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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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quality patient safety toh

Quality & Patient Safety TOH

Linda Hunter

Director, Quality and Patient Safety


Deep River & District Hospital

Ottawa Area Hospitals

- The Ottawa Hospital

- Royal Ottawa

Pembroke General Hospital


- Montfort

- 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

Champlain LHIN

The Ottawa HospitalFacts and Figures


  • ~$1B Operating Budget
  • 1,172 Inpatient Beds
  • 12,000 Staff
  • 1,200 Physicians


  • 46,000 Admissions
  • 49,000 Surgical Cases
  • 127,000 ED Visits
To provide each patient with the world class care, exceptional service and compassion that we would want for our loved ones


To Become a Top 10% Performer in Quality and Patient Safety in North America

  • Access
  • Wait Times:
  • DI, Hip/Knee, Cancer & ED


Re-admission rates

Surg. Site Infections




  • Safety
  • HSMR
  • Hospital Infections:
  • MRSA, VRE & C-Difficile







Create a culture of compassionate people, world-class care

Service Excellence

Performance Measurement

Physician Engagement & Accountability


& Tactics

Patient Experience

Enabling environments

Clinical transformations

Staff Engagement

Our Patients

Quality Plan

Research Plan

Our Staff

Human Resources Plan

Our Finances

Operating Plan

Our Environment

Capital Plan

Information Services Plan

Our Partners

Communication & Community Outreach Plan

Commitment to Quality

Working Together


for the Individual



Quality and Performance Measurement
  • Define
  • Align
  • Prioritize
  • Measure
  • Report
Definition of Quality
  • Providing the patient with appropriate consistent health care in a clean and safe environment in which the patient is treated with respect.
      • - TOH Board, January 2003, reconfirmed 2008
Defining the Quadrants

OHQC: Attributes of a High-Performing Health System, Ontario Health Quality Council

HQCA: Quality Matrix for Health, Health Quality Council of Alberta



  • TOH Strategic Direction
  • Best Practice
  • Legislation
  • Accreditation Recommendations
  • Ministry of Health Mandated Requirements
  • Future Trends
  • Others?
Corporate Quality Plan Prioritization
  • Corporate in scope
  • Aligns with TOH mission and vision
  • Aligns with at least one of the following:
    • Addresses issues occurring frequently or to a high volume of patients
    • Addresses high risk for patient safety issues
    • Addresses accreditation or regulatory requirements
  • High probability of impact on outcomes/process measurement/indicators
  • Scorecard
  • Workplan
  • Colour coded – green, yellow, red
  • Trend charts
  • Others

…to different end stakeholder groups

The Ottawa Hospital

Corporate Quality Plan

Balanced Scorecard

  • Access
  • Emergency Offload (Q)
    • 90th percentile CTAS 1
    • 90th percentile CTAS 2-5
  • Emergency Access Times (Q)
    • % admitted ED LOS < 8 hrs
    • % non-admit waiting < 8 hrs for CTAS 1&2
    • % non-admit wait < 6 hrs, CTAS 3
    • % non-admit wait < 4 hrs, CTAS 4&5
  • Number of cancer surgeries (Q)
  • Number of knee surgeries (Q)
  • Number of hip surgeries (Q)
  • Number of cataract procedures (Q)
  • Number of hours MRI delivered (Q)
  • Number of hours CT delivered (Q)
  • Safety
  • Ventilator Associated Pneumonia rate (Q)
  • Central Line Infection rate (Q)
  • Surgical Site Infection rate (Q)
  • Hand Hygiene compliance rate (Q)
  • Hip fractures receiving surgery < 48 hours (Q)
  • C Difficile rate (Q)
  • MRSA rate (Q)
  • VRE rate (Q)
  • HSMR (Q)
  • - Data currently available

A - Reported annually

Q - Reported quarterly


  • Satisfaction
  • NRC-Picker Pt Satisfaction Results (Q)
    • Medicine
    • Surgery
    • Obstetrics and Gynecology
    • Emergency Department
    • Same Day Surgery
    • Rehabilitation
    • Ambulatory Care
  • Effective

Ottawa Model for Diabetes(Q)

  • Inpatient satisfaction with pain control (Q)
    • Medicine
    • Surgery
    • Obstetrics and Gynecology
    • Emergency Department
    • Rehabilitation
  • Efficient
  • Cost per weighted case (A)
  • % clinical pathways revised (Q)
  • # new clinical pathways / program (Q)
Indicator Assumptions

Selection criteria for indicators:

  • Data is available
  • Data is timely
  • Indicator is valid and reliable
  • Indicator is actionable
  • Impact on high volume, high cost and high risk

Focus on the vital few versus the trivial many

Mandatory Indicators

For accreditation:

  • Percentage of patients receiving medication reconciliation at admission
  • MRSA infection rate
  • C. Diff infection rate
  • Rate of post surgical infections
  • Rate of timely administration of prophylactic antibiotic

Submitted quarterly in each three year cycle

For MOH Public Reporting:

  • CLI rate
  • VAP rate
  • MRSA
  • C. Diff
  • VRE
  • SSI antibx
  • HH compliance
  • HSMR
  • SSCL

Submitted quarterly to annually

Quality Monitoring
  • Insanity is doing the same thing over and over again and expecting a different result.
          • -Albert Einstein
  • It’s not the data.
  • It’s what you do with it.
Model of a work system

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.

  • Patient safety is defined as the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes.
  • Patient Safety Culture is defined as a commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.

(CPSI, 2008)

CPSI – The Safety Competencies

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.

Fostering Patient Safety Culture at TOH


  • A vision of where we want to go
  • Senior leadership buy-in
  • Actions to get us there
  • Passionate clinicians and support staff
  • Accountabilities defined
  • An action plan to move forward
Patient Safety Culture Surveys at TOH

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:

  • Asking for help is a sign of incompetence (93% disagree)
  • If I make mistake, and nobody notices, I do not tell anyone (95% disagree)
  • I will suffer negative consequence if I report a patient safety problem (86% disagree; 9% neutral)
  • I engage in unsafe practices in order to get the job done (95% disagree)
  • I report the errors I make (86% often/always; 11% occasionally)
  • I learn from errors made by my colleagues (81% often/always; 16% occasionally)
Develop a Culture of Safety
  • Relay safety reports at shift changes
  • Create an adverse event respond team
  • Re-enact adverse events
  • Appoint a patient safety champion for every area/unit
  • Simulate possible adverse events
  • Involve patients in safety initiatives
  • Create a reporting system (PSLS)
  • Designate a patient safety officer
  • Conduct safety briefings
  • Provide feedback to frontline staff
  • Conduct patient safety walkabouts (rounds)
Comparison of Patient Safety Culture Surveys

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

  • Focus on how we can prevent and intercept errors
  • Statistical data that can be analyzed to determine trends
  • Understand and improve practices that promote a safe care environment for patients

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”)

more definitions
More definitions

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

Goals of Root Cause Analysis (RCA)

To find out:

  • What happened
  • Why it happened
  • What can be done to reduce the likelihood of a recurrence?

Resources: CPSI RCA Toolkit & TOH RCA Lite Toolkit

steps of a rca
Steps of a RCA
  • Determine the team
  • Organize the meeting
  • Gather information and the facts of the incident
      • Who, What, Where, When but not the Why
  • At the meeting
      • Review the information gathered and determine what did happen compared with what should have happened
  • Determine contributing factors and root causes
      • Keep asking “why” until the contributing factors and root causes are found
  • Develop actions and determine performance measurements
  • Implement the actions
  • Measure and evaluate the effectiveness of the actions
common root causes
Common Root Causes

Rules, Policies, Procedures, Protocols and Processes:

  • Lack of awareness of what protocols, policies and procedures are available
  • Lack of standardization of processes

Communication Issues:

  • Breakdown in communication primarily at the point of transition, both internally and externally
  • Lack of information in the patient health record

Equipment Issues:

  • Lack of available equipment (department specific requirements)

Staff Factors (Knowledge, skill)

  • Incomplete & inaccurate documentation across all disciplines
  • Lack of ongoing education related to policies, procedures and protocols

Patient Safety Culture Project