Strategic priorities in Patient Safety

1,511 views

Published on

Strategic priorities in Patient Safety. Philip Hassen. IV International Conference on Patient Safety. (Madrid, Ministry of Health and Consumer Affairs, 2008)

Strategic priorities in Patient Safety

  1. 1. Advancing Patient Safety- Canada’s Vision for the Future IV International Conference on Patient Safety November 25, 2008 Philip Hassen, CEO Canadian Patient Safety Institute 1
  2. 2. Overview • Canadian Health System • OECD-Comparing Spain, Canada, Other • Background CPSI • Concluding Remarks/Questions 2
  3. 3. Canadian Population in 2006 was at 32.5 Million Canadian health- care spending for 2007 will reach $160.1 billion. Public-sector health care spending forecast projected to reach 70.6%. Private-sector health-care spending forecast projected to reach 29.4%. 3
  4. 4. 4 Canadian Health System Key Differences Highlighted • one fully socialized health care system • Federal government funds the provincial government as long as they abide by the Canada Health Act which explicitly prohibits end user billing for procedures covered through the publicly funded system • All provinces except Ontario have "mature" Regions • These are vertically and horizontally fully integrated health and health care under one organization • Focuses as much on population as individual health Canadian Government Involvement Central structural difference is in health insurance
  5. 5. OECD Health Data 2007 3.8 3.4 2.8 4.0 0.0 1.0 2.0 3.0 4.0 adaFrance Italy United States OECD Ave Acute Care Hospital Beds per 1000 Population 2004 3.9 4.1 6.8 5.7 0.0 2.0 4.0 6.0 8.0 anadaFrance Italy United States OECD Maternal and Infant Mortality Deaths per 1000 Live Births 2004 Canada Spain Canada Spain 29 26 53 40 Health Employment Health Employment Practicing PhysiciansPracticing Nurses Density per 1000 Population (Head Counts) Density per 1000 Population (Head Counts) 2005 16.0 4.7 15.0 0.0 9.9 France Italy United States OCEDAveSpain 81 Canada 55 4.0 14.0 3.5 12.0 3.0 10.0 2.5 8.0 2.0 6.0 1.5 4.0 1.0 2.0 0.5 0.0 0.0 3.4 3.8 2.4 3.0 France Italy United States OCEDAve 2005 Canada Spain 22 39 OECD Health Data 2007, October 2007 Not Available 5
  6. 6. OECD Health Data 2007 Health expenditure as a share of GDP, OECD countries, 2005 15.3 11.1 10.7 9.8 9.2 9 8.9 8.3 8.2 7.5 0 2 4 6 8 10 12 14 16 18 U nited States France G erm any C anadaN etherlands O EC D Italy U nited Kingdom Spain Ireland %GDP OECD Health Data 2007, July 2007 6
  7. 7. 7 • Patients for Patient Safety Patients for Patient Safety • Global Patient Safety Challenges: • Clean Care is Safer Care (GPSC 1) • Safe Surgery Saves Lives (GPSC 2) • Reporting & Learning • Classification • Research • Safety Solutions and High 5s Alliance Programmes
  8. 8. Canadian Patient Safety Institute Mission To provide national leadership in building and advancing a safer Canadian health system Vision We envision a Canadian health system where: • Patients, providers, governments and others work together to build and advance a safer health system; • Providers take pride in their ability to deliver the safest and highest quality of care possible; and • Every Canadian in need of healthcare can be confident that the care they receive is the safest in the world. 8
  9. 9. Patient Safety: Barriers to Action • Access is more urgent in Canada • Shortages of clinical professionals • Concern about liability • Jurisdictional conflicts • Delays in building the Electronic Health Record • Culture of patient safety is lacking 9
  10. 10. A Culture of Safety 31,033 Pilots, Surgeons, Nurses and Residents Surveyed* *Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross sectional surveys. BrMedJour, 3-18-2000. % Positive Responses from: Pilots Medical Is there a negative impact of fatigue on your performance? 74% 30% Do you reject advice from juniors? 3% 45% Is error analysis system-wide? 100% 30% Do you think you make mistakes? 100% 30% Easy to discuss/report mistakes? 100% 56% 10
  11. 11. 11
  12. 12. Human Error – the New View The point of an investigation is not to find where people went wrong. It is to understand why their assessments and actions made sense at the time. Sidney Dekker (2002); The Field Guide to Human Error Investigations 12
  13. 13. 14
  14. 14. Human Error – the New View HUMAN ERRORS ARE SYMPTOMS OF DEEPER TROUBLE Sidney Dekker (2002); The Field Guide to Human Error Investigations 15
  15. 15. A Systems Approach “The systems approach is not about changing the human condition but rather the conditions under which humans work.” J.T. Reason, 2001 16
  16. 16. 17
  17. 17. 18 . Tools & Resources Interventions & Programs ResearchEducation . Influence Change Measure & Evaluate Communicate Build Capacity Engage Stakeholders Understand the Issues
  18. 18. Examples of Collaboration & Partnerships Canadian Institute for Health Information • Hospital Standardized Mortality Ratio (HSMR) Institute for Safe Medication Practices • Canadian Root Cause Canada and Saskatchewan Health Analysis Framework Canada Health Infoway • Patient Safety and the Electronic Health Record Community and Hospital Infection Control • Canada’s Hand Hygiene Association, Canadian Council on Health Campaign . Services Accreditation, Public Health Agency of Canada World Health Organization • Patients for Patient Safety Canada; High 5s Ministère de la santé et des services • Projet de formation sur les facteurs humains sociaux (Québec) Canadian Council on Health Services • Align efforts Accreditation, HIROC 19
  19. 19. CPSI Strategic Direction Education Executive Patient Safety Series Governance for Quality and Safety Canadian Patient Safety Officer Course Simulation IHI Re-broadcast Halifax Conference Studentships Patient Safety Competencies Canada’s Forum on QI and Patient Safety . Interventions & Programs World Health Organization High 5’s Patients for Patient Safety Canada Infection Control Hand Hygiene Campaign Safer Healthcare Now! Research Home Care Long Term Care Mental Health Services Emergency Medical Services Primary Health Care Building Capacity through Research Tools & Resources Event Analysis Electronic Health Record Canadian Disclosure Guidelines Canadian Adverse Event Reporting and Learning System WHO Safe Surgery Saves Lives Human Factors 20
  20. 20. Education Governance for Patient Safety • National leadership, coordination and collaboration with current provincial/territorial and regional initiatives • Co-commissioned research - partnership with CHSRF • “Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations” (Baker, Denis, Pomey & MacIntosh Murray, 2009) • Development of a framework and supporting tools, resources and education to assist boards in their understanding of and efforts to improve patient safety 2121
  21. 21. Education Education Simulation GOAL: • To establish a national coordinating group to promote and endorse simulation and provide a foundation for collaboration (or: “framework for the sharing of resources”) • To facilitate the development of a national simulation strategy for healthcare through focused collaboration with stakeholders 22
  22. 22. Education Halifax Conferences • Annual National Patient Safety Conference Patient Safety Officer Course- One week intense education/training session Patient Safety Competencies • First edition released September 25, 2008. Activities for dissemination and stakeholder engagement are underway 23
  23. 23. Research • Over 60 research and demonstration projects have been funded in the last three years, these will form the basis for new knowledge of Canadian patient safety challenges and solutions • Work Collaboratively with Other Research Funding Groups • Research Dollars Spent to date: $5.8Million 24
  24. 24. Research Building Capacity Through Research • Development of Patient Safety background papers to identify the current state of knowledge, future research priorities, key issues, and strategies and opportunities for action and improvement: • Mental Health Emergency Medical Services • Primary Health Care • Home Care • Long-Term Care 2525
  25. 25. Interventions & Programs Patients for Patient Safety: Why? • More to offer than simply the ‘victims’ story of tragic medical error. • Consumers offer the richest resource of information related to medical errors as many have witnessed every detail of systems failures from beginning to end. • Patients want to know the truth when things go wrong and be treated with honesty and openness rather than face a closed door of denial 26
  26. 26. Health-care providers’ compliance with hand hygiene practices is less than 40% on average 27
  27. 27. Interventions & Programs Canada’s Hand Hygiene Campaign Hand Hygiene Campaign Goals: • Promote the importance of hand hygiene in reducing the occurrence of healthcare associated infections • Respond to the needs of healthcare organizations for capacity building and leadership development by creating and providing them with tools to help promote good hand hygiene SHN MRSA Intervention Goals: • Enable healthcare organizations and caregivers to prevent patient harm from MRSA • Reduce MRSA infection rates 28
  28. 28. Interventions & Programs Canada • 33 million people • 10 interventions + 2 pilots • 1035 teams enrolled • 80% of acute care hospitals enrolled • All regional health organizations outside of Quebec enrolled Aim • Reduce adverse events by 40-100% according to intervention www.saferhealthcarenow.ca
  29. 29. Interventions & Programs Campaign Structure Partner Network Peer Support Network CAPHC Measurement Working Group & CMT Education & Resource Working Group Clinical Support Canadian ICU Collaborative ISMP Canada Operations Teams Other Canadian Faculty Communications Advisory Group Atlantic Node Ontario Node Western Node Campaign Support SHN National Steering Committee Secretariat - CPSI Patients CCHSA CIHI Quebec Campaign IHI 30
  30. 30. Interventions & Programs SHN Interventions Initial Interventions • Improve Care for Acute Myocardial Infarction • Prevention of Central Line Associated Bloodstream Infection • Medication Reconciliation • Rapid Response Teams • Prevention of Surgical Site Infection • Prevention of Ventilator-Association Pneumonia New Interventions • Prevention of Adverse Drug Event in Long-Term Care • Prevention of Harm from Falls in Long-Term Care • Prevention of Harm from MRSA • Improve Care for Venous Thromboembolism (VTE) Pilot Projects • Prevent Adverse Drug Events Related to High Risk Medication Delivery in Paediatrics • Prevent Adverse Drug Events Through Medication Reconciliation in Home Care 31
  31. 31. Interventions & Programs Safer Healthcare Now! Teams Continue to Enroll Total # of Enrolled Teams Sep-05 Nov-05 Jun-06 Nov-06 Jan-07 Mar-07 Jun-07 Aug-07 Oct-07 Jan-08 Mar-08 Apr-08 May-08 Jul-08 Aug-08 Oct. 08 Safer Healthcare Now! Overview Total # Enrolled Teams September 2005 to September 2008 118 296 443 546 579 628 695 734 789 817 860 933 962 1004 1021 1050 0 100 200 300 400 500 600 700 800 900 1000 1100 Total at September 23, 2008
  32. 32. M onth 13 M on th 13 Interventions & Programs SHN: End of Phase I – January 2007 Med Rec Results – Unintentional discrepancies È from 1.16 to 0.65 per patient (goal of 0.30) 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Months in SHN! Ventilator-associated Pneumonia Central Line-Associated Blood Stream Infections �bloodstream infections 4.8 per 1,000 central line days to 1.6 6 5 4 3 2 1 0 M onths in SHN! Rapid Response Team � in the national rate for VAP from a baseline of 19.88 per â 1,000 ventilator days to 3.76 after 13 months, (goal was 7.00) Rate 18 16 10 14 812 10 8 6 4 2 0 6 4 2 0 national rate of Codes (occurring outside ICU) per 1,000 discharges from 7.46 to 4.61, Months in SHN Months in SHN 33
  33. 33. Tools & Resources Event Analysis • The French adaptation for the Canadian Root Cause Analysis Framework is completed and Failure Mode Effect Analysis is in progress Electronic Health Record • Plans are underway to examine the role of EHR as it relates to the process of medication reconciliation Canadian Disclosure Guidelines • Are available on the CPSI website. 34
  34. 34. Tools & Resources Canadian Adverse Event Reporting and Learning System (CAERLS) • The CAERLS Consultation Paper is available on the CPSI website. Planning for consultation meetings to be held throughout Canada are currently underway. WHO “Safe Surgery Saves Lives” • An in-country working group has been assembled to adapt the Safe Surgery Checklist for use in Canada Human Factors • Development of educational strategies is being contemplated to assist organizations to better understand this important area of patient safety 35
  35. 35. Other Challenges and Key Issues • Develop other indicators • Build patient safety expert capacity • Collaborate and Increase Engagement (F/P/T, “patient safety” agencies/organizations) • Keep patient safety on the national agenda; inform the public, patients, providers, policy- and decision-makers • Misdiagnosis • Culture of Patient Safety 36
  36. 36. Summary Patient Safety • CPSI is “leading without owning” resulting in significant and measurable patient safety improvements by many Healthcare organizations in just three years of operations • Safer Healthcare Now! is a pan-Canadian success story – “changing the face of safety in the Canadian healthcare system” • The success of CPSI will continue to be assessed with the emergence of Hospital Standardized Mortality Ratios and other measures 37
  37. 37. Commitment to Our Patients “…there are some patients we cannot help, there are none we should harm...” Dr. Ken Stahl 38

×