Quality & Patient Safety TOH. Linda Hunter Director, Quality and Patient Safety 2011. Deep River & District Hospital. Ottawa Area Hospitals. - The Ottawa Hospital. - Royal Ottawa. Pembroke General Hospital. - CHEO. - Montfort. - Bruyere Continuing Care.
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Director, Quality and Patient Safety
Ottawa Area Hospitals
- The Ottawa Hospital
- Royal Ottawa
Pembroke General Hospital
- Bruyere Continuing Care
Hawkesbury & District General Hospital
- Queensway-Carleton Hospital
St. Francis Memrial Hospital
Renfrew Victoria Hospital
Arnprior & District Memorial Hospital
Glengarry Memorial Hospital
Almonte General Hospital
Winchester District Memorial Hospital
Carleton Place & District Hospital
Cornwall General Hospital
Kemptville District Hospital
Hotel Dieu Hospital
Perth & Smith's Falls District Hospital
To Become a Top 10% Performer in Quality and Patient Safety in North America
Surg. Site Infections
Create a culture of compassionate people, world-class care
Physician Engagement & Accountability
Human Resources Plan
Information Services Plan
Communication & Community Outreach Plan
Commitment to Quality
for the Individual
OHQC: Attributes of a High-Performing Health System, Ontario Health Quality Council
HQCA: Quality Matrix for Health, Health Quality Council of Alberta
…to different end stakeholder groups
Corporate Quality Plan
A - Reported annually
Q - Reported quarterly
Ottawa Model for Diabetes(Q)
Selection criteria for indicators:
Focus on the vital few versus the trivial many
Submitted quarterly in each three year cycle
For MOH Public Reporting:
Submitted quarterly to annually
Updated Jan 2011
UW-Madison Systems Engineering Initiative for Patient Safety (SEIPS)
Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P. Alvarado, C. J., Smith, M., and Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. Quality and Safety in Healthcare, 15(Suppl I), i50-i58.
Framework which includes 6 core domains that provide for safer patient care:
Domain 1: Contribute to a Culture of Patient Safety
Domain 2: Work in Teams for Patient Safety
Domain 3: Communicate Effectively for Patient Safety
Domain 4: Manage Safety Risks
Domain 5: Optimize Human and Environmental Factors
Domain 6: Recognize, Respond to and Disclose Adverse Events
Visit CPSI – Safety Competencies www.safetycomp.ca for complete framework information.
The Survey on Patient Safety Culture (AHRQ) was launched in August 2006, and offered to all staff, physicians and volunteers at TOH.
A second survey, the Patient Safety Culture in Healthcare Organizations Survey, a tool developed by Stanford and modified by York University and supported by AC was run on four TOH inpatient units the following year. Further surveys were done in 2010 and 2011.
There were six survey items where the large majority of staff members responded the same way in both surveys. (i.e. there was very little variation in responses); these include:
Survey on Patient Safety Culture (n 738)
Both sets of survey results reflect staff with direct patient interaction only.
Patient Safety Culture in Healthcare Organizations Survey(n 109)
Adverse Event Reporting
A reportable incident is … any unusual occurrence that is inconsistent with the routine care of a patient; or that adversely affects patients, volunteers, visitors or hospital property; or an unexpected negative treatment outcome.
e.g. falls, med errors, equipment problems, lab incidents
Injury does not have to occur for an event to be reportable (“near misses”)
As defined in TOH Critical Incident Review Policy and in accordance with the Public Hospitals Act a “Critical Incident” means any unintended event that occurs when a patient receives treatment in the hospital:
(a) that results in death, or serious disability, injury or harm to the patient, and
(b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing the treatment.
As defined in TOH Patient / Visitor Incident Reporting Policy a “Serious Incident”is one that results in a fracture, haemorrhage, aspiration, serious drug variance/reaction or death, transfer to a critical care area, increased length of stay or admission to hospital.
Disclosure is a professional, ethical, moral and legislative requirement
“Disclosure” refers to the communication of information regarding an
adverse event, adverse outcome or critical incident.
Public Hospitals Act directs that the disclosure conversation must include:
(a) the material facts of what occurred with respect to the critical incident;
(b) the consequences for the patient of the critical incident, as they become known; and
(c) the actions taken and recommended to be taken to address the consequences to the patient of the critical incident, including any health care or treatment that is advisable.
Documentation of the disclosure discussion is also a legislative requirement.
TOH Disclosure Toolkit available
To find out:
Resources: CPSI RCA Toolkit & TOH RCA Lite Toolkit
Rules, Policies, Procedures, Protocols and Processes:
Staff Factors (Knowledge, skill)
Patient Safety Culture Project