PATIENT SAFETY through COMMUNICATION March 11, 2008

1. PATIENT SAFETY through COMMUNICATION March 11, 2008

2. BACKGROUND on MIPS: • Independent, non-profit corporation • Created in May 2004 • Governed by 12 member board: • Majority (7) elected by our membership and 5 appointed by Minister of Health • Board – citizens, providers, administrators

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

4. Objective 1 Promote patient safety activities in Manitoba health care system.

5. Objective 2 Identify emerging patient safety & quality care issues.

6. Objective 3 Promote “best practices” in patient safety.

7. Objective 4 Raise awareness of patient safety issues.

8. MIPS PATIENT ADVISORY COMMITTEE “MPAC”

9. MPAC • Provide a voice for patients/families interested in patient safety & its promotion in healthcare settings • Do activities to promote MIPS mission & objectives • Create long-term strategies for patient & family involvement in MB Health care system

10. FACTS Canadian Adverse Events Study (2004): The results suggest that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about: • 7. 5% (185,000) of adult hospital admissions (acute care) resulted in an adverse event • Of these, 37% (70,000) were considered preventable, and • 9000-24000 died.

11. Safety in Long-Term Care Settings (2008)Wagner & Rust FACTS • Accidental injury - most common adverse event among nursing home residents with dementia & psychosis • Falls - most frequently reported adverse event in LTC settings • Medications- 42% of all adverse drug events preventable

12. “Patient safety is everyone’s responsibility.”

13. PATIENT SAFETY IS A COMMON GOAL • Reduce preventable harm to patients • Provide the safest quality care possible

14. DO I PROMOTE PATIENT SAFETY? Ask yourself: • Do I value resident safety? • Do I communicate effectively with residents & their families? • Do I do all that I can to promote patient safety in my organization?

15. ACTION CHECKLIST(Reality Check) Do I: • Communicate in respectful open, honest manner daily? • Communicate regularly with families & HC team? • Provide families with timely health information? • Use plain language and visual clues when discussing the patient with families? • Regularly ask families to clarify what was discussed?

16. ACTION CHECKLIST DO I: • Encourage families to ask questions? • Discuss patient safety with families & HC team? • Look for latent safety threats every day? • Report/disclose any errors or potential errors that may impact on patients? DO I PROMOTE PATIENT SAFETY??

17. BUILDING BLOCKS TOPATIENT SAFETY

18. BUILDING BLOCKS TO PATIENT SAFETY Communication

19. Communication Patient Safety

20. COMMUNICATION Why is it important? Bridge between HC providers, patients/ families & rest of HC team to achieve patient safety & quality care.

21. Communication • Root cause of 70% of sentinel events reported to the Joint Commission, US.

22. WHAT TYPE OF COMMUNICATION IS NEEDED ? • Verbal & Non-Verbal • Respectful • Honest • Mutually trusting • Accepting • Empathetic

23. COMMUNICATION • Interdisciplinary • Engage family • Care planning • Reporting/disclosing incidents • Medication safety • Critical to culture of safety • Timely shared

24. Action BUILDING BLOCKS TO PATIENT SAFETY Communication

25. What can you-Health Care Provider- do?

26. ACTIONS OF HEALTH CARE PROVIDERS • Open two-way communication • Ongoing involvement • Ongoing sharing • Teamwork • Advocate for Culture of Patient Safety

27. ACTION • OPEN TWO-WAY COMMUNICATION: • Talk with families/care givers. • Listen to families/care givers. • Talk with HC team. • Listen to HC team.

28. ACTION • ONGOING INVOLVEMENT: • Families/care givers in health decisions • Health care team • Upper management

29. ACTION • ONGOING SHARING of: • Patient information • Importance of patient safety • Latent threats to patient safety • Reporting/disclosure of adverse events With: • Families/care givers • Rest of HC team

30. ACTION • TEAMWORK: • Effectively collaborate with others • Give and receive feedback on performance • “No Blame” approach to incident reporting & analysis

31. ACTION 5. ADVOCATE - CULTURE of PATIENT SAFETY • Be a site “champion” • Stay positive • Involve families in important decisions • Be persistent

32. Support Action BUILDING BLOCKS TO PATIENT SAFETY Communication

33. SUPPORT: • Is there a patient safety culture? • Is patient safety: • A top priority in your organization & among leaders? • Viewed as a positive concept? • The focus of attention for all organizational activities?

34. SUPPORT: • Is there a collaborative environment? • “Blame-free reporting system” • Proactive approach (errors/problems anticipated) • Share information (3 Cs) • Accountability - safety is everyone’s responsibility • Monitoring of situations & actions taken

35. SUPPORT: • Are families/care givers involved in process of patient safety improvement? • Is there a clear organizational policy? • Are there adequate resources to respond to identified concerns?

36. SUPPORT: For residents, Balance Patient SafetyQuality of Life/ Independence

37. TOOL for FAMILIES & HC PROVIDERS Is It … Safe to Ask? ISTA

38. It’s Safe to Ask Offers information and tips for providers and patients/families to: • Enhance clear communication • Make care a more positive experience • Increase health literacy • Help reduce adverse events

39. It’s Safe to Ask (ISTA) Target Groups: • Public Groups in Manitoba (such as elderly, low literacy, people with disabilities) • Health care providers

40. It’s Safe to Ask • What is my health problem? • What do I need to do? • Why do I need to do this?

43. What are the values behind in ISTA? • Know your rights as patients/families. • Personal Health Information Act (PHIA) • Right of patient to receive healthcare instructions and information in a way they/care givers can understand. (Standards for PCH #1 Pte Bill of Rights) • Ask questions.

44. What is MPAC telling families/care givers? Communicate with HC providers: • Ask questions • Learn some medical terminology • Seek credible resources • Gain support

45. Material translated into: Amharic English Arabic French Chinese Cree Ojibway Oji-Cree Eritrean German Korean Punjabi Russian Spanish Tagalog15 languages!

46. PHASE 2, ISTA • Medication Card

47. Support Patient Safety is achievable! Everyone must be willing to: Act Communicate

48. Look for windows of opportunity

49. FAMILY STORIES

50. www.mbips.ca www.safetoask.ca