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Patient Safety: New Trends and Strategies for Implementation Canadian College of Health Service Executives March 2006. Speakers Donna Towers, CHE Capital Health (Alberta) John King, CHE St. Michael’s Hospital, Toronto Anne McGuire, CHE IWK Health Centre, Halifax.

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Patient Safety: New Trends and Strategies for Implementation

Canadian College of Health Service Executives

March 2006


Donna Towers, CHE

Capital Health (Alberta)

John King, CHE

St. Michael’s Hospital, Toronto

Anne McGuire, CHE

IWK Health Centre, Halifax



  • Canadian College of Health Service Executives
  • Collaboration to date on the common patient safety agenda
  • The executive’s role in patient safety
  • Practical examples

Capital Health (Alberta)

St. Michael’s Hospital

IWK Health Centre


Canadian College of Health Service Executives (CCHSE)

A professional association with 3,000 members across all sectors of health services.


CCHSE Vision and Mission


To be the professional association of choice for Canada’s health leaders


To develop, promote, advance and recognize excellence in health leadership


CCHSE Strategic Directions

  • Position the College as a ‘must belong to’ organization, responsive to its members
  • Raise the profile of health leaders and their contribution to public policy, the health system, and the health of Canadians
  • Raise the stature of the College so that it is recognized as a resource and source of solutions in addressing health leadership issues
cchse strategic directions
CCHSE Strategic Directions
  • Position the College as responsive to all health leaders, regardless of their professional background
  • Promote evidence-based practices for health leaders across the public, corporate, voluntary and university sectors

Canadian Patient Safety Institute

  • (CPSI)
  • Announced in December 2003
  • Located in Edmonton
  • Mandate: to provide leadership and coordinate the work to build a culture of patient safety and quality improvement throughout the Canadian health system
collaboration and cross representation

Collaboration and Cross Representation

CCHSE is a voting member of CPSI

CPSI is a corporate member of CCHSE


College’s Role in Patient Safety

    • Developed a position paper for members (2004) which states that responsibilities and accountabilities for patient safety need to be delineated in governance, management and clinical processes
    • Advocate effectively communicating improvements in patient safety
        • Internally
        • Externally
Health Executive’s Role

in Patient Safety

  • Culture
  • Accountability
  • Measures
  • High Reliability/Redesign
  • Communication and Teamwork
  • Professional Development


  • Critical role for leaders is to drive cultural change by demonstrating commitment to safety through:
    • Clearly communicating patient safety goals
    • Supporting resources and tools required to achieve success
    • Visible commitment to openly share information
    • Driving patient safety education at every level and at every opportunity

Culture of Safety: Accreditation

  • Canadian Council on Health Services Accreditation (CCHSA)
  • Quality and patient safety are important components of CCHSA standards
  • Major focus areas for accreditation
CCHSA Patient Safety Goals
  • Create a culture of safety within the organization
  • Improve the effectiveness and coordination of communication among service providers and with the recipients across the continuum
  • Ensure the safe use of high risk medications
  • Create a work life and physical environment that supports the safe delivery of care/service
  • Reduce the risk of health service organization-acquired infections, and their impact across the continuum of care/service


  • Organizations must clearly define accountabilities for patient safety
  • Capital Health (Alberta): patient safety accountability resides with VP Medical and VP/CLO
  • Report bimonthly to the board on quality and patient safety issues
  • Regional Quality Council with representation from all sites and sectors – advisory to Executive Committee


  • Develop reporting policies within a quality improvement framework across the organization that promote learning
  • Executive’s role is to ensure appropriate reporting and monitoring mechanisms are in place

High Reliability/Redesign

  • Based on learnings from the aviation industry and the nuclear industry
  • Reliability principles:
    • simplification
    • standardization
    • relation of humans to the work
    • environment (Resar & Leonard, 2004)

High Reliability/Redesign: KCl

  • Appropriate monitoring from other countries resulted in Capital Health (Alberta) taking early action in the area of potassium chloride (KCl) purchase and storage on patient units to minimize the risk of potential error of incorrect potassium chloride administration
  • In 2002 moved to purchase dialysate for CRRT based on environmental scanning

Communication and Teamwork

Health care personnel, patients and all others within the system:

  • must be informed participants
  • understand that human error is inevitable
  • underlying systemic factors including ongoing system change contribute to most near misses, adverse events and critical incidents

Communication and Teamwork

  • Communication and team-building to improve teamwork including across sites/sectors
  • Safer hand-offs and transitions
  • Openness in communication with staff, key stakeholders, patients and the general public
  • Sharing and dissemination of “lessons learned” about improving patient safety throughout the continuum of care

Communication and Teamwork

  • Communications threaded into all areas
  • Transparent/open communication is essential for a culture of quality and patient safety
  • Behaviour change is a key indicator of effective communications

Professional Development

  • Maintenance of professional competency is an important aspect of ensuring patient safety
  • CCHSE Certified Health Executive
  • CCHSE role
  • To continue professional development and networking in the area of patient safety and its associated techniques and theory

Translation of National Level to the Organizational Level

  • Challenge for health executives is to take what is being developed at the national level and operationalize patient safety within their organizations
st michael s hospital safety program and plan

St. Michael’s Hospital Safety Program and Plan

Mr. John King, CHE

Executive Vice President

st michael s approach
St. Michael’s Approach
  • Strategic commitment to “adopt a leadership role in the implementation of patient safety initiatives” (Reaching New Heights 2004)
  • White paper on Patient Safety (2004)
  • Patient Safety Plan (2005)
  • Corporate Objective for 2006/2007
Strategies are in place under five IOM Principles:


Respect Human Limits in Process Design

Effective Team Functioning

Anticipate the Unexpected

A Learning Environment

SMH Safety Plan is based on the Institute of Medicine (IOM) and Canadian Council on Health Services Accreditation Goals
  • Clear organizational leadership and professional support, including involvement of governing boards, management, and clinical leadership
    • Strategic direction (2004)
    • EVP sponsors for all strategic safety initiatives
    • Safety policy
    • Quarterly safety reports to senior management and Board of Directors
    • Accountability for all staff defined (MAC, professional practice, performance appraisals for all staff)
respect human limits in process design
Respect Human Limits in Process Design
  • Job design with attention to human factors [1]
  • Current projects selected that affect work (individuals’) safety include:
    • Patient safety audits (ERM Framework)
    • Clinical documentation, order entry, scheduling (Gemini)
    • Pharmacy medication packaging and distribution technology
    • Supply chain redesign in cath lab, OR and laboratory

[1] Haberstroh, Charles H. “Organization, Design Systems Analysis,” in Handbook of Organizations, J. J. March, ed. Chicago: Rand McNally, 1965.

effective team functioning
Effective Team Functioning
  • Team training for safety
    • Team Safety Education Plan
    • Interdisciplinary collaborative practice model (Gemini)
    • Critical care and perioperative services safety strategy
    • Patient safety education (OHA’s “Your Healthcare. Be Involved”)
anticipate the unexpected
Anticipate the Unexpected
  • Continuous examination of processes of care to identify safety problems:
    • Failure mode analysis for selected new technologies – collaborative work involving ORNT and simulation center (e.g. IV pumps)
    • Sharps Exposure Control Program
    • Patient Falls Prevention Program
    • Wound Care Program
    • Patient Lifts and Transfers Program
    • OHA Safety Group (WSIB Workplace Safety Program)
a learning environment
Communication, education and support for learning:

Electronic Event Tracking System and Root Cause Analysis Database

Communication of Adverse Event Policy

Quality of Care Committee under QCIPA

A Learning Environment
positioning patient safety on the strategic agenda

Positioning Patient Safety on the Strategic Agenda

Anne McGuire, CHE

President & CEO

IWK Health Centre

getting a handle on patient safety
Getting a Handle on Patient Safety
  • Medication and non-medication occurrence reporting (including near miss)
  • Committees with patient safety component:
      • Patient Care Committee
      • Drugs and Therapeutics Committee
      • Children’s Mortality Committee
      • Perinatal Peer Review Committee
      • Nursing Professional Practice Committee
      • Infection Control Committee
      • Professional Practice Committee
      • Medical Advisory Committee
getting a handle on patient safety1
Getting a Handle on Patient Safety
  • MOM committees:
  • Multidisciplinary “patient safety” teams
  • Initiative underway for 5 years (currently 29 teams)
  • Profile of the MOM committees has increased significantly
      • Mortality review
      • Morbidity review
      • Occurrence review
      • Sentinel event review
      • Root cause analysis
      • Report through teams and programs to the Centre- wide Morbidity (Patient Safety) Committee
a lot is happening no strategic focus
A Lot is Happening – No Strategic Focus!
  • Combination of centralized and decentralized supports
  • No representation at the senior executive table
  • “Patient safety” language not used to describe patient safety activities
  • No single person or department leading and coordinating all activities
  • Not on the radar at the Board level
  • 10 Step Program
step one
Step One
  • Organizational leader responsible for quality resources and decision support services (patient safety) to report directly to the CEO
step two
Step Two
  • Included quality/patient safety leadership on the executive team
    • October 2005 Director, Quality Resources and Decision Support Services became a member of the senior management team
step three
Step Three
  • As part of the senior management team reorganization, quality and patient safety was positioned as one of three communities of practice to be lead by the Director
step four
Step Four
  • Centralized all supports and programming related to patient safety under the Centralized Quality Division
    • All Quality Improvement Coordinators
    • Infection prevention and control
step five
Step Five
  • Reorganization of the Quality Division with three new management positions:
    • Manager, Quality
    • Manager, Patient Safety
    • Manager, Risk and Legal Services
    • Manager, Decision Support Services (existing)
step six
Step Six
  • Patient safety positioned at the Board level
    • International patient safety expertise
    • Updates on patient safety initiatives included in CEO Report to the Board
    • Patient safety strategic focus
step seven
Step Seven
  • Patient safety identified as one of the five organizational strategic themes:
    • Improving the health of the population
    • Becoming a workplace of choice
    • Wise investment and efficient management of resources – sustainability
    • Advancing (not creating) a culture of patient safety (recognizing the work already underway)
    • Leading in learning, discovery and innovation
more about the patient safety strategic theme
More About the Patient Safety Strategic Theme
  • Goal 1: Create a climate for patient safety by ensuring that structures and processes that permit spread of best practices are consistently in place
  • Goal 2: Apply best practice initiatives where they are proven and appropriate to increase patient safety
more about the patient safety strategic theme1
More About the Patient Safety Strategic Theme
  • Goal 3: Develop an environment which supports and enhances a patient safety culture
  • Goal 4: Live patient safety as a strategic priority
    • One of the measures of success for Goal 4: “Patient safety issues are an important component of Board and Senior Management meeting agendas”
step eight
Step Eight
  • Positioning patient safety on the senior executive agenda
    • “Real life” IWK cases presented to SMT
    • Progress of patient safety initiatives reviewed:
      • Safer Healthcare Now!
      • CAPHC Patient Safety Collaborative
      • Pediatric Trigger Tool – CAPHC – replication of the Baker Norton study
      • CPSI research participation: culture survey, indicators
      • Discussion of new initiatives: patient safety leadership walkabouts, MORE OB, SBAR
step nine
Step Nine
  • Communicated patient safety initiatives:
    • PULSE (IWK intranet)
    • Leadership Forums
    • Town Halls
    • IWK website (patient safety component under development)
    • Etc…
step ten
Step Ten
  • Link strategies with provincial, regional and national strategies:
    • Halifax Patient Safety Symposiums
    • Provincial Healthcare Safety Working Group
    • Patient Safety Advisory Group – CDHA
    • Safer Healthcare Now! Steering Committee
    • National Patient Safety Collaborative – CAPHC
    • National Medbuy linkage with IHI
    • CCHSA patient safety standards

In conclusion, health service executives have enhanced roles and responsibilities in patient safety that include:

      • Culture
      • Accountability
      • Measures
      • High Reliability/Redesign
      • Communication and Teamwork
      • Professional Development


The safety of patients within the health care system depends on all levels working together toward the common goal of patient safety.