S w W12328 PATIENT SAFETY AT GRAND RIVER HOSPI.docx

S w
W12328
PATIENT SAFETY AT GRAND RIVER HOSPITAL & ST.
MARY’S
GENERAL HOSPITAL
Alex Cestnik and Ashok Sharma wrote this case under the
supervision of Professor Murray Bryant solely to provide
material for
class discussion. The authors do not intend to illustrate either
effective or ineffective handling of a managerial situation. The
authors
may have disguised certain names and other identifying
information to protect confidentiality.
Richard Ivey School of Business Foundation prohibits any form
of reproduction, storage or transmittal without its written
permission.
Reproduction of this material is not covered under authorization
by any reproduction rights organization. To order copies or
request
permission to reproduce materials, contact Ivey Publishing,
Richard Ivey School of Business Foundation, c/o Richard Ivey
School of
Business, The University of Western Ontario, London, Ontario,

Canada, N6A 3K7; phone (519) 661-3208; fax (519) 661-3882;
e-
mail [email protected]
Copyright © 2012, Richard Ivey School of Business Foundation
Version: 2012-11-21
After completing a comprehensive patient safety leadership
fellowship in 2011, Dr. Ashok Sharma reflects
on how he could most positively impact his local medical
community to develop a safety culture and
minimize medical errors. As the chief of staff at both Grand
River Hospital and St. Mary’s General
Hospital in Kitchener-Waterloo, Ontario, Dr. Sharma would like
to influence his practicing physicians
without threatening their professional autonomy or being
perceived as paternalistic.
Despite being recognized as an area for improvement as early as
the 1990s, the patient safety movement is
still in its infancy. Medical error remains a sensitive topic for
patients, physicians, hospital administration
and virtually all who rely on health care, making the issue
increasingly difficult to resolve. Only recently
has the topic been openly addressed, and there remains a
significant gap between the care that is delivered
and that should be delivered.
PATIENT SAFETY
A medical error is considered “the failure of a planned action to
be completed as intended or the use of a

wrong plan to achieve an aim.”1 An adverse event refers to the
additional harm that results from medical
mismanagement rather than the underlying disease. When an
error results in an adverse event, it is
considered a preventable adverse event (see Exhibit 1).
Research has suggested that approximately 10 per
cent of primary care medical errors result in patient harm.2 In
1997, large studies were completed in the
United States suggesting that as many as 98,000 Americans die
each year due to medical error.3 This figure
positions medical error as the eighth leading cause of death,
exceeding the number of deaths from motor
vehicle accidents and breast cancer combined. Such a mortality
rate equates to one jumbo jet crashing each
1 Institute of Medicine (U.S.), To Err is Human: Building a
Safer Health System, National Academy Press, Washington, DC,
2000.
2 Ibid.
3 Ibid.
This document is authorized for use only in Laureate Education,
Inc. 's WAL MMHA 6900 - Healthcare Quality Management at
Laureate Education - Baltimore from Oct 2017 to Nov 2018.
Page 2 9B12M080
day. In response to the evident problem of inadequate patient
safety, the National Patient Safety
Foundation (NPSF) was established in 1997. NPSF defines
patient safety as “the avoidance, prevention

and amelioration of adverse outcomes or injuries stemming from
the process of healthcare.”4 In 1999, the
Institute of Medicine (IOM) identified patient safety as an
explicit concern when it proposed the six aims
of high-quality health care: safety, effectiveness, patient-
centeredness, timeliness, efficiency and equity. In
order to improve safety, research has been conducted5 to better
understand the underlying causes of
preventable adverse events. In general, two factors contribute to
the likelihood of errors in any industry:
complexity and coupling. Complexity refers to the
unpredictability of events, and coupling measures the
interdependence of tasks.6 Given that health care is both
complex and tightly coupled, concerted efforts
must be made to prevent adverse events from occurring. There
are a multitude of actions that can reduce
medical errors and improve patient safety, and they begin at an
organizational rather than an individual
level. The IOM emphasizes that safety is a systemic property
rather than an individual physician’s
responsibility:
“Unsafe acts are like mosquitoes: you can try to swat them one
at a time, but there will always be others to
take their place. The only effective remedy is to drain the
swamps in which they breed. In the case of errors
and violations, the “swamps” are equipment designs that
promote operator error, bad communications,
high workloads, budgetary and commercial pressures,
procedures that necessitate violations in order to get
the job done, inadequate organization and missing barriers and
safeguards — the list is potentially long,
but all of these latent factors are, in theory, detectable and
correctable before a mishap occurs.”7
Thus, patient safety is a systemic and cultural problem within

the health care industry and cannot be
addressed by simply correcting or reprimanding the individual
who errs. The solution requires analysis of
systemic failures related to factors such as equipment design
and staff workload (see Exhibit 2). All
clinicians must be transparent about their errors and near misses
in order to resolve underlying systemic
causes. Likewise, hospital administration must foster a safety
culture in which physicians and other
clinicians can feel comfortable discussing errors and proactively
seeking solutions.
Too frequently, physicians consider that patient safety is a
product of a good clinical practice and not as
impacted by the broader system of patient care. A number of
variables beyond an individual’s clinical
practice do play a role in patient safety including: technology,
interdisciplinary care, physician trade-offs,
nursing staff, allied health professionals, medical device and
product design, etc. Furthermore, the
organizational structure of hospitals suggests that
responsibilities are diffused across many individuals. The
additional complexity resulting from the interaction of people
and processes lead to a greater potential for
error.
CANADIAN PATIENT SAFETY INSTITUTE
Following the movement towards improving patient safety,
Health Canada established the Canadian
Patient Safety Institute (CPSI) in 2003 with an aim to “inspire
extraordinary improvement in patient safety
and quality.”8 The institute develops evidence-based best
practices, supports research, measures results,

2000.
5 Ibid
6 James Reason and Alan Hobbs, Managing Maintenance Error:
A Practical Guide, Ashgate Publishing Company,
Burlington, VT, 2003.
2000.
8 Canadian Patient Safety Institute, “About CPSI,”.
http://www.patientsafetyinstitute.ca/English/About/Pages/defaul
t.aspx,
accessed April 6, 2012.
Page 3 9B12M080
promotes communication, nurtures partnerships and celebrates
successes. CPSI has implemented projects
and programs to work with all levels of the health care system,
including frontline health care providers,
governments and educators. “Safer Healthcare Now!,” CPSI’s
flagship program, provides clinicians with
the necessary tools and resources to improve health care quality
through safety. CPSI relies on
collaborative efforts with governments, health care
organizations and clinicians to accomplish the goal of
safer health care for all Canadians.

REGULATORY ENVIRONMENT
As awareness of inadequate patient safety increased, Canadian
legislation began to change in order to
promote improvements in health care quality. On June 3, 2010,
the government of Ontario passed Bill 46,
the Excellent Care for All Act, to “make health care providers
and executives accountable for improving
patient care and enhance the patient experience.” In accordance
with Bill 46, hospitals are required to
establish a quality committee to report directly to the board of
directors. Hospitals must also develop and
publicize annual quality improvement plans (QIP). Additionally,
hospitals are mandated to survey patients
yearly and employees every second year to collect their “views
on the quality of care.” Lastly and
importantly, boards of directors are required to ensure that
hospital executives are compensated according
to whether or not QIPs are met.9
In addition to Bill 46, on July 1, 2010, Regulation 156 of the
Ontario Public Hospitals Act came into
effect; it requires that critical incidents be reported to the
medical advisory committee (MAC) and hospital
administrators. A critical incident is “any unintended event that
occurs when patients receive treatment in
hospitals that results in death, serious disability, injury, or
harm, and does not result primarily from the
patient’s underlying condition or a known risk in providing
treatment” (see Exhibits 3 and 4). Hospital
boards and administrators are legally required to ensure
disclosure of critical incidents and establish
systems to analyze the reported incidents for root causes.10

In March 2012, the Ontario Ministry of Health and Long-Term
Care announced that a patient-centred
funding model would be phased in over three years (see Exhibit
5). The intended benefits include a focus
on quality and evidence-based care, improved access and wait
times, and an emphasis on cost containment.
The resulting funding composition for hospitals, community
care access centres and long-term care homes
will ultimately be 70 per cent quality-based. The quality-based
funding will be further divided to include a
40 per cent health-based allocation model (HBAM) and 30 per
cent clinical quality groupings (see Exhibit
6). HBAM allocates a proportion of health care costs to each
Ontario resident based on factors such as age,
sex, socioeconomic status, geography and clinical group. Each
resident’s allocated cost is associated with
the organization that provides their care, and these health care
providers are given funding based on this
predicted cost. Clinical quality grouping funding is calculated
by multiplying the determined price to
provide quality treatment for a particular condition (such as
chronic kidney disease, cataract surgery, hip
replacement, etc.) by the expected volume for the health care
organization. The remaining 30 per cent will
be global funding, reduced from 54 per cent in April 2012.
Overall, the government of Ontario’s funding
reform is intended to increase quality, appropriateness and
sustainability of care for patients and the overall
health care system. 11
9 Ashok Sharma, et al., Physician Matters [Kitchener-
Waterloo], 2010, Web. January 18, 2012.

10 Ibid.
11 “How Does HBAM work?: Step-By-Step Demonstration,”
2012, pages 3-6. Web. April 12, 2012.
Page 4 9B12M080
CRITICAL INCIDENT REPORTING AND ANALYSIS
Even prior to Bill 46, disclosure of critical incidents to patients
was mandated by law, and most hospitals
had systems to collect reports on such events. Yet, there remain
several problems with critical incident
reporting in health care organizations. First, underreporting is a
challenge because physicians often fear
professional criticism or legal repercussions. The Quality of
Care Information Protection Act (QCIPA) of
2004 provides statutory protection of information collected for
the purposes of quality assessment and
improvement. Thus, under QCIPA, clinicians are protected from
legal action resulting from information
disclosed to improve quality. Following each critical incident
report, QCIPA reviews are held by hospital
administration with all individuals involved in the critical
incident. The result of QCIPA reviews are
summaries of improvements to be made. However, in addition
to underreporting, clinicians often do not
attend the QCIPA reviews, even if attendance is mandatory,
because they fear legal consequences and

recognize that attendance is not enforceable. Thus, although a
healthcare organization’s chief of staff may
have authoritative power, individual physicians are largely
independent entrepreneurs.
A second challenge with critical incident reporting is that the
information collected from reports is often
inadequate and variable. Reporters tend to cite individual rather
than systemic factors as the root cause of
adverse events. Given that reporters were most often physicians
or clinicians, they are close to the error at
the “proximal side” or “sharp end” of the problem. As a result,
they do not consider latent errors that
occurred in the overall system at the “distal end” of the
problem. Attempts were made to improve this
through educating medical students and practicing clinicians to
develop a “systems” view of medical
operations.
In addition to education, effective reporting requires a non-
punitive environment so that clinicians are
comfortable reporting incidents, including detailed accounts and
sharing near misses. Reporting
questionnaires are most effective when they are open-ended,
allowing the reporter to develop a story of the
event. This format results in reports that provide a broader
systemic picture and often include more detail
than if the survey were more specific. Overall, reporting can be
a useful tool to improve patient safety and
prevent recurrences of critical incidents, yet it remains a
reactive strategy. Greater efforts and initiatives by
all individuals are required to foster a safety culture that
promotes proactive problem-solving.
SAFETY CULTURE

In order for the benefits of CPSI, regulatory advances and
incident reporting to be realized, health care
organizations must develop a safety culture. A safety culture
refers to an environment in which the desire
to achieve greater safety is apparent in intangible beliefs,
attitudes and values in addition to concrete
structures, practices and policies. In a safety culture, clinicians
and administrators do not expect that each
individual will be flawless; rather, they understand that people
are imperfect and that failures are
inevitable. As a result, there is a heightened diligence to detect
errors and to implement defences that will
prevent adverse outcomes. These attitudes and behaviours exist
throughout the organization from the
administration to the frontline clinicians and will persist
through changes ton senior management. Once a
safety culture is achieved, reporting becomes more frequent and
complete, and near misses are willingly
shared for greater quality improvement. In order to achieve such
a result, a significant amount of trust must
exist among care providers so that adverse events may be
openly discussed and solutions developed
through collaboration. A safety culture is not a static state but a
dynamic system that is constantly changing
as opportunities arise.

9B12M080
GRAND RIVER HOSPITAL & ST. MARY’S GENERAL
HOSPITAL
Grand River Hospital (GRH) is one of Ontario’s largest
community hospitals with over 3,500 staff
members working towards their stated vision of being a “leader
in providing 24/7 patient care programs
through innovation and collaboration, within available
resources.” In 2010/11, 23,391 patients were
admitted with 12,671 day surgery visits, 58,596 emergency
visits and 210,557 ambulatory care visits. GRH
developed a quality framework, which includes a quality and
patient safety committee, a senior quality
team and clinical programs and services quality councils to hold
the hospital accountable for quality and
safety (see Exhibit 7). The hospital continually evaluates itself
on four dimensions: access to care,
appropriateness of care, safety of care and patient experience
with care. GRH uses benchmark indicators to
assess its performance and track its progress. This analysis is
made available to the public to demonstrate
transparency and openness.
St. Mary’s General Hospital (SMGH) has been providing health
care in the Kitchener community since
1924. The hospital has nearly 2,000 staff and volunteers that
annually support more than 7,000 admissions,
100,000 outpatient visits, 47,000 emergency visits and 20,000
surgical procedures. SMGH instituted their
new vision in 2011/12 of becoming the “safest and most
effective hospital in Canada characterized by
innovation, compassion and respect.” University of Waterloo

management science researchers have
partnered with SMGH to conduct deep analyses of actions and
outcomes within the hospital. SMGH
frequently employes “lean” management techniques to achieve
continuous improvement on the frontlines
of health care delivery. To encourage bedside initiatives, SMGH
announced a goal to implement 1,000
measurable improvements in one year and reported on multiple
successes to recognize and celebrate
employees’ efforts. SMGH also has a guiding quality committee
framework and an algorithm of actions
following critical incidents (see Exhibits 8 and 9).
Given their proximity to one another, GRH and SMGH partner
to specialize in certain procedures. They
are both committed to being leaders in patient safety and quality
of care, and as such, have begun various
efforts to accomplish their visions. Nonetheless, Dr. Sharma
believes that significant improvements can
still be made to patient safety in both hospitals. The hospitals
had yet to adopt a true safety culture from
administrative to frontline levels, and this is hindering
improvement to quality of care. As evidenced by
underreporting and poor attendance at QCIPA reviews, there is
a lack of physician buy-in to many quality
improvement efforts. Dr. Sharma’s greatest challenge is
influencing the intangible aspects that define a
safety culture – the attitudes, beliefs and values of clinicians.
Over a decade of pressure from the IOM,
increased legislative requirements, QCIPA legal protection,
administrative encouragement and
demonstrated positive outcomes have all been insufficient to
truly change physicians’ attitudes and
behaviour.
Dr. Sharma has considered making adjustments to the hospitals’

organizational structures to formalize
leadership positions and increase accountability on quality
metrics. He looked to the example of
Mississauga’s Trillium Health Centre, which included patient
safety accountability in the job descriptions
of department chiefs to assign responsibility for quality of care.
They also developed quality competitions
to recognize staff contributions to patient safety improvements.
These initiatives were launched following
a decade’s worth of monthly workshops to collaborate and train
staff. The successes resulting from
Trillium’s efforts are not guaranteed to be replicated in other
health care organizations, but they are
certainly attributable to physician leadership and grassroots
participation.12
Dr. Sharma is also aware of the importance of teamwork and
communication (T&C) skills to provide the
highest levels of patient satisfaction. The IOM recognized the
lack of training in T&C and called for
12 Ashok Sharma, et al., Physician Matters [Kitchener-
Waterloo], 2012, Web. March, 2 2012.
Page 6 9B12M080
medical education providers to incorporate patient safety into
their curriculums. The Johns Hopkins School

of Medicine developed a model demonstrating that failures of
T&C contribute to the majority of adverse
events. This model was used during a three-day intersession on
patient safety aimed at developing medical
students’ skills in T&C and systems thinking.13 Perhaps Dr.
Sharma could host a similar workshop to
develop the practicing clinicians’ skills, given that team
dynamics had been shown to be directly correlated
to patient satisfaction. He wonders how this could be
implemented and whether it would have a direct
enough impact on the hospitals’ cultures.
A third approach that Dr. Sharma has considered is to conduct
an extensive analysis and process redesign.
Intermountain Healthcare, a much admired health care delivery
system, adopted this approach, measured
variation in care for particular services and analyzed the
quality, efficiency and financial outcomes to
determine best practices. An administrative structure was
created to implement guidelines based on such
standards.14 Although quite successful for Intermountain, Dr.
Sharma is concerned that this approach might
cause physicians to feel their professional autonomy is not
respected.
Evidently, there are advantages and disadvantages with each
approach, but the chief of staff must make a
decision and implement a plan of action to mitigate any
drawbacks. How could Dr. Sharma best influence
the medical community, beginning with the two hospitals for
which he is responsible, to foster a safety
culture and most greatly improve patient safety?
13 Rebecca Lawton, et al., “Development of an Evidence-based

Framework of Factors Contributing to Patient Safety
Incidents in Hospital Settings: A Systematic Review,” BMJ
Quality Safety 10.1136, 2012, pages 1-10. Web. March 16,
2012.
14 Brent C. James and Lucy A. Savitz, “How Intermountain
Trimmed Health Care Costs Through Robust Quality
Improvement Efforts,” Health Affairs 30.6, 2011, pages 1-6.
Web. January 18, 2012.
Page 7 9B12M080
Exhibit 1
CONCEPTUAL MODEL OF ADVERSE EVENTS AND
ERRORS

Researchers have begun to question the existence of non-
preventable adverse events. Previously,
examples of non-preventable adverse events included incidents
such as infections at the catheter site.
However, with improved hand washing and sanitation
procedures, such adverse events can be prevented.
As such, a new model is proposed in which errors result in
either a near miss or an adverse event and all
adverse events are considered preventable.
Adverse Events Errors
Near-Misses
Non-Preventable
Adverse
Events
Preventable
Adverse
Events
Adverse
Events
Near-Misses

Errors
Page 8 9B12M080
Exhibit 2
FACTORS CONTRIBUTING TO PATIENT SAFETY
INCIDENTS1
2012.
Page 9 9B12M080

Exhibit 3
CRITICAL INCIDENT LEVELS OF HARM1
Level 0 – Near Miss or Potential Harm/Damage
Circumstances had potential to cause harm/damage. Follow-up
may be required. Disclosure not required.
Level 1 – No Harm/Damage
Event results in no harm/damage. Follow-up may be required.
Disclosure not required.
Level 2 – Temporary or Minor Harm/Damage
Event results in temporary minor harm/damage. Additional
monitoring or follow-up required. Disclosure to the
patient is not required by legislation but is strongly encouraged.
Level 3 – Permanent Harm/Damage
Event results in permanent harm/damage. Additional
monitoring, prolonged stay and extensive follow-up
required (management of critical incidents policy may be
initiated). Disclosure to patient, hospital
administrator and medical advisory committee is required.
Level 4 – Death
Event results in death. Extensive follow-up and investigation
required (management of critical incidents policy
must be initiated). Disclosure to patient, hospital administrator
and medical advisory committee is required.

Exhibit 4
EXAMPLES OF CRITICAL INCIDENTS2
1 St. Mary’s General Hospital, “Policy & Procedure, Subject:
Management of Critical Events/Incidents,” April 12, 2012.
2 Ibid
Page 10 9B12M080
Exhibit 5
3-YEAR FUNDING REFORM IMPLEMENTATION1
54%
45%
30%
40%
40%

40%
6%
15%
30%
Year 1 (April 2012) Year 2 (April 2013) Year 3 (April 2014)
Quality Groupings
HBAM
Global
Exhibit 6
ONTARIO MINISTRY OF HEALTH FUNDING REFORM2
1 Ministry of Health and Long-Term Care, “Health System
Funding Reform,” 2012, pages 3-7. Web. April 12, 2012.
2 Ibid.
Page 11 9B12M080

Quality
Plan, Goals
& Targets
Reports &
Scorecard
Program
Quality
Reporting Indicators
Senior Quality Team Senior Quality Team
Quality and Patient Safety Committee
Clinical Programs and Services Quality Management
Medical Advisory
Committee
Board
GRH Strategic Plan & Goals
Mission,
Vision,
Values
Lines of
Communication
Lines of
Communication

Quality Framework
Exhibit 7
GRAND RIVER HOSPITAL QUALITY FRAMEWORK1
Page 12 9B12M080
Exhibit 8
ST. MARY’S GENERAL HOSPITAL QUALITY
FRAMEWORK1

Page 13 9B12M080
Exhibit 9
ST. MARY’S GENERAL HOSPITAL CRITICAL INCIDENT
ALGORITHM FOR ACTION1
The most immediate actions are to ensure the safety and well-
being of the patient. Then, as soon as it is
reasonably appropriate, complete the following five items:
PATIENT/FAMILY NOTIFICATION DOCUMENTATION
STAFF SUPPORT OTHER ACTIONS
Manager /delegate
address immediate
needs of
patient/family
Most responsible
professional(s)
disclose

circumstances of
event
Provide manager’s
name as contact
person to family
Manager/delegate
provides ongoing
updates to family
Involved staff notify
most responsible
physician and
manager/ supervisor
(Clinical On Call)
Manager/supervisor
notifies Program
Director, Clinical-on-
call, Admin.-on-call (if
applicable)
Staff document (factual,
concise, objective,
accurate, timely) specific
facts of events and
immediate follow-up
actions in health record
— avoid personal notes
or subjective
Late chart entries

only as appropriate
with
manager/director
Complete critical
incident report
Manager/delegate
address immediate
needs of staff:
Manager/delegate
provide ongoing
updates to staff as
permitted under
QCIPA
Manager/delegate
secure and label
equipment, supplies,
medication involved
in the event – send to
the Director of Risk
Management for
safekeeping
If Coroner involved:

directed by Coroner
If biomedical
equipment involved,
contact Biomedical
Engineering
Manager to begin
investigation
Manager/delegate
notifies:
patient services
Executive
Management
(e.g., Medical
Director, Chief of
Staff)
Risk Management
to secure chart with
Health Records

Adapted from St. Joseph’s Healthcare,
Complete
Disclosure
Templates
Page 14 9B12M080
Exhibit 10
MISCOMMUNICATION AND REDUCED TEAMWORK
CONTRIBUTING TO ADVERSE EVENTS1
2012.

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