informed culture) • Just and fair culture • Learning culture • Flexible culture • Making patient safety a core value • Promote systems perspective

18. (System Culture Change, continued) • Re-aligning HR policies to support a culture of safety • Direct leadership involvement with front-line providers

19. PS 101: GETTING THERE • Culture change in society • Moving from blaming to learning

20. PS 101: GETTING THERE • Improved measurement • How will we know if we have improved? • Why no Hospital Standardized Mortality Rate (HSMR)? • When will “preventable deaths” be a regular agenda item for Boards and Senior Management groups?

21. PS 101: GETTING THERE • Adopt process improvement methodology • Participate in Canada-wide collaboratives • Prioritize specific clinical improvement projects • Develop multi-disciplinary teams

22. PS 101: GETTING THERE • Where are the patients in “patient safety”? • Promote full disclosure of adverse events • Provide appropriate support for patients/families and providers • Share recommendations of specific CCO reviews • Create patient and family advisory councils

23. PS 101: GETTING THERE • Learn from the experience of Dana Farber Cancer Institute (Boston) • Patients have been involved “at every level” for more than eight years and “Nothing bad has happened” (Jim Conway, COO)

24. Patient Safety • Unnecessary injuries and preventable deaths can be reduced • Benchmarks that are based on average outcomes are no longer acceptable • Healthcare systems can be improved • The idea of a “zero-defect” system is not pie in the sky

25. CONSULTATIONS WILL SEEK OPINIONS ON: • challenges to patient safety and suggestions on actions to improve patient safety in Manitoba • key short term and longer term priorities for the Manitoba Institute for Patient Safety • patient safety related activities underway

26. STAKEHOLDER GROUPS • Reps from public, front line providers/managers from RHAs, CCMB, First Nation communities • Reps from regulatory associations, unions, educational programs, RHA/CCMB Board, Sr. management

27. CONTACT US: Phone: (204) 788-6684 Email: mbips.gov.mb.ca Web link: www.mbips.ca Fax: 779 – MIPS (6477) 1027 – 300 Carlton St. Winnipeg Mb R3B 3M9