Mark daly final cpsi course presentation w videos

Patient Safety Officer McGill University Health Centre Montreal, Quebec... Required Organizational Practice: Inform and educate patients and/or families about their role in patient safe

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

Share tools and techniques to help you develop or improve your patient safety

program.

Definition of patient safety

Examples of national, provincial, and

organizational frameworks to help move you and your champions forward

Strategies to meet potential resistance

Parking Lot

Ideas for future discussion

What does the phrase

“Patient Safety”

mean to you?

P A T I E N T

S A F E T Y

Pre-work Activity 1

Herding Cats

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.

Josie King video

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)

What is Sorell King asking you to do?

Accreditation Canada

What is Accreditation Canada?

is to help health services organizations,

they provide to their clients.

client files and documentsQmentum process Tracer Activities

TALK and LISTEN

individual interviews with patients and staff/ group discussions

http://www.accreditation.caWhat 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

What is a Required Organizational Practice?

Communication/Education Strategy

Pre-work Activities 2 and 3

AC Patient Safety Area: Communication

1 Required Organizational Practice:

Inform and educate patients and/or families about their role

in patient safety, using both written and verbal

communication

2 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

3 Describe the major reason the

initiative was successful.

4 How is the tool shared with the

patient/family or staff?

Pre-work Activities 2 and 3

AC Patient Safety Area: Communication

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

Reporting adverse events and near misses:

Organizational framework

1 Committee on Quality and Risk Management

 Created in 1998

 Reports to the Board

2 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

 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

Reporting adverse events and near misses:

MUHC sentinel event policy

Outcome of using a framework: Code Stroke Algorithm

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

Learning from adverse events involves

implementing change

Name some changes you have

experienced with respect to patient

safety.

Juggling Change

START 1

END

START 2END

Team Juggling

Discussion Questions

1 How did you feel after each change was

introduced?

2 What made the process work well?

3 What hindered the process?

4 What is one lesson you learned from this

exercise?

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.

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

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?

Sacred Cows:

Step 1 – Rounding up sacred cows

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?

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

Sacred Cows:

Step 3 - Turning resistance into readiness

 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

Change Management Strategies: Sharing a Story

Change Management Strategies: Goal setting – S.M.A.R.T

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”

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.”

Change Management Strategies:

Goal setting - S.M.A.R.T

Capitalize on the synergy of an

interprofessional team to ensure all aspects of the goal are considered

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.

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

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

Pre-work Activity 4

Goal 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

• Developed by Dr Walter Shewart

• Modified by Dr W Edwards Deming

• Rapid cycle test-of-change model

Improvement model/framework:

Plan, Do, Study, Act

 What modifications are

to be made?

 Next cycle?

 Objective

 Questions & predictions

 (What will happen and why?)

 Plan to carry out the cycle

 (Who, what, where, when?)

 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

Improvement model/framework:

Plan, Do, Study, Act

O2 Ticket to Ride

O2 Ticket to Ride

1 Definition of patient safety

2 Frameworks for program development

a AC – Required Organizational Practices

b Provincial legislation

c Organizational initiatives

3 Frameworks for managing change

a Sacred cows (challenging assumptions, sense of

urgency, turning resistance into readiness)

"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.

McGill University Health Centre Quality, Patient Safety, Performance

Improvement

Questions and Comments?

Mark Daly Patient Safety Officer 514-934-1934 local 35662 mark.daly@muhc.mcgill.ca

Supplemental Reading List

• Bagian, J.P (2001) Developing and deploying a patient safety program

in a large health care delivery system: You can't fix what you don't

know about Journal on Quality Improvement, Joint Commission on

Accreditation of Healthcare Organizations, 27:10, 522-532.

• Daly, M (2006) The McGill University Health Centre policy on sentinel

events: Using a standardized framework to manage sentinel events,

facilitate learning and improve patient safety Healthcare Quarterly:

Patient Safety Papers, 9, 28-34.

• Patient safety program manual (2006) Retrieved July 1, 2007, from

http://www.dhs.ca.gov/lnc/download/PSPM/PatientSafetyProgramManu al09-20-2006.pdf

• Stevens, P., Matlow, A., & Laxer, R (2005) Building from a blueprint for

patient safety at the Hospital for Sick Children Healthcare Quarterly:

Patient Safety Papers, 8, 132-139

• Zimmerman, R., Christoffersen, E., Shaver, J., & Smith, T (2006) A

framework for local accountability for patient safety Healthcare

Quarterly: Patient Safety Papers, 9, 65-68.