Looking East: How CanAlberta’s Blueprint Guide Us?    Margot Harvie RN BN MEd  Quality & Safety Education Lead           F...
Blueprint Project• Vision• All those involved in  providing healthcare have a  common understanding of  key components of ...
Blueprint Project• Mission• Work collaboratively to develop a detailed  framework of learning outcomes and  objectives and...
Blueprint Project• Project Partners• HQCA, Alberta Health Services, University of  Alberta, University of Calgary, Univers...
Genesis of the Blueprint Project                               Blueprint Project Multi-year                               ...
Healthcare System Safety Model                                 6
Early lessons.....• Curriculum Framework not the right  terminology to use• Simple is better!                             ...
Evolution of the Model                               Personnel                                  Environment /             ...
UNSAFE ACTS                 UNSAFE ACTS                                    CrewLOCAL WORKPLACE FACTORS    LOCAL WORKPLACE ...
Patient           Crew                      PERSONNEL                                        Crew   PHYSICAL ENVIRONMENT  ...
The Healthcare Encounter Safety   and Quality Model            Health             CareProviding            Receiving      ...
The Healthcare Encounter Safetyand Quality Model     The functions         players                              12
The Healthcare Encounter Safetyand Quality Model
The Patient Safety Puzzle
The Patient Safety Puzzle
The Patient Safety Puzzle
May - First Steering               Committee meeting2007   2008   2009        2010         2011   2012   2013             ...
Blueprint Project Structure                              18
A few things we learned...• Individuals interested, but really needed core  ‘working group’• Collaboration takes time!• Gr...
Spring -                     Environmental Scan                        September - Patient Safety                        F...
Environmental Scan• Purpose• Determine extent to which systems approach  to patient safety integrated into healthcare  pro...
Environmental Scan• Method• Based on literature review, a draft Patient  Safety Education Self-Assessment Tool  (PSESAT) w...
Environmental Scan• Tool• Three themes explored through tool items1. Patient safety-related concepts taught in the  progra...
PSESAT         24
Environmental Scan• Key Findings• Patient safety scale ratings were high  suggesting that patient safety is well-  integra...
Environmental Scan• Key Findings• A disconnect between educational programs  and clinical settings was evident which may  ...
Environmental Scan• Key Findings• Respondents recognized that the process of  completing the self-assessment tool may be i...
Patient Safety FrameworkBased on an understanding of what is required to make healthcare safer                            ...
Certificate in Patient Safety & Quality• Partnership with Office of Continuing Medical  Education & Professional Practice,...
May - Faculty                              Development                              Workshops                             ...
Faculty Development Workshops• Opportunity identified in environmental scan• Help make the shift from “individual provider...
Outcomes Matrix                  32
More learning•   HUGE project•   Difficult to juggle big picture and deep dives•   Can’t be done off the side of anyone’s ...
Full time Quality &                                   Safety Education                                   Lead hired2007   ...
SSA:PSR• Theory-based, developed  specifically for healthcare  reviews• Draws from aviation and  human factors investigati...
Yes - more lessons!• Project needs more of a stakeholder group  than a steering committee• Still tons more work to do• Str...
What’s next?  SSA:PSR  February - pilot  certificate course     Map learning objectives to CPSI     competencies and CanMe...
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Academic. Margot Harvie.

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Academic. Margot Harvie.

  1. 1. Looking East: How CanAlberta’s Blueprint Guide Us? Margot Harvie RN BN MEd Quality & Safety Education Lead February 27, 2013
  2. 2. Blueprint Project• Vision• All those involved in providing healthcare have a common understanding of key components of patient safety and quality and use this to continually invest in making patient care safer 2
  3. 3. Blueprint Project• Mission• Work collaboratively to develop a detailed framework of learning outcomes and objectives and some priority supporting curriculum resources incorporating key messages about patient safety concepts/topics that can be used in educating all who work in the healthcare system about the principles and processes of patient safety 3
  4. 4. Blueprint Project• Project Partners• HQCA, Alberta Health Services, University of Alberta, University of Calgary, University of Lethbridge, Mount Royal University, Northern Alberta Institute of Technology, Norquest College, Canadian Patient Safety Institute, BC Patient Safety and Quality Council, Manitoba Institute for Patient Safety 4
  5. 5. Genesis of the Blueprint Project Blueprint Project Multi-year collaborative sponsored byPatient Safety the HQCACurriculum ProjectWorking GroupCalgary Health Region -development of model2007 2008 2009 2010 2011 2012 2013 Patient Safety Curriculum: Gaining Consensus workshop 200 individuals providing feedback on initial model and framework 5
  6. 6. Healthcare System Safety Model 6
  7. 7. Early lessons.....• Curriculum Framework not the right terminology to use• Simple is better! 7
  8. 8. Evolution of the Model Personnel Environment / Equipment Organization Regulatory Patients Agency 8
  9. 9. UNSAFE ACTS UNSAFE ACTS CrewLOCAL WORKPLACE FACTORS LOCAL WORKPLACE FACTORS PHYSICAL ENVIRONMENTORGANIZATIONAL FACTORS ORGANIZATIONAL ENVIRONMENT ORGANIZATIONAL FACTORS REGULATORY ENVIRONMENT 9
  10. 10. Patient Crew PERSONNEL Crew PHYSICAL ENVIRONMENT ENVIRONMENT / EQUIPMENT PHYSICAL ENVIRONMENTORGANIZATIONAL ENVIRONMENT ORGANIZATIONAL ENVIRONMENT THE ORGANIZATION REGULATORY ENVIRONMENT REGULATORY ENVIRONMENT REGULATORY AGENCIES 10
  11. 11. The Healthcare Encounter Safety and Quality Model Health CareProviding Receiving 11
  12. 12. The Healthcare Encounter Safetyand Quality Model The functions players 12
  13. 13. The Healthcare Encounter Safetyand Quality Model
  14. 14. The Patient Safety Puzzle
  15. 15. The Patient Safety Puzzle
  16. 16. The Patient Safety Puzzle
  17. 17. May - First Steering Committee meeting2007 2008 2009 2010 2011 2012 2013 September Principles Think Tank Meeting 17
  18. 18. Blueprint Project Structure 18
  19. 19. A few things we learned...• Individuals interested, but really needed core ‘working group’• Collaboration takes time!• Group writing is painful and time consuming, but very rich 19
  20. 20. Spring - Environmental Scan September - Patient Safety Framework for Albertans Certificate in Patent Safety & Quality Course2007 2008 2009 2010 2011 2012 2013 June - Patient Safety Principles Document First Event Analysis Think- tank 20
  21. 21. Environmental Scan• Purpose• Determine extent to which systems approach to patient safety integrated into healthcare provider education programs• Determine what kinds of resources would be helpful in supporting integration of systems approach to patient safety• Gather feedback about utility and content of Patient Safety Education Self-Assessment tool 21
  22. 22. Environmental Scan• Method• Based on literature review, a draft Patient Safety Education Self-Assessment Tool (PSESAT) was developed to assist post- secondary healthcare provider education programs in determining to what extent a systems approach to patient safety has been integrated into their curriculum• Tool developed in collaboration with educators across Alberta 22
  23. 23. Environmental Scan• Tool• Three themes explored through tool items1. Patient safety-related concepts taught in the program with a focus on a systems orientation to patient safety2. Leadership and organizational factors that support a systems approach to patient safety within an education program3. Responding to close calls and adverse events involving students 23
  24. 24. PSESAT 24
  25. 25. Environmental Scan• Key Findings• Patient safety scale ratings were high suggesting that patient safety is well- integrated into most programs, however it is not clear to what extent this reflects a systems oriented view of safety• Respondents often stated that they did not completely understand the terms or concepts related to a systems approach that were embedded in the tool items 25
  26. 26. Environmental Scan• Key Findings• A disconnect between educational programs and clinical settings was evident which may hinder student practice of newly learned patient safety concepts• Programs expressed interest in user-friendly resources to help them learn about the concepts of a systems approach to patient safety - case studies, interactive technology- based resources and networking opportunities 26
  27. 27. Environmental Scan• Key Findings• Respondents recognized that the process of completing the self-assessment tool may be its most important function• Critically reflecting on the tool items as a group raises awareness of a systems oriented approach• Suggestions to improve tool mainly centered on improving clarity of wording and developing a consistent rating scale 27
  28. 28. Patient Safety FrameworkBased on an understanding of what is required to make healthcare safer 28
  29. 29. Certificate in Patient Safety & Quality• Partnership with Office of Continuing Medical Education & Professional Practice, W21C University of Calgary & HQCA• Third year of course - now using blended on- line and face to face format 29
  30. 30. May - Faculty Development Workshops Completion of Patient Safety Principles Outcomes Matrix2007 2008 2009 2010 2011 2012 2013 Patient Safety Conundrum Document Second Event Analysis Think- tank 30
  31. 31. Faculty Development Workshops• Opportunity identified in environmental scan• Help make the shift from “individual provider responsibility for safe patient care” to an integrated “systems view of patient safety”• Important step in addressing Strategy 5 in the Patient Safety Framework for Albertans• about 30 participants - positive feedback 31
  32. 32. Outcomes Matrix 32
  33. 33. More learning• HUGE project• Difficult to juggle big picture and deep dives• Can’t be done off the side of anyone’s desk• Lots of great ideas... 33
  34. 34. Full time Quality & Safety Education Lead hired2007 2008 2009 2010 2011 2012 2013 SSA:PSR June - Advisory Nov - Workshop 34
  35. 35. SSA:PSR• Theory-based, developed specifically for healthcare reviews• Draws from aviation and human factors investigation techniques 35
  36. 36. Yes - more lessons!• Project needs more of a stakeholder group than a steering committee• Still tons more work to do• Struggling with engagement vs getting the work done• New process for completing learning outcomes 36
  37. 37. What’s next? SSA:PSR February - pilot certificate course Map learning objectives to CPSI competencies and CanMeds2013.......... Map learning topics to U of C medical school curriculum Focus on completing learning outcomes for 21 remaining learning topics 37

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