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RESEARCH VOLUNTEERS NEEDED!235488/22/2016 8:13:59 PMPatient Safety News Are you a clinician who has been part of an adverse clinical event? Did it lead to a career transition into a new role or position? If so, we need your insights! Researchers at the University of Missouri Health Care and University of Massachusetts-Boston are seeking clinicians to participate in a short online survey about the impact of adverse events on career transitions. The survey has been designed to help us better understand the experiences of these clinicians and takes approximately 10-15 minutes to complete. There will be no uniquely identifying information collected or linked to the participant's responses and all data will be collected confidentially according to institutional review board (IRB) requirements. Participation is voluntary and may be terminated at any point. To take part in the survey, please click here. The survey will remain open until early to mid-October 2016. For more information, please contact Dr. Susan Scott at (573) 884‐2373 or Dr. Jason Rodriquez 8:00:00 PMAre you a clinician who has been part of an adverse clinical event?   Did it lead to a career transition into a new role or position?  8/23/2016 2:26:07 PM155
Measurement: a look back and a new approach3748/3/2016 3:15:02 PMPatient Safety News ​​This is the second article in a two-part feature on measurement and the Central Measurement Team. Click here to view the first article, Measuring for safety The evolving role of the Central Measurement Team A look back on Patient Safety Metrics The initial measurement tool used for Safer Healthcare Now! data submission was developed over a decade ago, using Excel spreadsheets. By 2009, it became obvious that an online tool was needed. A web-based tool was developed as a data submission and reporting system that provided teams with the ability to aggregate and disaggregate results to report by region, facility or individual patient samples by team. The Excel spreadsheets were phased out with the launch of Patient Safety Metrics in January 2011. Patient Safety Metrics allowed organizations to track and report on over 100 key process measures aligned with the Safer Healthcare Now! interventions. Numerous National Calls were conducted to provide users with training on how to measure, what to measure and how to use the Patient Safety Metrics tools. Stephanie Howse, a Clinical Coordinator with Alberta Health was new to her position when one of her colleagues suggested that she use Patient Safety Metrics to monitor medication reconciliation compliance across the Northern Lights Health Region. Stephanie was surprised to find how intuitive and user-friendly the tool was. "Patient Safety Metrics provides a bird's eye view of how we are doing," says Stephanie. "You can drill down and identify trends with the data. There are self-study modules available on how to interpret the data and the Central Measurement Team is always available to troubleshoot and help you to better understand the findings.""The Patient Safety Metrics tool is easy to use and provides the right reports that allows you to do the comparisons that you need to do," says Dr. Elizabeth MacKay, Medical Leader, Provincial VTE Prophylaxis Accreditation Working Group, Alberta Health Services. "The ability to compare your results to national groups provides information that is invaluable." Virginia Flintoft says that aside from all of its benefits, there was one small flaw of the Patient Safety Metrics system. It was designed for teams to directly access their reports; however, most often the teams would call the Central Measurement Team to run the reports for them. "The ownership wasn't there; most often they were just too busy," says Virginia Flintoft, Project Manager, Central Measurement Team (CMT). "What we found with Patient Safety Metrics is that the people entering the data were not the ones looking at the results and accessing the reports," says Alex Titeu, Project Coordinator, CMT. "The goal behind Patient Safety Metrics was for the individual entering the data to see their results right away." Patient safety and quality improvement has evolved immensely over the years and so too has the CMT. "It is definitely time that organizations manage and monitor their own data," says Virginia Flintoft. "Most hospitals now have the talent inhouse and the resources." The data collection segment of Patient Safety Metrics was phased out this spring. The CMT has permission to hold the data and all records will continue to be held in a secure location for up to seven years. Data has been sent back to participating healthcare organizations, who the owners of the data. Over half of the data has since been repopulated. The CMT has been communicating with the remaining participating organization's CEO to ensure they have downloaded their data, or to indicate where it is to be sent to. A new approach to solutions that stick With the unveiling of Shift to Safety, the role of the CMT will also transition to more of an expert coach and mentor approach that leverages the most up-to-date thinking related to the measurement and monitoring of patient safety. "The CMT will no longer support a measurement database," says Virginia Flintoft. "The approach now will be to get the teams to identify the opportunities for improvement and the CMT will coach and mentor them through their improvement journey, focusing on measuring and monitoring for safety." Under the guidance of Dr. G. Ross Baker and Dr. Charles Vincent (Oxford University, UK), a comprehensive measurement program is being developed based on Vincent's framework for Measurement and Monitoring Safety. The framework specifies five elements required for safety measurement and monitoring past harm, reliability, sensitivity to operations, anticipating and preparedness, and integration and learning. The measurement platform will focus on guiding leaders, practitioners, patients, families and informal caregivers to find local and system level answers to how they can prevent harm, respond to harm and learn from harm through the application of the framework. "The beauty of the new framework is that it doesn't matter what your problem is," says Virginia Flintoft. "The framework teaches you how to find the solution to the problem; solutions that stick. It is very exciting as it will save teams time and help them to think bigger. It is learning about meaningful change that is clinically significant. Teams may see statistically significant change, but clinically significant change is really the crux of measurement." Improvement in the future will always include measurement and the CMT will continue to work with frontline staff on the wards, right up to Boards to help them monitor their performance. 8/4/2016 4:00:00 PM This is the second article in a two-part feature on measurement and the Central Measurement Team. Click here to view the first article,8/3/2016 3:56:42 PM227
Quarterly Update National Patient Safety Consortium294227/25/2016 8:21:02 PMPatient Safety News The 2014 – 2016 actions from the National Patient Safety Consortium are well underway, and overall 60% of all Consortium actions are complete, as of March 31, 2016 (see figure below). The Evaluation Action Team continues to meet to develop the evaluation plan for the National Patient Safety Consortium and Integrated Patient Safety Action Plan. The meetings are held monthly and co-chaired by Dr. Lianne Jeffs and the Canadian Patient Safety Institute. The Steering Committee also meets regularly with the next meeting scheduled for August. The National Patient Safety Consortium will meet face to face for the fourth time in September in Ottawa. ​ The National Patient Safety Consortium is thrilled with this progress and highlights two events below during the National Healthcare Leadership Conference in Ottawa from June 6-7 The Canadian Patient Safety Institute hosted a 90-minute panel presentation sharing the work of the National Patient Safety Consortium and the Integrated Patient Safety Action Plan. The session showcased key contributions from partners such as Health Quality Ontario and Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute). This was a chance for an in-depth dialogue with health care leaders about this large-scale, collective impact initiative. We were thrilled to have participants learn about this large scale change initiative. Helen Bevan also attended the session leading to fruitful discussions. The Canadian Patient Safety Institute, with support from Health Quality Ontario, sponsored motion "Public Reporting of the 15 Never Events" was selected as one of the top five motions of approximately 40 submissions for the Great Canadian Healthcare Debate by health leaders across Canada and was subsequently voted as one of the top three by the conference delegation. Never events are patient safety incidents that result in serious patient harm or death, and that can be prevented by using organizational checks and balances. The Never Events for Hospital Care in Canada report was prepared by the Canadian Patient Safety Institute and Health Quality Ontario along with the Atlantic Health Quality and Patient Safety Collaborative, British Columbia Patient Safety and Quality Council, Health Quality Council of Alberta, Manitoba Institute for Patient Safety, New Brunswick Health Council, Newfoundland and Labrador Provincial Safety and Quality Committee, and Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute) for the National Patient Safety Consortium. 8/3/2016 4:00:00 PMThe 2014 – 2016 actions from the National Patient Safety Consortium are well underway, and overall 60% of all Consortium actions are complete, as of8/4/2016 7:08:28 PM324
Quarterly Update Home Care Safety294357/26/2016 3:46:45 PMPatient Safety News Coaching of Wave One teams from the Home Care Falls Prevention Improvement Collaborative is ongoing. Insights from this work will inform Wave Two of the Collaborative. Evaluation of the Wave One Collaborative has started and is on track for a final report to be delivered in December 2016. The partner organizations (CHCA, CFHI and CPSI) met in April to debrief Wave One. Planning for Wave Two will include leveraging Team STEPPS® content where applicable to empower patients and families, as well as utilizing best practices in fall prevention as identified by ISMP Canada and RNAO. Members of the Home Care Safety Expert Faculty have expressed interest in supporting Wave Two and have identified areas of focus to build on. CPSI is working with the Canadian Home Care Association to find tools and resources to guide safety conversations between health care providers and patients when receiving home care services. The result of phase one of the work is the Am I Safe? report. Am I Safe? seeks to help healthcare providers, patients, and caregivers work together to evaluate and manage risk when receiving care at home. If you are aware of tools or resources that can help facilitate conversations about managing safety in the home please contact us at 8/3/2016 4:00:00 PMCoaching of Wave One teams from the Home Care Falls Prevention Improvement Collaborative is ongoing.  Insights from this work will inform Wave8/3/2016 9:42:50 PM271
Quarterly Update Infection Prevention and Control294367/26/2016 4:18:37 PMPatient Safety News ​Over the past year the Infection Prevention and Control (IPAC) Action Teams have made progress on three actions from the IPAC Action Plan conducting an environmental scan, the creation of a pan-Canadian set of case definitions for surveillance of healthcare associated infections, as well as improving infection prevention and control through the use of strategies known to improve behaviour and culture. Since the last update, CPSI has engaged an expert Intervention Lead to provide strategic direction and guidance to CPSI regarding the integration of behaviour change to existing and potentially new campaigns. Over the next year, the Intervention Lead will be working with CPSI on the recruitment and selection of the behaviour change and implementation science volunteer faculty. This newly minted faculty will lead the behaviour change work associated with the IPAC Integrated Action Plan. 8/3/2016 4:00:00 PMOver the past year the Infection Prevention and Control (IPAC) Action Teams have made progress on three actions from the IPAC Action Plan:8/3/2016 9:44:19 PM255
Quarterly Update Surgical Care Safety294377/26/2016 5:30:51 PMPatient Safety News ​Nine actions from the three-year Surgical Care Safety Action Plan have been started. As at the end of March 2016 three actions have been completed and six are continuing. Overall, at the end of the first year (2015-2016), the Surgical Care Safety Action Plan was 29% complete. Highlight The Canadian Medical Protective Association (CMPA), which provides medical liability protection for most Canadian physicians, and the Healthcare Insurance Reciprocal of Canada (HIROC), which provides liability insurance for healthcare organizations and their employees, collaborated to conduct a retrospective analysis of Canadian surgical safety incident data. This analysis of medico-legal data advances knowledge in patient safety concepts, and is intended to lead to system and practice improvements. The summary report and detailed analysis were released in April 2016. UpdatesAfter undertaking an environmental scan of existing surgical safety indicators, the Canadian Institute for Health Information struck a working group to identify a limited number of potential national surgical care safety indicators.The action seeking to identify new leading practices in surgical safety is moving steadily forward. The working group continues to gather information and has identified an advisory group.The action team working to identify patient engagement tools and resources for engagement of surgical patients and families is moving through the results of literature reviews.A survey of healthcare organizations will be issued to inform the work of two action teams patient and family engagement for surgical safety and prospective analysis for surgical safety.The forward momentum of the action team that will identify practices for communication and teamwork in surgical settings is underway with a white literature search.The surgical action that will identify and recommend evidence-based resources and toolkits for quality improvement education in surgical safety for policy makers, executives and clinical leaders is being combined with work being undertaken through the Patient Safety Education Action Plan The Surgical Care Safety Leads Group continues to support and contribute to the advancement of the Surgical Care Safety Action Plan. The members areArlene Kraft, Healthcare Insurance Reciprocal of CanadaBonnie McLeod, Operating Room Nurses Association of CanadaCarla Williams, Canadian Patient Safety InstituteCindy Hollister, Canada Health InfowayClaude Laflamme, Canadian Anesthesiologists SocietyDonna Davis, Patients for Patient Safety CanadaJennifer Rodgers, Canadian Patient Safety InstituteKapka Petrov, Patients for Patient Safety Canada Lorraine LeGrand Westfall, Canadian Medical Protective AssociationSandi Kossey, Canadian Patient Safety Institute 8/3/2016 4:00:00 PMNine actions from the three-year Surgical Care Safety Action Plan have been started. As at the end of March 2016 three actions have been completed8/3/2016 9:47:35 PM237
Medication Safety Quarterly Update294427/26/2016 5:10:19 PMPatient Safety News From the Medication Safety Action Plan, 58% of all actions in the plan have started with an average action completion of 44%. Progress continues to be steady with new actions set to begin this year. Since the last update, the white paper on medication incident reporting in Canada has been completed by co-leads ISMP Canada and CIHI. A summary of findings and recommendations from the white paper aimed to further advance sharing and learning from medication incidents will be posted soon. Following the launch of the 5 questions to ask about your medications list earlier this year, dissemination and communication of the tool has been ongoing and there has been significant interest and uptake of the tool across Canada. The list was translated into Polish, Portuguese, Spanish, Hungarian and Tibetan with translation into 11 other languages ongoing so that patients and families who speak these languages have a resource to help guide them to ensure they receive the information they need to take their medication safely. In addition, the list has been shared on Canada Health Infoway's Medication Management Community portal in response to a request for patient related medication safety materials from a colleague in France. An abstract on the list was submitted and has been accepted for presentation at the Canadian Home Care Association Homecare Summit in October. Over the next several months, action teams will continue to make progress on the completion of 2015/16 actions and starting new actions for 2016/17. 8/3/2016 4:00:00 PMFrom the Medication Safety Action Plan, 58% of all actions in the plan have started with an average action completion of 44%. Progress continues to8/3/2016 9:47:09 PM277
Quarterly Update Patient Safety Education294488/2/2016 4:33:48 PMPatient Safety News The Patient Safety Education (PSE) Leads group has been meeting since Oct 2015 to discuss and advance the priorities of the education action plan. In this time the group has begun to focus on how best to approach the actions that will provide the most impact and ultimately achieve our goals by 2018. Action Teams have completed one action and have begun to work on two additional actions from the 12 actions identified in the PSE Action Plan. The first to get started are actions under the theme of "quality and patient safety education for leaders". The Canadian College of Health Leaders and HealthCareCAN are the co-leads for this action item, and it is inclusive of a three part approach. First, it will aim to confirm partnership interests and establish a working group (completed), second, it will serve to identify resources in the system that should be profiled as key resources for building leadership capability in patient safety, and last, an action will focus on the knowledge translation element. Another action which is currently underway is aligned to the "patient safety and quality improvement curricula, content, design, and delivery" theme area. Three actions are tied to this theme with five co-lead organizations – including the Health Quality Council of Alberta, University of Calgary, Queen's University, SIM-one and the Canadian Medical Protective Association. These co-leads convened a first working group meeting to introduce a guiding framework that could be used to anchor Patient Safety and Quality Improvement curricula for educators. 8/3/2016 4:00:00 PMThe Patient Safety Education (PSE) Leads group has been meeting since Oct 2015 to discuss and advance the priorities of the education action8/3/2016 9:48:24 PM169
Have you SHIFTED to Safety yet?294468/2/2016 5:58:13 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Shift%20Logo.png?Width=140" width="140" style="BORDER&#58;0px solid;" /> SHIFT to Safety. It feels good to finally be able to say it out loud! For months, we've had to bite our tongues in order to keep the announcement of the Canadian Patient Safety Institute's latest program under wraps. The shroud of secrecy was finally lifted July 20 at The Ottawa Hospital when SHIFT to Safety was unveiled to the country. And what an unveiling it was! From the increase in web traffic (double what we see on a normal day) and the flurry of people watching the launch on Facebook Live, it's safe to say the Canadian healthcare community is pretty excited about the latest patient safety and quality improvement tools at their disposal. So they should be! is your new source for patient safety. Whether you're a member of the public, a healthcare provider, or a leader, we've got tools built to meet your specific needs. Furthermore, our mobile-friendly site means that you can access all of the content from anywhere and on any device. For us, the best part is that we're reaching out to the public like never before. We know patients and their families are vital members of the healthcare team and its time to treat them as such. The easily accessible materials available to them free of charge will allow patients and families to truly embrace that role. What's online right now, is just a sample of what's to come in the year ahead. We've got additional tools and resources in the works and we'll get them out to you as soon as they're ready! We know you appreciate the quality CPSI is known for and that it will be worth the wait. In the meantime, visit and browse around and let us know what you think! We want to provide you with the best, and your feedback will go a long way towards helping us hit that mark. As always, you can contact me directly at or connect with me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power, CEO Canadian Patient Safety Institute8/3/2016 6:00:00 AMSHIFT to Safety . It feels good to finally be able to say it out loud! For months, we've had to bite our tongues in order to keep the announcement8/2/2016 6:06:46 PM83
Measuring for safety: The evolving role of the Central Measurement Team294538/2/2016 5:51:40 PMPatient Safety News ​​This is the first article in a two-part feature on measurement and the Central Measurement Team. Click here​ to view the second article, Measurement a look back and a new approach. Measurement is the cornerstone of improvement. You can't manage what you don't measure. If you don't measure, you can't improve. That has been the mantra of the Central Measurement Team (CMT) since its inception, more than 10 years ago. According to Dr. G. Ross Baker, lead of the CMT, "Trying to improve without measurement is like trying to sail without a compass." Dr. Baker, along with the dynamic duo of Virginia Flintoft, Project Manager and Alex Titeu, Project Coordinator and Data Analyst has been an invaluable resource to frontline teams in measuring quality improvement initiatives. Based out of the University of Toronto, the CMT officially opened for business on March 1, 2006 and started to receive data for Safer Healthcare Now! interventions in June that year. Initially, there were six interventions with anywhere from two to 10 measures per intervention. A measurement tool was developed to make it easy to collect and submit data on the initial six interventions. In 2008, four more interventions were added and the work of the CMT has evolved ever since, adding new interventions and extending their work in both topic areas and across healthcare sectors. The Go-to Resource for Measurement ​Virginia Flintoft "Baseline data provides direction," says Flintoft. "Before you implement any change strategies, you need to know if you have a problem or opportunity for improvement. After we launched the measurement tool, we found that measurement was really falling into the lap of frontline staff," says Flintoft. "The frontline staff didn't have the time to do measurement and they didn't have the knowledge. The CMT was a port in the storm for these teams and we still are." The CMT has relieved a burden for the frontline staff charged with collecting and analyzing data for improvement initiatives. "Patient Safety Metrics was designed to have the teams put in their data and access the reports themselves, without interaction," says Titeu. "However, once the teams started calling us with technical and clinical questions, we formed a lasting relationship with them." ​Alex Titeu Users know that once their email is received, the CMT will get back to them promptly. The CMT has an unwritten policy that when users called, Virginia or Alex will get back to them within less than 24 hours. The relationships forged with the CMT are highly regarded and valued by its users. Kristen Parise of Saint Elizabeth Health Care says, "Virginia Flintoft is amazing. She is so easy to work with and is very practical and logical in her progression of questioning. She was so excited about the work we are doing and that helps from our perspective to stay focused on what we need to achieve. She is not that consultant who comes in and gives you all the answers. She wants to impart some of her vast knowledge on you so that at the end of the day, you are better at it the next time. I don't think we would not be as far along on our work with Falls incontinence without her guidance." Supporting National Audits To accelerate large scale improvement, the CMT developed quality audit forms for National Audit Months where data was collected for Venous Thromboembolism (VTE), Medication Reconciliation, Hand Hygiene, Falls Prevention and Surgical Site Infection interventions. Participating teams used these forms to collect data and once complete, faxed them to the CMT. Data was populated automatically into the Patient Safety Metrics system to expedite data collection and reporting. "The audits reduced the burden of measurement because they were at the patient level and there were multiple indicators collected for each patient in one fell swoop," says Flintoft. "Our users really loved to see how they were doing relative to other organizations, within their regions, with other provinces and across the country. It was competition is a real driver of performance." "In my mind, the SSI Audit is a nice, tidy parcel with a bow on it," says Samantha Steward, Infection Control Practitioner at the Whitehorse General Hospital. "You are provided with the audit tool to compare with national best practices, it is easy to use, and the data analysis is provided for you. It makes it very easy to get and use the information effectively. If I had to do all of the auditing, data collection, analyzing and reporting, an audit like this would not have been a feasible option." "The Safer Healthcare Now! SSI Audit provided a baseline granular view of where we have gaps in data collection and practice," says Wing-Si Luk, Director, Hospital Acquired Conditions Prevention & Management, University Health Network (UHN). "We did not have a robust ongoing mechanism to collect data on the status of practice related to surgical site infection prevention at UHN. The audit was really helpful in terms of providing a snapshot of what we are doing well and where we need to improve. It created a current state for us and an opportunity to compare our data with other healthcare organizations across Canada." The quality audit tool was also helpful in evaluating if the required steps of the MedRec process had been completed, helping to identify if staff are using more than one source to create the Best Possible Medication History (BPMH). "Using the Patient Safety Metrics tools and resources enable us to do sample audits, and get our audit results back very quickly," says John Glidden, Horizon Health Network. "Patient Safety Metrics allows us to provide real-time analysis and feedback which helps to keep the momentum going and the enthusiasm up." "The VTE audit tool available through Patient Safety Metrics is very straightforward and easy to use," says Chantal Bellerose, Quality Improvement Advisor and Accreditation Coordinator, Jewish General Hospital. "It includes all the relevant measures to audit and benchmark." Measuring and Monitoring for Safety With the launch of Shift to Safety, the CMT will no longer support a measurement database. The CMT has taken on more of an expert coach and mentor approach, helping teams to identify opportunities for improvement and supporting their improvement journey, with a focus on measuring and monitoring for safety. 8/2/2016 4:00:00 PM This is the first article in a two-part feature on measurement and the Central Measurement Team.  Click here to view the second article,8/3/2016 4:00:22 PM338