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Canadian Patient Safety Institute

Safe care....accepting no less​

The Canadian Patient Safety Institute (CPSI) has over 10-years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum.​

SHIFT to Safety

 

Improving patient care safety and quality in Canada requires everyone’s involvement—SHIFT to Safety gives you the tools and resources you need to keep patients safe, whether you are a member of the public, a provider, or a leader.


 

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Our Programs​

 CPSI Latest News

 

 

#SuperSHIFTERS - An Interview with Jim Ruiter33206Patient Safety News How do you build insight with education innovation? Jim Ruiter has the answer a play in three acts Jim, can you tell us about your initiative? Early in 2017 Salus Global™ was asked by District II of the American College of Obstetricians and Gynecologists, as part of their Bundle Implementation workshop in Albany New York, to present to obstetrical and gynecological physician representatives from many of the New York state hospitals. This was a 90 minute session presenting to a group of well-tenured academic obstetricians and gynecologists on how to use simulation effectively. As I pondered this opportunity, I was nervous. I am not an expert in simulation, nor is the organization I work for. Salus Global™ prides itself on being experts in teamwork, communication and high-functioning teams. With that in mind, I wondered how I could keep such a group engaged for 90 minutes on a topic they were already experts in. I started to reflect on all the successes Salus Global and the MOREOB® program have seen, and began to create a list of pearls of wisdom to share. As I completed the list, I realized this could be another boring lecture. A boring lecture would leave no lasting impact from the presentation. The more I thought about the lecture format the more I realized that I needed to present in a way that allowed others in the room to build their own insights. I wondered if a demo would fit the bill, but I've never been totally impressed with demos. Demos often don't 'cut-it'. I needed a way to create scenarios, which allowed the audience to build their own insight. I found myself building a script. The script process resulted in the creation of a play. A play could highlight the benefits and challenges of simulation. A play could build the insight and impact I was looking for. How did you build the play? I built the play in three acts. It's meant to demonstrate potential uses of simulation beyond simply for education purposes. The three acts allow us to run the same clinical simulation scenario twice using two different simulation approaches. These two opposing approaches are what allow the audience to build their own insights. In act I, the narrator comes out and interacts with the audience, trying to pull out from the audience what it knows of simulation – essentially identifying where the audience is starting from. During that first act, the scene is also set for the ensuing two acts. In act II, we have the actors play out a simulation scenario in one way, what I call a run-through modality (no breaks in the scenario till the end where the team debriefs). In act III, the same actors play out the same scenario, but with a pause-scenario modality (where the objectives are stated out front, and where the participants are encouraged to pause the scenario to discuss what ever issue on their mind – and then debrief). Act III allows them to demonstrate simulation conducted within a continuous quality improvement framework, using a modality that builds psychological safety and organisational trust. In the denouement, we brought all the actors to the front of the stage and the audience interacted with them, and by a simple show of hands we could show an increase in the number of individuals wishing to develop their own simulation program. The first time we presented the play, I recruited four actors. I had wanted seven, but the four turned out to be a gift. I quickly re-wrote the script to present the scenario as if another emergency was going on. We could accurately portray the limited resources often available to staff in an emergency. We assigned a narrator, simulation facilitator and staff taking part in the simulation as the roles. I was careful to include the frame of mind the actor was coming from in the script, this was the key to why simulation can succeed or can only be of value. One of the keys to developing insight in our audience, was not just demonstrating or acting out the play but, it was also the ability to peer into the minds of the actors throughout the play through freezing of the action. How we made this work was by having the narrator, at predetermined times – in response to body language for example – freeze the action on stage. The narrator would then ask the audience what they thought the actors were thinking at that time. The actor would then reveal their state of mind in a soliloquy. Utilizing audience feedback and multifaceted scripts we could demonstrate how complex adaptive systems can adapt, through simulation conducted within a continuous quality improvement framework. What do you think contributed to the success of this learning approach with your audience? There were many aspects that made the play a success. Firstly, we utilized real life scenarios. We chose to use the scenario of a post-partum hemorrhage and the secondary emergency that limited our human resources was a cord prolapse "down the hall." The scenario had realistic aspects that created stress that the audience was readily able to identify with. One aspect of the scenario was the lack of easy access to a refrigerated drug. The need for this drug forced the nurse to leave the physician with the patient alone. As this occurred, we could create insight by freezing the action and teasing out from the audience their thoughts, and then the thoughts of the characters in the play. Freezing the action allowed us to create learning we would not have gotten otherwise. Lastly, creating the play in three acts to provide an opportunity to act out the same simulation scenario two ways, while allowing the audience time to interpret and pick apart each portrayal. This approach allowed the audience to build their own insights into simulation by providing them two examples to compare. This was integral to the result, which ideally was the audience leaving with new learning they could apply in their own practice. What would you tell others planning or delivering education on simulation? My first thought would be, conduct your education in any way you think fits your audience. This example is not a one-size-fits-all solution. Do what works for your audience and helps you meet your goals. I would remind people that you couldn't bridge process gaps through simulation alone. You can identify gaps through simulation and address them through a continuous quality improvement framework, which may lead to a variety of strategies to close the gap. You need to offer simulation in the context of a continuous quality improvement cycle. Lastly, I would stress that simulation is a powerful tool, far more powerful that just education. It can help create psychological safety, identify an organization's external safety boundaries (allowing you to then push them), provides opportunities to engage and address issues and builds a more robust care system. Most importantly, it can build the overall organizational safety culture and creates safer, sustainable systems. If a simulation is used in isolation, nothing will change! Where can people go to learn more? You can contact me through Salus Global™ at http//www.salusglobal.com/contact-us Thank you to Dr. James Ruiter for his time and insights. Join us next month when we sit down with SuperSHIFTer Patrick Nellis to learn more about the launch of his new patient safety book entitled Ready for My Surgery Be Informed, Stay Safe and Take Control During Your Journey Through Surgery.10/20/2017 2:30:00 PMHow do you build insight with education innovation? Jim Ruiter has the answer: a play in three acts Jim, can you tell us about your10/16/2017 2:53:03 PM188http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Making the Case for Investing in Patient Safety33164Patient Safety Power Plays Benjamin Franklin told us that, "an ounce of prevention is worth a pound of cure", and this often-repeated homily is particularly applicable to the Canadian healthcare system. Or, as our business manager might phrase it now, statistics show that investing in patient safety today brings cost-saving further down the road. That it why we have taken into consideration, and will act accordingly, on the findings made by the report created by RiskAnalytica known as The Case for Investing in Patient Safety in Canada. We have done so to make sure that our mandate of providing safe care for all Canadians continues to be met. The report, which was released this year, estimates that over the next 30 years, 12.1 million Canadians will be harmed by a patient safety incident within acute and home care settings. A shocking statistic to be sure, even more so when compounded by findings that there could be roughly 400,000 annual cases of patient safety incidents, costing $6,800 per patient, resulting in an additional $2.75 billion in healthcare costs per year. I have been in healthcare for a long time, and have seen preventable incidents, and it saddens me to see such issues still occurring in our healthcare system. However, to those concerned, let me offer the following The Canadian Patient Safety Institute has a proven track record of delivering evidence-based tools and resources to healthcare organizations and providers so that they can provide the safest care to their patients. We are committed to continuing this work, but governments must also invest to show patient safety as something that cannot, and must not, be swept under the rug. We at the Canadian Patient Safety Institute have recently rolled out our new 2018-2023 Strategic Plan, known as Patient Safety Right Now, calling for immediate placement of well-crafted mechanisms to make sure patient safety is at the forefront of the Canadian healthcare landscape. The statistics produced by RiskAnalytica drive our new strategic plan as we hope to curb the trend of patient safety incidents and educate the public, healthcare providers, and healthcare leaders on the universal importance of patient safety. By working together, I know we can achieve wonderful things in the Canadian healthcare system, both immediately and in the years to come. The report, The Case for Investing in Patient Safety in Canada, may be viewed by clicking HERE Please let me know your comments on this important report at cpower@cpsi-icsp.ca Yours in patient safety, Chris PowerCEO, Canadian Patient Safety Institute10/10/2017 6:00:00 AMBenjamin Franklin told us that, "an ounce of prevention is worth a pound of cure", and this often-repeated homily is particularly10/10/2017 5:32:05 PM160http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SHIFTtalks Supercharge your hand-hygiene education: Are you a Tough Scrubber?33105Patient Safety News​​​ Photo caption Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right) helped develop Tough Scrubber at St. Michael’s Hospital. ​By the St. Michael’s Hospital Heart and Vascular Program’s Quality and Safety Leader Group ​​Fun, fast, challenging, hilarious. Is this how your staff would describe their hand-hygiene education? Try Tough Scrubber and they just might. In the Heart and Vascular Program at St. Michael's Hospital, our traditional hand hygiene interventions were feeling a bit stale. Engagement was low – and honestly, it showed in our compliance rates. We needed more than a poster. We needed a sensation! Enter Tough Scrubber, the brainchild of our program's Quality and Safety Leader Group. A play on the Tough Mudder concept, front-line staff go through a fast-paced, over-the-top simulation that's tailored for their clinical area. There's a quick quiz before they start and a quick debrief after they finish… and that's it. The whole process takes 10 minutes or less. We're happy to report, it was a huge hit! This five-minute video will tell you more about how Tough Scrubber works. We've also put together a toolkit to help hand-hygiene champions implement Tough Scrubber in their own hospitals and health-care organizations. For us at St. Michael's, Tough Scrubber opened the door to a new way of thinking about hand hygiene. It's OK to ask questions and to give your colleagues feedback – we're all learning. Doing hand hygiene correctly can be tough, but it's much easier when we help each other out. To date, 43 Heart and Vascular staff have completed Tough Scrubber, and our hope is that you will too. All it takes is our toolkit, 4-5 hand-hygiene leaders (to run the activity and pose as patients), an empty patient room with two beds, and the everyday equipment described in the scenarios (e.g. a wheelchair, a basin). In our Heart and Vascular Units, we've improved our compliance rate for Moment 1 by 27% in three years. This is certainly the result of a combination of years of education, hard work and many different kinds of interventions. However our Tough Scrubber sessions truly felt like the tipping point. For more information on Tough Scrubber and to download the toolkit, visit www.stmichaelshospital.com/toughscrubber. Try it, and let us know how it worked for you! If you have any questions or fe​edback, please contact us at BunstonR@smh.ca and ShapiroL@smh.ca.​​10/2/2017 6:00:00 AM Photo caption: Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right)10/3/2017 2:55:35 PM781http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTERS – Meet St. Boniface Hospital, TeamSTEPPS® enthusiasts!33061Super SHIFTERS​​​ ​​​​ St. Boniface Hospital in Winnipeg, MB, is our SuperSHIFTER for September. They embody the spirit of Canadian Patient Safety Institute's SHIFT to Safety program, providing support and content that improves patient safety through an emphasis on teamwork, communication and positive safety culture. Members of the team at St. Boniface, including Michaele Rivet, Patient Safety Consultant; Jen Kostyshyn, ED nurse; Dr. Jeff Klassen, ED physician; and Cheryl Bilawka, Educational and Development Specialist, recently spoke with CPSI's Vanessa Walsh to explore their unique journey implementing the TeamSTEPPS program (click here to learn more about TeamSTEPPS). Here is that conversation Q How did St. Boniface Hospital get started with TeamSTEPPS? A We started implementing TeamSTEPPS in our ED and shortly after our cardiac care program in 2010-11. We really liked how simple it was, and how it provided the concepts, tools and training for free. We sent a contingent of staff, physicians and leaders to an Agency for Healthcare Research and Quality (AHRQ) regional training centre in the United States for master trainer training. We linked up with our physicians, allied health, and support staff to begin running a training plan for all staff in the ICU's and ED. Q How did you measure your improvement efforts? A We administered the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) in the ED as a baseline, and again at three months, six months and one year after our initial staff trainings. Our department had a significant staff turnover, and the data reflected that change, showing we lost the initial improvements gained after a year. We gleaned two big lessons – first that we needed to build internal capacity and bring master training in-house to maintain momentum, and second, although we had a coaching model in place it seemed our biggest challenge was to keep people thinking about TeamSTEPPS after their training. Q How did you scale up and go hospital-wide with the training? A We trained 244 master trainers in 18 months! They took all the concepts and tools and spread them within their own programs and staff. We also added a TeamSTEPPS Fundamentals training to General Hospital Orientation. Q Did you modify the training at all? A We made it our own in a couple of ways. The message on the importance of patient safety can sometimes be uncomfortable, so we purposefully built in humour to help staff pay attention and get talking about it. We broke out key strategies and tools into videos, and engaged staff in whatever way they were comfortable in. The videos are educational, funny and incorporate input from staff. We knew that most staff were on some sort of social media, and leveraged these platforms to promote our focus on teamwork and communication. If we could just breakdown TeamSTEPPS messages into bite-sized, post-able pieces, so it was constantly showing up in people's news feeds, it would always be on their minds. We also started in-situ education around a huddle once or twice a week. We took people away from what they were doing for five minutes and talked about a very specific and focused safety idea. This was done in small enough groups so it was a discussion and not a didactic lecture. It was also done right where we want these behaviours to happen, right at the bedside, so they can turn around and immediately start using it. Q How are you planning to sustain the gains you've made in teamwork and communication for increased patient safety? ASTEPP UP for Patient Safety is St-Boniface's TeamSTEPPS sustainment plan. It is entering its third year this month. Driven by a representative group of staff, it is a tailored monthly refresher for everyone that includes a theme, activities for role playing, and discussion topics for huddles at all levels of the organization. Past themes have focused on communication tools and strategies for escalation, and this upcoming year will zero in on advocacy and assertion. In the ED, we're always gathering input from staff to make sure it's relevant and delivered in the best possible way. We have a core group to distribute the information and educate people. For example, we have a trivia group, a research group, an engagement group, a huddle group, etc. We are also working on a new simulation project, to develop a simulation curriculum that incorporates all the TeamSTEPPS tools and strategies. Q What would you recommend to someone wanting to adopt TeamSTEPPS strategies and tools within their organization? A Active leadership support has been crucial to our success. TeamSTEPPS is all about knocking down hierarchies and barriers to communication. Our leaders understand the tools and concepts, use them, and expect staff to do the same. Also, every department, even within one hospital, can be a different environment. Knowing the culture and people can make a huge difference. We really tried to understand the issues that we were facing as well as the personalities in our department to create something that would work for us. Q Where can people go if they're interested in learning more about your work? A Reach out to us at @sbh_winnipeg on Twitter or by email at mrivet@sbgh.mb.ca and cbilawka@sbgh.mb.ca.​​ Join us next month as SHIFT to Safety features #SuperSHIFTER Dr. James Ruiter from Salas Global Corporation, sharing an innovative insight into simulation methodology for patient safety. 9/25/2017 6:00:00 AM St. Boniface Hospital in Winnipeg, MB, is our SuperSHIFTER for September. They embody the spirit of Canadian Patient Safety10/19/2017 7:11:00 AM623http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI designated as WHO Collaborating Centre for Patient Safety and Patient Engagement32979Patient Safety News With the support of the Government of Canada, the World Health Organization (WHO) has officially designated the Canadian Patient Safety Institute as a WHO Collaborating Centre for Patient Safety and Patient Engagement to carry out activities in support of WHO programs internationally. Of the more than 800 WHO Collaborating Centres from 80 countries worldwide, 31 are from Canada. The Canadian Patient Safety Institute is the only WHO Collaborating Centre in Canada with a focus on both patient safety and patient engagement. The four-year agreement (2017-2021) will include activities targeted in four areasProvide coordination support and advice to the global Patients for Patient Safety (PFPS) advisory group Support global efforts and initiatives on patient safety reporting and learning systems Contribute to the planning and implementation of the 3rd Global Patient Safety Challenge on Medication Safety Support global patient safety initiatives in achieving safer care "The Canadian Patient Safety Institute has a long-standing collaborative relationship with the WHO Patient Safety Programme internationally, and has been a catalyst in developing collaborative partnerships across the country," says Chris Power, CEO, Canadian Patient Safety Institute. "We have benefited from the support of the WHO and their members in the development of Canadian products and services, and indirectly we have provided Canadian support to assist transitional and developing countries. We are excited about this opportunity to advance safer care through patient safety and patient engagement, both locally and globally." Building on the Canadian Patient Safety Institute's well established support to Patients for Patient Safety Canada over the past 10 years, the Canadian Patient Safety Institute will provide support to the global PFPS advisory group that will include coordination and secretariat support for the WHO PFPS Advisory Network and building capacity for patient/family champions and leaders of PFPS global networks. Each year of the agreement, the Canadian Patient Safety Institute will coordinate quarterly meetings of the PFPS advisory group and deliver three knowledge transfer webinars in English and French, to build capacity of the Network's patient safety champions and leaders. "The WHO's PFPS programme engages patients and families in improving the safety of health care, to enhance and build capacity, and to become informed and knowledgeable partners in their own care," says Helen Haskell, Co-chair, WHO Patients for Patient Safety Advisory Group. "PFPS workshops bring together PFPS advocates, health care professionals, local leaders, health care organizations and policy-makers to share knowledge about the national health system and to explore mechanisms to improve patient engagement for safety. Working with the Canadian Patient Safety Institute as a WHO Collaborating Centre provides the opportunity to share our experiences and knowledge on patient safety and patient engagement." To broaden reporting, learning and sharing from harm, the Canadian Patient Safety Institute hosts Global Patient Safety Alerts, a web-based resource featuring a comprehensive collection of patient safety alerts, advisories and recommendations from around the world. Work will continue to expand its use and contributions from international organizations. "Too much healthcare delivered around the world carries avoidable harm," says Sir Liam Donaldson, Patient Safety Envoy, WHO. "With tools like Global Patient Safety Alerts, we can effectively share information about patient safety risks and effective ways to manage those risks and prevent harm. Through initiatives like the WHO Collaborating Centers, the processes to collect, analyze, communicate and disseminate information and trends to users and potential contributors can be improved." As the Canadian coordinating body, the Canadian Patient Safety Institute is participating in the 3rd Global Patient Safety Challenge on Medication Safety. The Canadian Patient Safety Institute is a member of the WHO Patients and Public Working Group and provides expertise and support to the global medication safety challenge. Maryann Murray, a member of Patients for Patient Safety Canada, recently addressed the World Health Assembly's annual meeting to share her experiences leading to her daughter's death, and highlighted the Five Questions to Ask about Your Medications, a Canadian tool developed by patients and providers on how to have a conversation about safe medication use. The tool is available in 20 different languages. "The challenge of improving medication safety is now being embraced in Canada and around the world. By sharing knowledge and resources, we contribute to the development of universal products and tools that will assist in significantly reducing medication harm around the globe," says Maryann Murray. To support global patient safety initiatives, the Canadian Patient Safety Institute will provide policy, strategic and technical advice and consultation at various platforms including WHO global and regional consultations or events, working groups, and committees; and provide advice and support in the development, adaptation, spread, and/or evaluation of patient safety tools and resources at a global level. Patient engagement is a priority for many Canadian organizations. Led by the Canadian Patient Safety Institute, the National Patient Safety Consortium, a group of more than 50 organizations, established the Integrated Patient Safety Action Plan, a shared action plan for safer healthcare. One of the plan's guiding principles is patient engagement. "Patient engagement is a core strategy for advancing universal health coverage, safe and quality health care, service coordination and people-centredness," says Dr. Neelam Dhingra-Kumar, Coordinator, Patient Safety and Quality Improvement, WHO headquarters, Geneva. "Canada is recognized as a world leader in both patient safety and patient engagement so we believe that this collaboration will help improve lives around the world." For more information about the WHO Collaborating Centre designation, visit the WHO website. 9/17/2017 6:00:00 AMWith the support of the Government of Canada, the World Health Organization (WHO) has officially designated the Canadian Patient Safety Institute as9/17/2017 7:52:08 PM862http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

2017 CAPHC Annual Conference5053Montréal, Québec https://caphcevents.org/conf2017/index10/22/2017 2:00:00 PM10/24/2017 10:00:00 PMThe Canadian Patient Safety Institute is proud to support this event.8/15/2017 7:14:17 PM44http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConference
Health Quality Transformation33223http://www.hqontario.ca/Events/Health-Quality-Transformation-201710/24/2017 12:00:00 AM10/24/2017 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is presented by Health Quality Ontario10/19/2017 5:56:28 PMhttp://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConference
Canadian Patient Safety Week5012http://www.patientsafetyinstitute.ca/en/Events/cpsw/Pages/default.aspx10/30/2017 1:00:00 PM11/3/2017 10:30:00 PMCanadian Patient Safety Week is a national, annual campaign that started in 2005 to inspire extraordinary improvement in patient safety and quality. As the momentum for promoting best practices in patient safety has grown, so has the participation in Canadian Patient Safety Week. Canadian Patient Safety week is relevant to anyone who engages with our healthcare system providers, patients, and citizens. Working together, thousands help spread the message to Ask. Listen. Talk.11/24/2016 8:22:37 PM59http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseSpecial Event;Campaign
National Conversation: A Partnership to Raise Awareness and Engage the Healthcare Community 33083Webcasthttp://www.patientsafetyinstitute.ca/en/Events/cpsw/Pages/National-Conversation.aspx10/30/2017 2:00:00 PM10/30/2017 3:00:00 PMThe National Conversation is an attempt at igniting dialogue across the country around quality and safety in healthcare. 9/26/2017 9:20:58 PM26http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcast
Registration Deadline: Advancing Safety for Patients In Residency Education 5029Ottawahttp://www.patientsafetyinstitute.ca/en/education/advancing-safety-for-patients-in-residency-education/pages/default.aspx11/3/2017 2:00:00 PM11/3/2017 8:00:00 PMThe Canadian Patient Safety Institute in collaboration with the Royal College of Physicians and Surgeons of Canada are offering an Advancing Safety for Patients in Residency Education (ASPIRE) workshop from November 28 to December 1, 2017 in Ottawa ON.2/7/2017 8:50:25 PM13http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshop