Volume 5 Issue 2 - February 2010

Inside this Issue:

• My parting words – An editorial from Phil Hassen
• A Farewell Tribute to Phil Hassen
• Register Now! Canada's Forum on Patient Safety and Quality Improvement: “Improving Safety Across the Continuum”
• Facilitating Patient-Centred Simulation in Canada
• Bar Coding for Improved Medication Safety in Canada - One Step Closer
• Competition Announcement: Patient/Client Safety in Home Care in Canada
• Safe Surgery Saves Lives Workshop
• Teamwork and Communications Disclosure Working Group
• STOP! “Clean Your Hands” Day

Dear Colleagues:

This is officially my last editorial as the CEO for the Canadian Patient Safety Institute. It is hard to believe that this day has come. There are many thoughts that come to mind. The most important one – is to express to each of you – my heartfelt thank you.

The amount that the Canadian Patient Safety Institute has been able to achieve is a simple testament to our stakeholders and partners that are in the trenches – truly making healthcare safer for every Canadian.

I have met so many incredible people over the past five years. Many are true heroes. Those of you that go above and beyond the call of duty to ensure what we are tasked with is achieved.

The dedicated staff team at the Canadian Patient Safety Institute is one I will never forget. The can-do attitude has accomplished so many initiatives that will be a legacy for many years to come. I have commented before how shocked people are when they realize how small our organization really is. Every single person who works at the Canadian Patient Safety Institute is passionate about what you want to achieve. It is this passion that has made so many projects a reality - Canadian Disclosure Guidelines, Governance Tool Kit, Research, Safety Competencies, Patient Safety Officer Course, Canadian Patient Safety Week, Root Cause Analysis, Safe Surgery Saves Lives, Safer Healthcare Now! and so many more. Along with your colleagues in healthcare - feel proud Canadian Patient Safety Institute staff! These are major accomplishments.

As I walk out the door for the last time at the end of February – I am so proud of all of you. I know we have contributed to building a safer healthcare system. I also know that the Canadian Patient Safety Institute is in exceptional hands with Hugh MacLeod coming on as CEO.

Keep doing what you are doing. It is working. I look forward to our paths crossing again with my work at the International Society of Quality in Health Care.

Yours in patient safety,

Philip Hassen

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Phil Hassen first became involved and committed to patient safety in the early 1980s. Since that time he has made his mark and his name has become synonymous with patient safety, both nationally and internationally. His last day at the Canadian Patient Safety Institute will be at the end of February and Phil will transition into “retirement”, continuing in a leadership position as president of the International Society for Quality and Safety in Health Care (ISQua) and his work with The Canadian Network for International Surgery. As the valued Chief Executive Officer of the Canadian Patient Safety Institute for the past five years, Phil’s leadership and dedication are honoured by some of those who have had the opportunity to work with him.

When the Board of the Canadian Patient Safety Institute hired Phil Hassen, they had high expectations for their new Chief Executive Officer (CEO). Board Chair, Doug Cochrane, reflects on Phil’s achievements: “Throughout his career, Phil Hassen has dedicated himself to the betterment of healthcare services to patients, using his positions to advocate for quality and to build the structures necessary to achieve improvement. The Canadian Patient Safety Institute is but one example of the capacity that has been built and nurtured by Phil. There are many others. In Canada and throughout the world, patients have benefited from his dedication and commitment to the safety and quality of their health care.”

Wendy Nicklin, Board member and former Board Chair commends Phil for his contribution to advancing patient safety, both nationally and internationally: “Under his strong leadership over a five-year period, the foundation has been set. Considering not only his role as CEO of the Canadian Patient Safety Institute, but also his many impressive contributions in the varied preceding healthcare leadership roles, his measurable contribution and impact on patient safety and healthcare quality are significant and sincerely valued. Phil's passion, commitment and knowledge will continue to permeate and influence the healthcare system."

Board member Dr. Édouard Hendriks says: “Many say that Phil’s vast experience, his very thorough knowledge of the challenges of the health system, and his commitment to the patient safety cause are traits that have enabled him to quickly make the Canadian Patient Safety Institute the Canadian leader in patient safety and it is true. I believe however that his biggest assets are his ability to listen, his respect for the views of others, calm, and strength of character that have gained him the admiration of all. Thank you, Phil!"

The staff at the Ottawa office of the Canadian Patient Safety Institute extended these words of appreciation to their dynamic leader: "Phil, thank you for the opportunity to share your vision, learn from your leadership, and continue to create a safer health system for Canadians," says Laurel Taylor, Director of Operations. Pierrette Leonard, Senior Advisor, National Partners adds: Under Phil’s leadership, an astute combination of guidance and a laissez-faire attitude, I was able to get involved in projects that I have a personal interest in to advance the patient safety agenda further. This is the first time in my career that I have been able to, to this extent, define, nurse along and ultimately own work in areas I am passionate about and convinced that I can make a difference.”

The Edmonton office staff also reflected on how Phil Hassen has impacted patient safety. “Phil is of the rarest of leaders!” says Joe Gebran, Director of Corporate Services. “He engages the heart, challenges the mind, and impacts the soul of his colleagues. His energy and enthusiasm have propelled the Canadian Patient Safety Institute from an upstart to a leading national organization. His contributions and legacy will be remembered and he will be missed!”

“Phil Hassen is synonymous with patient safety in this country and internationally,” says Marie Owen, Director of Operations, Edmonton. “Through his strong leadership and unwavering commitment, the Canadian Patient Safety Institute has raised the bar for safety in healthcare organizations across Canada.”

Paula Beard, Director of Operations, Edmonton says: “Phil’s guidance and support have been key as the Canadian Patient Safety Institute has developed from inception to a respected and valued patient safety organization within Canada and the global patient safety community. Incredibly, this isn’t Phil’s complete body of work, just the flourish as he makes yet another transition. Congratulations Phil and thank you for all your wisdom and acts of kindness!”

Working under Phil Hassen’s stewardship, the Communications team speak highly of Phil’s dedication and passion. Director of Communications Cecilia Bloxom expresses how Phil has influenced her career:  “It has been a major opportunity for me in my career that I have had the chance to learn from Phil Hassen as a leader, a patient safety expert, a negotiator and a human being. He is a class act that treats everyone with respect. He encourages people to be who they are. He provides quiet and strong wisdom.” “It has been a great pleasure working with Phil Hassen,” says Jody White, Administrative Assistant. “He knows how to make things happen and leads by example and enthusiasm.”

A German poet once said that ‘nothing great in the world has ever been accomplished without passion’. The passion Phil Hassen has for his work is evident in all that he does and the work that the Canadian Patient Safety Institute has accomplished since Phil began as the CEO is a clear testament to this. Kelly Bowman, Communications Officer says: “Phil has inspired passion in many of us who have been so lucky to work under him by doing himself what the Canadian Patient Safety Institute does as an organization – leading without owning. He has encouraged our ideas and creativity and has allowed for the entrepreneurial spirit of the Canadian Patient Safety Institute to flourish, which, I think, is what makes it a truly great organization to work for. Phil has been an incredibly approachable and down-to-earth leader, and whether he’s working alongside of you while you sort through clothes or prepare a meal while volunteering at a local homeless shelter, or taking the time to tell you all of the ‘must see’ attractions of a city you’re visiting for the first time, he has always taken the time to be engaged and involved with his staff.”

As Phil Hassen begins his well-earned retirement, Ali Alidina, Information Manager remembers his first encounter with Phil a little over two years ago: “When I first met Phil, he spoke so passionately about improving the quality of patient care and how the work of the Canadian Patient Safety Institute makes a difference in the lives of Canadians. It was at that point that I knew that I had to be a part of this team. Thank you Phil, and congratulations on your retirement.”

“For the short time I have known Phil Hassen, I have seen absolute dedication and passion to patient safety from both him and this organization,” says Abisaac Saraga, Web Coordinator. “That passion has been a great motivation for me to help the Canadian Patient Safety Institute strive forward with its online efforts to be the forefront of patient safety in Canada by creating a stronger web presence through its website and social media.”

“I have learned much about leadership from Phil, especially in observing his interactions with others,” says Sandi Kossey, Project Manager. “He has truly been a very passionate and spirited leader for the Canadian Patient Safety Institute – quite necessary for this very passionate and hardworking team! I have always appreciated his advice, humour, and our hallway conversations about ‘life in general’.”

“It has been phenomenal to start my career under the leadership of Phil, who has fully committed himself to making healthcare safer for Canadians,” says Orvie Dingwall, former Librarian and Project Manager. “He is open to new ideas and approaches and as a result of his open-mindedness, he is now one of the biggest advocates of health librarianship and fully endorses the importance of involving librarians in evidence-based healthcare.”

The Western Node of Safer Healthcare Now! express their thanks and appreciation for Phil’s inspiration and vision for the evolution of Safer Healthcare Now! “The Western node staff have felt supported throughout the last five years and will miss your leadership as we move to our new iteration of Safer Healthcare Now!” says Marlies van Dijk, Node Leader. “We felt that you listened to our challenges and you consequently worked your magic at a strategic level. We look forward to crossing your path on the international patient safety journey!”

In the words of Cynthia Majewski, Executive Director of the Quality Healthcare Network (QHN) and Ontario Node Leader for Safer Healthcare Now!, “it’s been an exciting ride!” Cynthia established an early connection with Phil Hassen when he was CEO of St. Joseph’s Health Centre in London, ON. “Over the years I have worked with Phil Hassen, his passion and commitment for quality and safety has never faltered,” says Cynthia. “During his time at St. Joseph’s, the Quality Healthcare Network (formerly The CQI Network) was fortunate to have Phil as our Chair. His energy in this role was endless, as was his interest in building leadership skills and capacity for improvement as we launched an innovative learning network in Ontario. It has been our pleasure to continue that relationship, in new capacities over the years - most recently in his role at the Canadian Patient Safety Institute and through his leadership in Safer Healthcare Now! On behalf of all of us in Ontario, our founding partners of QHN and our Members, we wish Phil the very best!”

Theresa Filllatre, Atlantic Node Leader says, “Phil's support to the Safer Healthcare Now! Atlantic Node since May 2005 has been consistently responsive, thoughtful, intuitive and respectful. His unique personal strength is the ability to help others consider the issues and the harm reduction options through the eyes, ears and hearts of patients and families. We wish Phil every success in his continued quality and patient safety leadership roles.”

“Phil Hassen has been a true patient safety champion and national leader, and has made a huge contribution,” says Elaine Orrbine, President and CEO of the Canadian Paediatric Health Centres (CAPHC). “We are most grateful to Phil for his leadership and support of CAPHC’s patient safety work. Best wishes for all the wonderful opportunities ahead!”

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Register now for Canada’s Forum on Patient Safety and Quality Improvement!  The 2nd annual forum will take place from April 12 to 14, 2010 at the Westin Harbour Castle, Toronto (Ontario).

As physicians, nurses, pharmacists, health care providers, educators, leaders, researchers, and board members you are encouraged to experience the international perspective in areas across the continuum including palliative care, home and community care, long-term/residential care, acute care, mental health and primary care.

This Forum is designed to highlight safety issues across disciplines, across settings, across the country and around the world, offering you many solutions, tools and other resources that have proven effective in care settings both nationally and internationally.

An outstanding list of international speakers will talk about the challenges and successes of leading national initiatives to improve the quality and the safety of care provided across nations and across all sectors. The speakers list will include:

• Jim Easton, National Director for Improvement and Efficiency for the National Health Service in the UK, is currently leading the UK’s national strategy to deliver a better quality of care in an environment of cost containment. Jim will speak to the link between quality and safety and the current cost environment.
• Rahaf Harfoush is a ‘New Media’ expert who was integral to the success of the Obama presidential campaign.  She will talk about the value and the role of social media in creating national campaigns that capture the hearts and minds of leaders and frontline workers across the country.
• Jason Leitch, National Clinical Lead for Safety and improvement for the Scottish Government Health Foundation will talk about their two-year journey to reduce mortality in acute-care by 15 per cent over five years and reduce adverse events by 30 per cent across the Scottish Healthcare System.

Canada’s Forum will also have six concurrent streams that will provide specific examples of successful initiatives that have made care safer for patients across the healthcare continuum. The streams will include Infection Prevention and Control, Medication Safety, Learning from Adverse Events, Partnering for Patient Safety, and Building a Culture of Quality and Safety. An applied learning stream will provide attendees with tools to improve safety as well as the opportunity for hands on learning of the use of these tools.

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Healthcare simulation is growing rapidly across Canada and indeed globally. Simulation training goes far beyond the adoption of the latest and most sophisticated technologies. It brings together educators and innovators to create a positive environment where healthcare professionals learn and practice their skills. Such an environment substantially enhances the educational experience through individual and team-based training. Adding simulation activities to the learning environment will contribute to improving patient safety throughout the healthcare system in Canada – truly ‘an evolution in education’.

The patient-centred simulation community in Canada is now much closer to establishing a facilitative body to help move the simulation agenda forward on a pan-Canadian basis. Based on a need identified through national simulation stakeholder consultations, the Canadian Network for Simulation in Healthcare (CNSH) was formed in 2009. The CNSH currently operates with a Steering Committee providing strategic guidance, assisted by four Working Groups designed to build the network into a vibrant community, focused on improving patient outcomes through improved education. The Steering Committee and working groups are comprised of key simulation stakeholders from across Canada and also from a variety of health care professions. This inter-professional approach to building the network reflects the team-based collaboration that many simulation programs are creating.

Although initially developed and supported by the Canadian Patient Safety Institute through a funding agreement with Health Canada, the CNSH is actively seeking incorporation this year as a distinct non-profit entity. This exciting step will allow the CNSH to grow as a member-driven network that will serve the simulation community by sharing innovative strategies, hosting professional development events and promoting the advancement of patient-centred simulation among health professionals, educators, administrators, regulators and policy-makers across Canada.

With a very busy and challenging year ahead, the CNSH welcomes individuals who wish to help shape the future of simulation in Canada. If you want to participate, please contact the CNSH at their new toll-free number: 1-877-339-3465, or send an email to: mdoggett@cpsi-icsp.ca.

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Bar Coding for Improved Medication
Safety in Canada - One Step Closer

National consensus reached on Global Standard and Joint Technical Statement for drug products.

A pan-Canadian initiative was announced on February 3, 2010, in Toronto, during the annual Professional Practice Conference (PPC) of the Canadian Society of Hospital Pharmacists. The initiative will one day have a major impact on patient safety by drastically reducing preventable medication errors.

In collaboration with a broad range of pharmacy supply chain stakeholders, the Institute for Safe Medication Practices Canada (ISMP) and the Canadian Patient Safety Institute announced at the PPC that a consensus was achieved between ISMP Canada, the Canadian Patient Safety Institute, GS1 Canada and pharmacy industry stakeholders on using GS1 global bar coding standards as the standard format for labeling medication packaging in Canada. More importantly, a consensus was achieved by a 34-member task force on the adoption of a Joint Technical Statement to govern the use of the bar coding standard.

Serious medication adverse events causing permanent disabilities or death occur in Canadian hospitals, as shown in the 2004 Ross Baker and Peter Norton study. In the study, they estimated that 7.5 per cent of national hospital admissions involved an adverse event, and 20 per cent of these adverse events resulted in death of the patient. Of these events, the second highest cause was medication or fluid therapies. Baker and Norton also found that approximately 37 per cent were preventable.

Changes in practice need to occur at the national, provincial/territorial and local levels to promote a more collaborative and standardized approach to medication traceability to keep Canadian patients safe, while retaining current supply chain efficiencies. Human vigilance, using pen and paper for medication orders, is no longer acceptable in 21st century healthcare. With over 30,000 commercial drugs in the marketplace, there is a significant and overdue need for a coordinated approach to bar coding pharmaceuticals in order to enable automated identification throughout the Canadian healthcare system.

It is well know that automatic identification such as bar coding adds a layer of safety to the medication use system. It is one of the safest ways to track pharmaceutical products through the supply chain; from the point of manufacturing, to administering medication to patients. By using machine-readable bar codes, healthcare practitioners and organizations will improve internal efficiencies, and more importantly improve patient safety. In order for this to become a reality, bar codes must be deployed in a standard format on all medication packaging, and readable by health system scanners and software. The GS1 system of standards enables this interoperability.

For more information on bar coding, visit the ISMP-Canada website.

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For the first time, not only in Canada, but internationally, major funding will be available for researchers to study patient safety in home care. Up to $1.1 million is being provided by the Canadian Patient Safety Institute (CPSI) and other sponsoring organizations – including the Canadian Institutes of Health Research (CIHR) Institute of Health Services and Policy Research (IHSPR), Institute of Aging (IA), and Institute of Circulatory and Respiratory Health (ICRH); The Change Foundation; and the Canadian Health Services Research Foundation (CHSRF) – to help identify the scope and magnitude of the patient safety challenge in home care.

While there is increasing evidence about patient safety issues and potential solutions in hospital or acute care settings, there is a need for more evidence on the nature of patient safety issues in all healthcare sectors and settings to guide effective approaches to improving patient safety and the quality of healthcare services in Canada.

“We know there are unique risks involved in the home care setting,” said Phil Hassen, CEO, Canadian Patient Safety Institute. “While there is a lot of anecdotal information, we do not yet fully understand these risks. This research will provide evidence to help us better target our resources and efforts.”

The research, which comes at a critical time given Canada’s aging population and growing demand for home care services, will help to generate new knowledge and contribute to improving the safety of home care services for Canadian home care clients.

“The research that will be generated by this initiative will fill a major gap” said Maureen O’Neil, President, CHSRF. “Home care will be playing an increasingly important role in health service delivery, and there is a need for solid evidence to help policy-makers and providers put in place measures to ensure that patients consistently receive high quality, safe care in the home setting.”

The research project will be completed over a period of two years, and the sponsoring organizations have committed to widely sharing the results of this groundbreaking work, with a view that the results will inform changes in policy, practice and behaviour in home care settings.

“The creation of this funding opportunity recognizes the critical importance of the home care sector in the patient safety agenda. Health policy-makers, managers and care providers need strong research-based evidence on effective and practical solutions to improve patient safety in home care,” said Dr. Colleen Flood, Scientific Director of CIHR’s Institute of Health Services and Policy Research. “On behalf of my CIHR colleagues and partners Dr. Peter Liu (Scientific Director, Institute of Circulatory and Respiratory Health) and Dr. Anne Martin-Matthews (Scientific Director, Institute of Aging), we are thrilled to support this important national effort to make home care safer for Canadians.”

"The Change Foundation is pleased to participate in this national effort which builds on our previous work and comes at a crucial time given Canada’s demographics and growing demand for home-care services,” said CEO Cathy Fooks. “Without this commitment to identify the size of the challenge we’re facing, it would be difficult to make measurable and meaningful progress on improving safety in home care for the millions of Canadians who rely on it,” she said.

To find out more about the Patient/Client Safety in Home Care in Canada Request for Applications please click here, or visit any of the sponsoring organizations’ websites.

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Only three weeks until the 2nd Safe Surgery Saves Lives Workshop!

Designed to meet YOUR needs, this workshop aims to arm each participant with practical tools that can be used immediately in their home organizations. We listened carefully to what you told us over the last year - during the workshop, virtual grand rounds, presentations, community of practice and the checklist action series. In addition we consulted with national and international experts, researchers, clinicians with practical experience in implementing the surgical safety checklist, quality improvement experts working on surgical safety projects and others working on various surgical safety initiatives. With the help of our partners at the World Health Organizations we also looked at what other countries around the world are doing to make surgery safer.

The planning group and our faculty will ensure that at the end of the workshop you will be able to:

• Access and utilize available knowledge and resources to sustainably implement the Surgical Safety Checklist
• Articulate advanced concepts regarding the effectiveness of the checklist on surgical safety
• Develop customized strategies to improve team work and team communication as key elements for culture change
• Incorporate practical knowledge around adapting, integrating and aligning the different elements of surgical safety and the Checklist
• Design customized measurement and evaluation tools to sustain the implementation of the Checklist
• Develop formal and informal support networks

Register NOW!

The fee to participate is $150. This event will be accredited for RCPSC Section 1 MOC credits.

Click here to access the provisional agenda. Visit www.safesurgerysaveslives.ca for more information.

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On January 28 and 29, 2010, members of the Teamwork and Communication and Disclosure Working Groups met in Toronto to further scope and refine the tenets of a framework to support patient safety through effective teamwork and communication. Through the skilful facilitation of Kelly Kay, Tavia Nazarko and Paula Beard, the group engaged in a process of discovery underpinned by Applied Inquiry Based Learning. The essence of this inquiry method is learning through questioning and the use of critical thinking to seek resolutions.

The participants truly lived the old adage, "tell me and I forget, show me and I remember, involve me and I understand." The understanding at the end of the process resulted in the development of a structure upon which future concepts of the framework can be premised. The group’s immediate challenge is to refine the plethora of questions posed with regard to the concepts of “effective” “teamwork” and “communication” to guide the literature review.

Dr. Michael Gardam, Director of the Ontario Agency for Health Protection and Promotion kicked off day one of the meeting presenting on positive deviance (PD). The PD approach that suggests that in every hospital there are positive deviants; individuals who display attitudes or employ practices or behaviours that allow them to function more effectively that others who may have access to the same resources or work under identical circumstances. Through employing the tools of positive deviance, Dr. Gardam has recruited six Canadian hospitals to go through the PD process over a period of 18 months, in a Canadian Patient Safety Institute funded project. Through empowering staff the project aims to bring about sustainable changes in the organizations’ cultures and result in decreases in rates of hospital-associated infections including Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), and Clostridium difficile Associated Disease (CDAD).  The Working Group could readily envision the application of the PD approach as strategies are developed to support effective communication within organizations.

Dr. Ivy Oandasan, Associate Professor and Research Scholar with the Department of Family and Community Medicine at the University of Toronto and lead author of the CHSRF (2005) literature review on Effective Teamwork in Healthcare in Canada opened the second day by sharing her vast knowledge on what is known about effective team functioning. Dr. Oandasan detailed the individual and organizational factors that influence teamwork, how teams can move from low to functioning, the norms and values in teams and the barriers to collaboration. The application of theory to practice as a means to support communication and improve patient safety was soundly stated by Dr. Oandasan and will guide the working group as strategies are developed.

Click here to obtain future updates of this initiative. For more information please contact Cindy Winfield at: cwinfield@cpsi-icsp.ca.

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Wednesday, May 5, 2010

Each year in Canada, 8,000 to 12,000 patients die as a result of complications of hospital acquired infections. Through the simple act of practicing optimal hand hygiene, you can help reduce that number by half! The spread of pathogens by human hands creates risk at home, in the community, and particularly in healthcare settings. Without action, patients and healthcare workers are at risk. Help us help you to save lives!

In Canada, STOP! Clean Your Hands Day will be held Wednesday, May 5, 2010, in conjunction with the World Health Organization's global event. Canada's Hand Hygiene challenge "STOP! Clean Your Hands" website will be re-launched shortly with a new look, renewed emphasis, new tools, information, and strategies.

Stay tuned to www.handhygiene.ca for how you can participate in Canada’s Stop! Clean Your Hands Day.

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