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Holland Bloorview driving the client and family voice338711/29/2016 3:16:50 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Holland%20Bloorview%20PSEP%20team%20(Thumbnail).jpg" style="BORDER&#58;0px solid;" /> Holland Bloorview Kids Rehabilitation Hospital recently offered families and youth an education conference to provide key elements of understanding system issues that contribute to patient safety, as well as how to partner effectively with clinicians to co-create safe systems within healthcare. The Become a Family/Youth Leader Patient Safety Trainer conference was delivered in partnership with the Canadian Patient Safety Institute, to members of the hospital's Family Leader Accreditation Group and Youth Advisory Council on September 30 and October 1, 2016. In total, 14 family leaders, three youth and one child leader were trained during the conference. Holland Bloorview's Family Leader PSEP – Canada Planning Team (left to right) Nicholas Joachimides (Manager, Patient Safety), Elena Garisto (Quality Coordinator), Louise Kublick (Interim Director of Client and Family Integrated Care), Alifa Khan (Family Leader), Sonia Pagura (Senior Director, Quality, Safety and Performance), and Laura Oxenham-Murphy (Manager of Quality) "As we were thinking about meaningful engagement and partnership to drive the client and family voice, the thought was if we could train our family leaders in understanding what patient safety meant from the lens of families, then they would be on an equal playing field with our staff that has always been a part of accreditation," says Sonia Pagura, Senior Director, Quality, Safety and Performance. "We know what happens from the professional health discipline and the organizational perspective, but that is only one part. We also need the understanding that the family also have an active role in patient safety. They have an active role in all of the dimensions of quality and how they might be able to shift this paradigm." Holland Bloorview reached out to the Patient Safety Education Program – Canada (PSEP – Canada), to adapt the modules and program to a patient and family perspective. Their vision was twofold. First was the immediacy to scale up understanding for family leaders as they were embarking on the accreditation journey. The family leaders had committed to participate for 18 months to drive changes through excellence in accreditation. Second was within a three-year timeframe, to train just over 200 family, youth and children leaders participating in Holland Bloorview's Family, Youth and Children Programs to create capacity within the system. "We are already training staff and by building this critical mass within the organization on understanding what are the issues, what are some of the system drivers and human factor drivers, and our family, youth and children will eventually be the drivers of change for safety and quality," says Sonia Pagura. A team was formed and a Family Leader enlisted to adapt the PSEP – Canada p​rogram. When they looked at the curriculum, they found it to be provider-centric and profession centric and needed to make it family- and client-centric. For example, one of the modules says patients as partners, and that content was flipped to clinicians as partners, as it is not only providers partnering with families, it is families partnering with providers in that same knowledge and construct. Instead of just leadership, which would be leadership for providers, content was changed to leadership for families. "How does one take that leadership role through solution-focused leadership, through generative leadership and really look at tangible ways that we could bring some real live cases in building those skills that speak to families and partner effectively so that we have an actual dyad of having providers, families, and clients working together toward something that is meaningful, effective, efficient, safe, that has quality," says Sonia Pagura. Holland Bloorview is now developing their micro, meso and macro plans to ensure that staff and family leaders are all trained with the same information. Two of the family leaders, one youth leader and one child leader trained during the educational conference will be facilitating upcoming sessions for staff at Holland Bloorview. The 17-year-old youth leader, who is fully care-dependent, provided recently a session on communication with patients so that staff can actually see what that means. "This PSEP –​​ Canada program will have a system impact on a national and international scale," says Sonia Pagura. "If you look at legislation in Ontario, the Patient's First Act, it talks about coordination, transition, and about safety. This program lends itself very well to building that capacity. We have untapped potential and untapped capacity in the people we serve. It is our hope, that this will be the impetus for other organizations and that together we can continually build this critical mass that pushes change. We can't do this without partnering with our families. They are the ones that can see meaningfulness and the authenticity of how we want to change care to make it better for everyone. I get really excited and get goose bumps when I think about this opportunity." For more information on the Patient Safety Education Program – Canada, ​contact the PSEP – Canada team at psepcanada@cpsi-icsp.ca or call 1-866-421-6933. The Family Leader Accreditation Group at Holland Bloorview Kids Rehabilitation Hospital was recently recognized with honourable mention for the 2016 Volunteer Patient Safety Champion Award, for exemplifying the spirit of collaboration and engaging patients and families in patient safety. Click here to learn more.11/29/2016 3:00:00 PMHolland Bloorview Kids Rehabilitation Hospital recently offered families and youth an education conference to provide key elements of understanding12/1/2016 5:14:28 PM127http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Help us reduce falls and make care safer: join our expert faculty3066311/18/2016 4:39:46 PMPatient Safety News ​The Canadian Patient Safety Institute (CPSI) and the Registered Nurses' Association of Ontario (RNAO) are putting together a team of experts in fall prevention and injury reduction to help craft the next version of the Falls Getting Started Kit. The Getting Started Kit is a free resource designed to help care providers successfully implement evidenced-based falls prevention and injury reduction strategies to keep their patients, clients or residents safe. The primary role the faculty will be to assist in the revision and dissemination of the update of the Falls Getting Started Kit,contribute to knowledge transfer activities such as webinars; and offer expert knowledge to CPSI/RNAO and on occasion, to respond to inquiries from the field. If this sounds like an exciting opportunity, and you or someone you know, would like to get involved in improving safety by reducing falls, click the button below to learn more or email us at info@cpsi-icsp.ca. Learn More 11/18/2016 4:00:00 PMThe Canadian Patient Safety Institute (CPSI) and the Registered Nurses' Association of Ontario (RNAO) are putting together a team of experts in fall11/18/2016 4:51:46 PM592http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Questions Save Lives: How many questions does it take to save a life?3060411/4/2016 5:22:30 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/how%20many%20questions%20Thumbnail.jpg" style="BORDER&#58;0px solid;" /> ​When I began this monthly feature called, Patient Safety Power Play, it was conceived as a place to reflect on some of the hard work and the successes those in the field are achieving with respect to patient safety. It is a concentration of skill, commitment and passion. In other words, the power play is the advantage that breeds success. Well, if that is the criteria, then I believe this month's power play raises the bar to astronomical heights. As you probably know, Canadian Patient Safety Week was celebrated from October 24 to 28, and as part of that event, we launched the Questions Save Lives campaign. The premise was simple distribute blank Questions Save Lives frames across the country, have patients and providers inscribe their questions that save lives upon the frames, take a photo, and tweet it out. Although our communications team assured me it would be success, I had no idea what to expect, but I was thrilled with the returns! Hundreds of tweets, showcasing what must be more than a thousand questions! All those people, thinking about patient safety and sharing that thought with the world. I get goosebumps just thinking about it! The best part is every single tweet is saved and is now our own repository of life saving questions. Click here to see it and prepare to be blown away! Of course, this was just the tip of the iceberg! Other highlights of the week includeMore than 6,000 people taking the Canadian Patient Safety Week Quizzes154 participants taking part in our Questions Save Lives Twitter Talk with Dr. Joshua TepperMeasuring Hospital Harm resources were featured by CTV National, Global News, The Globe and Mail and The Canadian PressFederal Health Minister, the Honourable Jane Philpott, endorsing Canadian Patient Safety Week with an announcement on the Government of Canada websiteThe courageous patients and providers told their personal stories of harm to foster safety improvement What a week! Thank you to everyone who made it a smashing success! If you have any feedback for us, please complete our Canadian Patient Safety Week survey. What were your highlights? Let me know at cpower@cpsi-icsp.ca or on Twitter @CPowerCPSI. Yours in patient safety, Chris Power11/4/2016 5:00:00 PMWhen I began this monthly feature called, Patient Safety Power Play , it was conceived as a place to reflect on some of the hard work and the11/29/2016 4:51:20 PM341http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Is your mom on drugs? Addressing the dangers of overmedication in older adults3055511/2/2016 7:13:34 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Johanna%20Trimble.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Johanna Trimble receives 2016 Patient Safety Volunteer Champion Award Congratulations to 2016 Volunteer Patient Safety Champion, Johanna Trimble from the Vancouver Coastal Health Community Engagement Advisory Network. Johanna has mobilized her passion and commitment to affect change within the healthcare system and raise awareness around overmedication of seniors. Like many, Johanna Trimble had a challenging experience with a family member in the healthcare system and sought to affect change for the better, not just for her family, but for many others. It was 2010 when Johanna began to share the compelling story about her mother-in-law, Fervid Trimble. The galvanizing patient narrative, Is Your Mom on Drugs, drew interest from many working in and connected to healthcare and since then Johanna has effectively used that interest to lead initiatives for change that have resulted in greater awareness and new tools. With unwavering passion, Johanna has sought out various mechanisms for having her voice heard and to engage others in addressing the dangers of overmedication of older adults. Johanna recently joined a new organization, the Canadian Deprescribing Network (CaDeN), to raise that awareness about the dangers of overprescribing with health professionals, as well as the general public. She is also a public member in the development of MedStopper, a new deprescribing resource that helps prescribers and patients alike to make decisions around medication use. When the list of medications is entered on the web-based tool, the database ranks them from the least efficacious and safe to the ones that are safer and better, and details what to consider when monitoring, pausing, or stopping them. "Medstopper.com is a reputable tool developed for healthcare professionals. The general public can also use it to do a preliminary medication review themselves to find out which medications are most necessary and indicate the ones that may be causing problems," says Johanna. "The list can then be printed out to review with your doctor. Most people have a misconception about drug safety. Just because a drug has been passed by a drug regulator does not mean they are without harms. All drugs have side effects; you may or may not experience them. When you are older and taking many medications, there is a much higher likelihood that you will have side effects or interactions between them." Johanna's willingness to share her message broadly has created an interest and opportunities to share her story and advocate for change at various conferences and symposia the world over. She recently attended an international conference in Barcelona where a full day was devoted to issues about overmedication with the elderly. "I was so amazed and impressed that there are so many different countries now seeing this as a real problem that urgently needs to be addressed. I am doing everything that I can to raise awareness and do something practical about it," says Johanna. During the Conference, Johanna reconnected with a Swedish doctor who has developed a manual outlining drug classes and everything you need to know about getting people off those drugs safely. It is given to every prescriber in Sweden and used throughout Scandinavia. It has recently been translated into German. She has been inspired to make it a personal goal to try to get a consortium together to have an English translation done. "The Swedish manual has all the information and it would be silly to reinvent the wheel," says Johanna. "The information is detailed and the translation has to be done carefully and properly. I am reaching out to colleagues I have met in Australia, the UK and across Canada to see if there is some way between us we can find funding to publish an English version." Johanna is a volunteer member of the Vancouver Coastal Health (VCH) Community Engagement Advisory Network and the BC Patient Voices Network. She is a valued member of Patients for Patient Safety Canada and has obtained the Patient Safety Champion designation from the World Health Organization. She sits on a number of provincial and national committees working to solve the problems of Polypharmacy in the elderly, including the BC Polypharmacy Risk Reduction Initiative Steering Committee. She was recently appointed as a Council Member with the BC Patient Safety and Quality Council. Johanna is an honorary lecturer in Community Geriatrics in the Family Practice Department, Faculty of Medicine at the University of British Columbia. "I want to influence first-year medical students who are coming into the healthcare system and raise awareness about involving the family when treating the elderly," says Johanna. "Patients and families need to be much more involved in designing healthcare, from the early planning stages, all the way through to implementation and evaluation," says Johanna. "What happens quite often is that patients are called in as an after-thought. The patient's perspective is so different from those who work in the healthcare system. We have to work together; that is the only way that things will improve." Belinda Boyd, Leader Community Engagement at Vancouver Coastal Health nominated Johanna for the Patient Safety Champion Award. "When Johanna began to share her story, she did so in a direct and honest way that has inspired others to join her in delivering the message that overmedication is harmful, dangerous and needs to be curtailed," says Belinda. "Johanna continually inspires others to bring their voice to healthcare planning and improvement and is a strong advocate for patient safety." HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Volunteer Champion Award salutes patient/family volunteers who, through commendable dedication and service, contribute to a project or initiative that result in identifiable improvement in patient safety outcomes.11/2/2016 7:00:00 PM Johanna Trimble receives 2016 Patient Safety Volunteer Champion Award Congratulations to 2016 Volunteer Patient Safety Champion, Johanna Trimble11/29/2016 4:55:45 PM336http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Volunteer ambassador Charles Pharand makes a positive impact on the patient experience3055811/2/2016 7:51:10 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Charles%20Pharand%20cropped.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Congratulations to Charles Pharand, a volunteer ambassador at Bruyère Continuing Care's Saint-Vincent Hospital, who received honourable mention for the 2016 Volunteer Champion Award, recognizing his outstanding contributions in providing a safe and caring welcome to patients and families. Saint-Vincent Hospital is a 336-bed facility and is the sole provider of complex continuing care in Ottawa, Ontario. The specialized program is intended for medically complex patients who require a hospital stay, regular on-site physician/nursing care and assessment, and active care management with specialized staff. The program aims to improve and maintain function for patients with complex care needs by providing them with required services and support to transition back to the community, when possible. Of the more than 200 volunteer at Saint-Vincent Hospital, one who stands out from the crowd is octogenarian Charles Pharand. Mr. Pharand plays a vital role in providing a positive experience for patients and families at Bruyère Continuing Care. Over the past year, he has spent more than 950 hours of his time engaging with patients and families during the admission process and throughout their stay. Mr. Pharand wears many hats in overseeing the ambassador program, answering phones in the volunteer office, helping with special events, getting patients to mass, making a friendly visit to say hello or marking a milestone by singing happy birthday to a patient. A former consultant, Mr. Pharand always gave money to charity. When he retired, he no longer had the disposable income to support the causes he was passionate about. His wife encouraged him to give of his time in lieu of that financial support. Bruyère Continuing Care is a two-block walk from his home and for the past six years, Mr. Pharand has made the short trek five days a week to help out. Typically, he mans the phone in the volunteer office on Monday, Tuesday and Thursday; does patient visits and tours on Wednesday; and helps patients get to the chapel for mass on Sunday. "I am a simple man and what I am doing is providing a simple service," says volunteer extraordinaire, Charles Pharand. "I am in great shape and will be here as long as I can walk, talk and have my mind. I enjoy the patients and everything I do is done with a smile. It is very rewarding to see that our services are so appreciated." The volunteer ambassadors play a vital role at the hospital, ensuring that patients and families feel welcomed and cared for. The ambassador orients the patient and family by reviewing the admission package with them, answering questions related to the hospital's non-medical services, introducing them to the Therapeutic Support Services program available to them during their stay and offering a tour of key areas of the unit and hospital. Any questions patients and families have related to specific care services are communicated to the clinical manager for follow-up. Heidi Duhaime, the volunteer coordinator at Saint-Vincent Hospital nominated Mr. Pharand for the 2016 Patient Safety Champion Award. "More than 350 patients have been welcomed to Saint-Vincent Hospital since the volunteer ambassador program started and many continue to benefit from this innovative program," she says. "The volunteer ambassador program has been recognized by Accreditation Canada as a leading practice of excellence and has proven to be an effective and sustainable program that emphasizes a patient-centred approach. Mr. Pharand is an exceptional volunteer who consistently contributes to improving the overall success of the program and growing our team of volunteer ambassadors." The ambassador program has expanded beyond Saint-Vincent Hospital. In addition to being offered on each unit, a modified program has been implemented on the palliative care unit at the Élisabeth Bruyère Hospital in order to meet the specific needs of that patient population. HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Volunteer Champion Award salutes patient/family volunteers who, through commendable dedication and service, contribute to a project or initiative that result in identifiable improvement in patient safety outcomes.11/2/2016 7:00:00 PM Congratulations to Charles Pharand, a volunteer ambassador at Bruyère Continuing Care's Saint-Vincent Hospital, who received honourable mention for11/29/2016 5:00:37 PM199http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Giving patients and families a voice at Michael Garron Hospital: 2016 Patient Safety Team/Organizational Champion Award3056311/2/2016 8:34:39 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Mari%20-%20headshot.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Congratulations to Michael Garron Hospital, the 2016 recipient of the Team/Organizational Champion Award for their outstanding work in engaging patients and families as partners in continuous improvement. At Toronto's Michael Garron Hospital (formerly the Toronto East General Hospital), Patient Experience Partners ensure that the voices of patients and families are heard, considered and included in program improvement, education and the design of the care environment. As early as 1996, patient representatives were appointed to the Research Ethics Board and since then patient involvement has become the cultural norm of the hospital. "At Michael Garron Hospital, we value a just and transparent culture that includes the patient voice and supports continuous quality improvement," says Mari Iromoto, Head of Organizational Quality, Risk, Privacy, Process Excellence & Innovation teams. "It is just the way of being and doing here." A Patient Video program was created to give patients a voice in providing a first-hand account of their hospital experience and sharing opportunities for change. Since 2011, 150 patient videos have been recorded and shared. The successful video program has helped to improve patient satisfaction scores (now over 95 per cent) and led to procedural improvements such as enhancing psychological/social work support in Oncology; addressing alarm fatigue in the Cardiac Integrated Unit (reducing provider response time by 56 percent); a Falls Prevention (Mobility Strategy) program (that led to a 10 per cent reduction in falls with harm hospital-wide and a 50 per cent reduction in the Memory Care Unit). The hospital's Patient Video Toolkit has been shared with more than 30 organizations across Canada and the United States interested in transforming the way care is delivered through reflection and the direct voice of patients. In 2015, the program was the recipient of the Change Foundation's 20 Faces of Change Award and a Best Practice Listing from the Association for Patient Experience. This year, the program received the Cleveland Clinic Patient Experience Practice of the Year Award. Patients have provided input into processes in place to manage critical incidents in order to help develop new processes and prevent similar incidents from reoccurring. When an incident does occur, the hospital's policy is to disclose all information to their patients. "We put the patient first and we always ask, what is the right thing to do?, says Mari Iromoto. It is a simple question and we are guided by that." Michael Garron Hospital (MGH) is one of the first hospitals in Canada to design a staff training program to build capacity and ensure a welcoming environment for LGBTQ (Lesbian, Gay, Bisexual, Transgender and Queer or Questioning) patients and staff alike. The mandate is to have 1,000 staff complete LGBTQ training in the next year. Partnering with a local organization heavily involved with the LGBTQ community has helped to ensure that the appropriate language is used and sensitivities are addressed. The hospital is committed to sharing its LGBTQ policies and procedures to improve and standardize care across the continuum of care. Michael Garron Hospital received Accreditation Canada's exemplary status for 2016 in recognition of a top percentile score of 99.64 per cent. In addition, MGH has been awarded with 15 Accreditation Canada leading practices, including creating a mobile app to support thoracic surgery patients and improve their experience and surgical outcomes; establishing the Diabetes Group Walking Clinic where patients walk with their doctors and nurse educators at a 'walk-while-we-talk' outpatient appointment; and implementing post-discharge phone calls where a nurse calls a patient 24 to 48 hours after discharge to improve safety in the transition from hospital to home. Other examples of engaging with patients and families to improve safety include conducting a bedside shift exchange with the full involvement of patients and families; and developing education tools for registration clerks, frontline providers, patients and their substitute decision-makers (SDM) to advance understanding of capacity assessments and identifying the correct SDM to improve safety and quality ethical care. Patient Experience Partners have many opportunities to participate and improve quality at MGH. For example, they have partnered in the redesign of the Emergency Room to enhance patient flow and experience; co-created the IDEAL discharge planning process to maximize patient experience and outcomes from admission to discharge; and are involved in co-designing educational materials and patient information. They are also invited to share their stories, which are shared by staff at daily unit huddles, and provide feedback through post-discharge phone calls, satisfaction surveys and the patient relations process. Patient Experience Partners are members of the hospital-wide Patient Experience Panel (PEP), as well as unit-based PEPs in mental health and dialysis; have a seat on the Senior Friendly Steering Committee, the Board Quality Committee, and the Medical Quality & Patient Safety Committee. Representatives also sit on the Community Advisory and Family Councils in Complex Continuing Care; Emergency and Maternal, Newborn & Child Care; and on hiring panels for managers, allied health staff and specialists. Francisco Grajales, the Canadian Envoy of Radboud University Medical Centre and a member of the MGH Innovation Committee nominated Michael Garron Hospital for the Patient Safety Champion Award. "MGH's commitment to excellence in partnering with patients, families and the community has created a solid foundation for a culture of improvement and innovation across every ward," says Francisco Grajales. "Being grounded in the patient voice with patients as stakeholders is a mantra that all hospitals should learn from, particularly in the patient safety domain." HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Team/Organizational Champion Award recognizes a team or organization who, through exemplary patient centred care and patient engagement practices, contributed to a project or initiative that resulted in identifiable positive impact on patient safety outcomes.11/2/2016 7:00:00 PM Congratulations to Michael Garron Hospital, the 2016 recipient of the Team/Organizational Champion Award for their outstanding work in engaging11/29/2016 9:50:24 PM351http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
We should talk: How three physicians championed effective communication at Montreal Children’s Hospital3056811/2/2016 9:03:36 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/MCH%20Patient%20Safety%20group.JPG?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Congratulations to Montreal Children's Hospital, who received honourable mention for the 2016 Team/Organizational Champion Award for the "We should talk" patient safety campaign. Communication is the foundation of everything in terms of optimizing the family experience in patient safety and enhancing staff safety and partnerships. We Should Talk was developed as an awareness campaign, aimed to inspire everyone at Montreal Children's Hospital to more effectively communicate, with the goal to prevent harm. The core mantra of the campaign is twofold When something's not right, we need to listen -- Our patients, our responsibility; and When something's not right, tell us, we are listening -- Your health is our priority. The idea for the We should talk campaign was conceived by Dr. Sasha Dubrovsky and Dr. Samara Zavalkoff while attending the Canadian Patient Safety Officer Course in Ottawa. Once back at the hospital, they enlisted the support of Dr. Nadine Korah, who had just completed a Master's degree in Quality Improvement and Patient Safety. The trio were quickly pegged, the Three Musketeers, in recognition of their leadership and passion for patient safety. The campaign has been supported by a multi-disciplinary team that included family advisors as fully-integrated members of the project team. By merging forces and collaborating the momentum for the campaign grew exponentially. We should talk promotes a culture of patient safety. Launched during Canadian Patient Safety Week 2015, the one-year innovative project has raised awareness through a fun and innovative multi-media campaign, and built capacity for data to be used as a continuous quality improvement (CQI) tool to drive vital behavioural change. A We should talk engagement wall was developed where staff, patients and families sign their names in support of the project. A social media campaign was deployed to reach community clients and partners, and to promote four humorous videos. We should talk tools, appropriately branded, were also embedded throughout the organization to promote awareness. A welcome guide was given to all new admissions; the volunteer "meet and greet" program introduced the campaign to in-patients and families; magnets on patient's white boards and lanyards worn by staff were used as a prompt to speak up and voice safety concerns; print ads, colouring books and games were strategically placed throughout the hospital; and video ads running in waiting rooms encouraged conversations between patients and staff. The results of these efforts are impressive! Between January and May 2016, the social media campaign generated 850,000 user impressions, as well as 18,000 users engaging with the content through likes, comments, shares and clicks. Throughout the campaign, the content generated 4,000 likes on Facebook. Visibility surveys with patients and families indicated that 80 per cent noticed the campaign and 50 per cent understood the core message. About one-third were encouraged to make changes in their interactions with providers as a result. Visibility surveys with staff indicated that 80 per cent saw the print adds more than five times, 45 per cent watched the videos, and 90 percent understood the core message. About one-third of respondents said they wore We should talk lanyards, amongst whom 55 per cent were positively influenced to communication more effectively. "We should talk has spurred a lot of changes in our organization," says Dr. Sasha Dubrovsky, an emergency doctor who led the project. "On the front end, it was an awareness campaign; on the back end it has helped to build the infrastructure necessary for continuous quality improvement. We are now measuring the patient experience in more care areas and sharing that data with frontline staff. By empowering frontline staff and managers in continuous quality improvement methodology we can spread our knowledge and lessons learned to effectively communicate for patient safety." Gabrielle Cunningham-Allard, Project Coordinator for the We should talk multi-disciplinary team and submitted the nomination for the 2016 Patient Safety Champion Award. "The We should talk campaign was meant to inspire actions that highlight how an organization can foster grassroots improvement ideas from frontline clinicians in order to improve patient engagement for patient safety," says Gabrielle Cunningham-Allard. "It is an exemplary case study that demonstrates how to speak up and listen up to successfully engage with patients and families." The campaign was aligned with multi-generational projects led by the hospital's Bureau de la Qualité et de l'Amélioration Continue (BQAC) where core messages and values are integrated into communication workshops, inter-professional simulations and Lean Six Sigma CQI courses. The We should talk campaign is now being handed over to BQAC for the next phase of its life cycle. "My dream is that our hospital transforms its culture of improvement to frontline staff with family partners," says Dr. Dubrovsky. "We are working hard to train and build that capacity with frontline teams and family advisors in improvement projects. Those projects need to be visible and engaging in real time. Not everything has to be a big project; we just need to get together in a huddle and fix things together. The challenge is how to transform the culture from being someone else's job, to quality being everyone's job." HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Team/Organizational Champion Award recognizes a team or organization who, through exemplary patient centred care and patient engagement practices, contributed to a project or initiative that resulted in identifiable positive impact on patient safety outcomes.11/2/2016 7:00:00 PM Congratulations to Montreal Children's Hospital, who received honourable mention for the 2016 Team/Organizational Champion Award for the " 11/29/2016 9:52:00 PM640http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Oriented Discharge: a self-management tool designed for patients with spinal cord injury3056911/2/2016 8:14:33 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Sandra%20Mills%20and%20Heather%20Flett%20CROPPED.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Congratulations to University Health Network (UHN) Toronto Rehab's Lyndhurst Spinal Cord Rehabilitation Team, who received honourable mention for the 2016 Team/Organizational Champion Award for creating a discharge process that ensures a safe transition between inpatient rehabilitation and the community. Transitions of care, particularly at discharge, are a vulnerable time for patients and it does not always go smoothly. Safe transitions can be compromised and lead to hospital readmission when patients are inadequately prepared for discharge. The Spinal Cord Rehab Team at Toronto Rehab's Lyndhurst Centre ensure the uptake of self-management skills such as medication management, early detection of symptoms to look out for, and who to contact in case of complications to ensure safe transitions between inpatient rehabilitation and the community. Sandra Mills and Heather Flett co-led the Patient Orientated Discharge Summary (PODS) pilot project to develop and implement a discharge process in a spinal cord rehabilitation context. The PODS is a simple tool and set of process changes that was co-designed by patients and providers. The feedback from patients and clinicians who participated in the pilot was overwhelmingly positive. In May 2016, the pilot program transformed into a new standard-of-care at Lyndhurst Centre, making it the first self-management tool of its kind in Canada for spinal cord injury patients using PODS in a teach-back style meeting. "The PODS meeting is oriented to the patient to consolidate their learnings," says Heather Flett, Advanced Practice Leader in Spinal Cord Rehab. "The PODS meeting is not a discharge planning meeting. We already have a meeting with patients and families and the entire Interprofessional team to talk about the discharge. The PODS meeting focuses on self-efficacy to determine if there are things that the patient has not clearly understood that can be addressed before discharge." The PODS process includes a written summary presented in an easy-to-understand format covering five key areas and a teach-back approach to educating patients. The first of the five sections in the spinal cord injury-specific PODS relates to medications and generates a conversation about a person's confidence and ability to manage their medications, as well as accessing bladder supplies once at home. The second section is the Care Plan. It covers issues specific to spinal cord injuries, including swallowing and breathing, skin, bladder, bowel, pain, memory, dressing and bathing, eating, mobility and transfers, equipment, shopping and cooking, housing, relationships and coping, transportation and leisure. "We ask questions, such as what is your plan for managing your bladder at home and the individual will then teach back their learnings from rehabilitation," says Sandra Mills, Patient and Family Educator at Lyndhurst Centre. "Teach-back validates the healthcare provider's ability to educate the patient and identifies what the patient knows or doesn't know so that we can close that gap prior to discharge." The third section addresses signs and symptoms and what to do. The content identifies worse-case scenarios that patients may need to work through at home, such as increased swelling or, pain, urinary tract infection or a fall, etc. The fourth section lists outpatient referrals and appointments. The project team found that patients liked having their appointments and referrals summarized in one spot to know exactly what they need to do during those first few weeks at home. The final section provides a My Contacts list. "This is one of the most valuable pieces of the patient's take-away," says Sandra Mills. "It is a complete list of contacts customized for that individual so that when they go home, they know exactly who to contact if they have a question or problem. Those contacts include both people here at Lyndhurst and people in the community." Funding for the original PODS pilot project was provided by UHN OpenLab, a design and innovation shop housed at the Toronto General Hospital that is dedicated to finding creative solutions that transform the way health care is delivered and experienced. "We received early-adopters funding from the Toronto Central LHIN and were able to secure a project coordinator and two patient advisors to move the project forward in a short timeline," says Sandra Mills. Two former patients with spinal cord injuries were an integral part of the project team and true partners in the project design, development and implementation. "We looked to our patient advisors for their thoughts on content, how to ask questions and ideal format of a PODS meeting," says Heather Flett. "The patient advisors conducted Focus Groups, did in-person and telephone interviews to seek information and validate the PODS template. When talking to other patients they could relate to them from their experience and the information gathered was a lot richer information than only that obtained from healthcare providers." Joanne Zee, Senior Clinical Director, Brain and Spinal Cord Program at Toronto Rehab's Lyndhurst Centre nominated the PODS team for the 2016 Team/Organization Champion Award. "Patient engagement and co-design transformed a simple discharge summary into a discharge process that is centered on the patient and focuses on safety, self-management and confidence-building," says Joanne Zee. "Engaging patient advisors as members of the team to better understand the needs and experiences of patients was invaluable to shape the outcome of a safer discharge system." HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Team/Organizational Champion Award recognizes a team or organization who, through exemplary patient centred care and patient engagement practices, contributed to a project or initiative that resulted in identifiable positive impact on patient safety outcomes.11/2/2016 7:00:00 PM Congratulations to University Health Network (UHN) Toronto Rehab's Lyndhurst Spinal Cord Rehabilitation Team, who received honourable mention for11/29/2016 9:53:29 PM106http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Holland Bloorview enlists Family Leaders to take Accreditation standards to the next level3055311/2/2016 5:59:03 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Adrienne%20Zaram.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Congratulations to Adrienne Zarem and Alifa Kahn, members of the Family Leader Accreditation Group at Holland Bloorview Kids Rehabilitation Hospital who received honourable mention for the 2016 Volunteer Champion Award, for exemplifying the spirit of collaboration and engaging patients and families in patient safety. When Accreditation Canada embedded specific and targeted client and family-centred care content into their standards, Holland Bloorview Kids Rehabilitation Hospital set out to not only meet the new standards, but to exceed them. In 2015, 14 family leaders were enlisted to form the Family Leader Accreditation Group (FLAG) and are now partnering with staff on each of the hospital's seven accreditation teams in preparation for the next accreditation survey, scheduled for the fall of 2017. Adrienne Zarem and Alifa Khan are two of the family leaders who have taken on key leadership roles in the development of the FLAG structure. Adrienne chairs the Family Leader Accreditation Group. She started working as a Family Leader at Holland Bloorview about two years ago, shortly after her daughter was diagnosed with autism. "Initially, I simply wanted to make myself more useful, but once I experienced the tremendous work the hospital was doing, I knew that I wanted to give more back to the organization," says Adrienne. "Holland Bloorview is very innovative and forward-looking in their approach to family engagement. The Family Leaders involved in accreditation have been encouraged to challenge the institution when their lived experience has given them the opportunity to identify gaps in the system, or opportunities for the hospital to improve." Adrienne's partnership, leadership and engagement have resulted in substantive improvements in the accreditation process. She assists other clinicians and family leaders in bridging difficult conversations and arriving at collaborative solutions to advance quality and safety processes. Adrienne has been an advocate for ensuring that the voices of family leaders are heard and incorporated into action plans. Sitting in the waiting room with her son who has special needs, Alifa saw a sign asking for family volunteers, but didn't think much about it at the time. After a couple of visits to the hospital, she thought, 'this is an amazing place that feels really special, I want to be part of it'. She became a family leader at Holland Bloorview three years ago. "I wanted to be a good example for my son," says Alifa. "By empowering myself, I can empower him and he can learn from that. The FLAG has such strong collaboration and authentic partnerships with everyone around the table. I want to carry that same message forward and empower the caregivers, youth and children at Holland Bloorview." When the Family Leaders discussed options for patient safety training that would give them a strong foundation to support the accreditation process, Alifa knew instantly that she wanted to take on that task. She has made a significant contribution to revising the Patient Safety Education Program - Canada (PSEP – Canada) modules to resonate with family leaders and provide them with fundamental knowledge to participate more fully in the accreditation journey and beyond. She was an integral working group member in revising and reframing the content of each of the individual PSEP – Canada modules, to ensure the perspective of the patient and family was at the core. The creation of a modified PSEP – Canada certification program will enable the training of more than 200 parents, youth and children who volunteer to advance quality and safety in paediatric rehabilitation at Holland Bloorview. A multi-year strategy is being develop that will get everyone on the same page, speaking the same language with a commonality and understanding of patient safety. Sonia Pagura, Senior Director, Quality, Safety and Performance (on behalf of Holland Bloorview) nominated Adrienne and Alifa for the 2016 Volunteer Champion Award. "Adrienne and Alifa are committed to expanding patient safety knowledge beyond just being involved in accreditation, building capacity within our clients and families and have taken on a sector-leading role of improving quality and safety in hospitals," says Sonia. "Their advice and partnership will be the foundation that other organizations, sectors, health systems can model to create an innovative method of authentically engaging patients and families in their quality of care journey." HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Volunteer Champion Award salutes patient/family volunteers who, through commendable dedication and service, contribute to a project or initiative that result in identifiable improvement in patient safety outcomes.11/2/2016 4:00:00 PM Congratulations to Adrienne Zarem and Alifa Kahn, members of the Family Leader Accreditation Group at Holland Bloorview Kids Rehabilitation Hospital11/29/2016 9:54:39 PM224http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
How often do patients experience harm in a hospital?1072510/25/2016 8:50:04 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Hospital%20Thumbnail.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> In 2014-15, one in 18 hospital stays in Canada involved at least one harmful event (138,000 out of 2.5 million hospital stays). Of those, 30,000 (or one in five) involved more than one form of harm. While most patients experience safe care, sometimes harmful events happen that affect patients. Many of these events are preventable. The Canadian Institute of Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI) are working to address a gap in patient safety measurement by collecting data on how often these events are happening and providing information on how these events can be prevented. Through the development a Hospital Harm Improvement Resource and the Measuring Patient Harm in Canadian Hospitals report, system decision-makers, hospital executives, clinicians and policy makers now have access to important information on patient safety in acute care hospitals and how to improve it. The measure and improvement resource comprise a new, readily available tool hospitals can use to improve the safety of their patients and reduce the occurrence of harm. "With the improvement resource, patient safety teams and clinicians can now spend less time researching what to do, and more time planning and implementing changes that are known to work," says Chris Power, CEO of CPSI. "One avoidable harmful event is one too many," says Bill Tholl, CEO of HealthcareCAN, a national organization that speaks for Canada's hospitals and works to foster informed and continuous improvement in healthcare. "HealthCareCAN‎ welcomes the release of this report and working with CPSI and CIHI to pursue the common goal of quality and reliability for patients." This work reflects a new approach in helping Canadian hospitals to measure and improve patient safety. "While most patients experience safe care in Canada, we must continually strive to do better," said the Honourable Jane Philpott, Minister of Health. "High-quality data is an important tool in assisting our improvement efforts, and we thank CIHI and CPSI for working together toward this goal." Why is a measure of harm important? Until now, there has been no single measure that provides perspective on patient safety in Canadian hospitals. The measure is designed to help organizations identify patient safety improvement priorities and track progress over time. Measuring Patient Harm in Canadian Hospitals The Measuring Patient Harm in Canadian Hospitals report provides a summary of the new approach to measuring hospital harm. It provides a big picture view of hospital harm and the status of patient safety in Canada; the number and types of events; and types of patients and their outcomes. The report introduces readers to the Improvement Resource and provides guidance on how to use the measure for improvement. It reinforces the importance of using the measurement data in conjunction with other currently available data. The Hospital Harm measure The Hospital Harm measure was developed jointly by CIHI and CPSI in consultation with leading patient safety experts. The measure represents a new approach to measuring and monitoring harm that occurs in Canadian hospitals. CIHI and CPSI are committed to working with stakeholders across the country to ensure this measure is a useful tool for monitoring and improving patient safety in acute care facilities. The measure is defined as the rate of acute care hospitalizations with at least one occurrence of unintended harm during a hospital stay that could have potentially been prevented by implementing known evidence-informed practices. A key advantage of this measure is that it uses existing data already being submitted to CIHI's Discharge Abstract Database (DAD) — no additional data collection is needed. The DAD captures information on hospital discharges across Canada (excluding Quebec). It is well established, has common standards for data collection and has built-in methods for auditing and assuring data quality. For harm to be included in the measure, it must meet the following three criteria it is identified within the same hospital stay; requires treatment or prolongs the patient's hospital stay; and is one of the conditions from the 31 clinical groups in the Hospital Harm measure framework. The Hospital Harm measure captures unintended occurrences of harm that happen during a hospital stay. The measure is made up of clinical groups that fall under four categories, including Health Care–/Medication-Associated Conditions; Health Care–Associated Infections; and Patient Accidents; and Procedure-Associated Conditions. The measure captures a range of harmful events, from "never events" — things that should never happen and are completely preventable (e.g., retained foreign body) — to events where implementing evidence-informed practices should reduce the incidence of harm but may not prevent every occurrence (e.g., aspiration pneumonia). While not all instances of harm captured by this measure can be prevented, implementing evidence-informed practices can help to reduce the rate of harm. The purpose of measuring quality and safety is to improve patient care and optimize patient outcomes. The measure should be used in conjunction with other sources of information about patient safety, including patient safety reporting and learning systems, chart reviews or audits, Accreditation Canada survey results, patient concerns and clinical quality improvement process measures. Together, this information can inform and optimize improvement initiatives. Hospital Harm Improvement Resource The Hospital Harm Improvement Resource links measurement and improvement by providing evidence-informed resources that will support patient safety and improvement efforts. The Improvement Resource will help to open conversations about patient safety and improvement. For patients and families, like Carole Jukosky, the Improvement Resource provides relevant information to prevent harmful events. Carole's dad Herbert Strasser died unexpectedly in September 2011, after a gruelling six-week hospital odyssey, growing sicker every day. Continuity and follow-through were huge issues that affected his care. "My dad's case is very complex and in the end he had a multitude of issues," says Carole. "It was very confusing to the medical system, very confusing to him and very confusing to our family." Carole had to dig deep through every medical file and lab result trying to make sense of it all. She met with all the facilities to review her dad's case, supported by a coroner's investigation into what was termed "a perfect storm" of miscues and false assumptions. Carole's prodding and inquiries have led to several healthcare improvements. The Hospital Harm Improvement Resource provides information on general patient safety tools and quality improvement resources, how to use the Hospital Harm measure, and references and resources specific to each of the 31 clinical groups. For more information and to access the Improvement Resource, visit www.patientsafetyinstitute.ca or www.cihi.ca 10/26/2016 9:05:00 AMIn 2014-15, one in 18 hospital stays in Canada involved at least one harmful event (138,000 out of 2.5 million hospital stays). Of those, 30,000 (or10/26/2016 9:04:03 AM833http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx