Invitational Forum on Reducing Harm - April 5, 2017
Transparency and culture change key to patient safety
See the patient in front of you as an individual, care for them to the best of your abilities and apologize to them directly in a timely manner if you make a mistake.
That is a distillation of some of the patient-centred advice provided at a comprehensive review of patient safety and reducing harm in hospitals provided by a range of participants at the forum held in conjunction with the 4th annual InnovationEX of the Joint Centres for Transformative Health Care Innovation held at Markham-Stouffville Hospital.
Markham-Stouffville is a member of the Joint Centres along with Mackenzie Health, Michael Garron Hospital, North York General Hospital, Southlake Regional Health Centre and St. Joseph's Health Centre.
In addition to this year's focus on patient safety, the event also showcased innovative work at the six hospitals aimed at improving quality, safety and bringing more value to the health care system.
"You're doing innovation in the best way. You're doing innovation as it's touching patients," said Dr. Bob Bell, Deputy Minister of Health and Long-term Care in his introductory remarks. In his presentation, Bell focused on how the revised Quality of Care Information Protection Act, to be proclaimed this summer, will increase transparency in dealing with preventable errors in hospitals.
As keynote speaker at the forum, Chris Power, CEO of the Canadian Patient Safety Institute (CPSI) provided a comprehensive overview of the status of patient safety in Canada today.
"We know that in health care things go wrong despite our best efforts. But most times we get it right," she said. However, Power said someone in a Canadian acute care hospital dies from a preventable event every 17 minutes and this statistic has not changed much in recent years.
Whether it is possible to totally eliminate such errors depends on your perspective, she said, with other speakers in the meeting opining that while total elimination of error was not possible much more could be done to reduce the impact to patients of such incidents.
With communication breakdown identified as the main cause of preventable errors, Power said, the key to changing the situation lies in creating a safety culture, and improving teamwork and communications.
Power then talked about work being done at CPSI to identify the "winning conditions" for improving patient safety. These conditions include:
- Improving the reliability of human decision-making – currently seriously underdeveloped in Canada because of a very strong tradition of clinical autonomy and suspicion of standardized work.
- Developing a sense of urgency about the issue – a sense that Power says that "appears to have waned" in recent years.
- A commitment to good governance and management commitment. Power and others talked about "pockets of excellence" in Canada while the governance capacity overall for system performance has not improved greatly.
- Access to reliable data of a granular nature that will be useful for individual clinician.
Power said with the increased cadre of sophisticated patient-advocates "patients and the public are going to be the ones that transform health care. Not us."
This was a theme that continued through the panel discussion that followed which included input from panel member, Diane McKenzie, patient and family advisor at St. Joseph's.
The other major focus of the panel discussion was the comparison between managing patient safety in hospitals with how safety is dealt with in the aviation and space industries. Insights were provided by former astronaut and emergency room physician and now CEO of Southlake, Dr. Dave Williams, and Samuel Elfassy, managing director, corporate safety, environment and quality for Air Canada.
The panel discussion was moderated by Dr. Joshua Tepper, president and CEO of Health Quality Ontario. Safety is one of the six dimensions of quality that defines a high quality health care system and drives the work of Health Quality Ontario.
Comparing and contrasting safety in the hospital sector with that of the aviation industry is a long-standing fixture in patient safety debates and from the panel discussion it was clear clinicians still need to do more to embrace the culture ingrained in pilots and astronauts.
Elfassy said changing the culture in hospitals will require a lot of transparency, data and personal story telling. Williams evoked the power of story-telling and shared the impact that unexpected outcomes let alone medical errors can have on clinical staff when he spoke of becoming tearful recently while giving rounds at Southlake discussing an incident from 30 years ago where no errors were made but there was a very tragic outcome.
Williams noted those in the aviation industry have an extensive exposure to a terminology and culture of safety that is only just starting to be embraced by medicine.
While Williams and Power focused on the need for more standardization in health care, McKenzie added that providers need to account for the individual needs of patients at the same time.
The discussion briefly touched on whether fiscal restraints on hospitals had an impact on patient safety.
Power and others noted all variables impacting patient care in hospital such as bed shortages should be viewed through a safety lens. Hospitals will continue to need to provide the highest quality and safest care within the constraints of their funding envelopes.
The discussion concluded by returning to the focus on individual patient care to improve patient safety and reduce medical error. McKenzie noted that while developing standards of care are very important there must also be recognition that some patients will not fit the care models that are developed and there must be a process to ensure they also receive optimal care.
"We promise patients the highest quality of care and we will build their trust when we fulfill that promise," said Tepper.
Dr. Tim Rutledge, Chair of the Joint Centres, wrapped up the forum and set the tone for continued work on the issue of reducing harm by reiterating "we need a culture of trust, a culture of learning and a culture of collaboration". He noted there was a palpable sense this existed in the organizations who participated in the forum.