Jennifer Quaglietta (Director, Patient Experience) and Quality and Renee Blomme (Manager Patient Experience & Corporate Risk)
North York General Hospital is the 2017 recipient of the Patient Safety Champion Award for organizations. Presented annually by the Canadian Patient Safety Institute, HealthCareCAN, and Patients for Patient Safety Canada, the Patient Safety Champion Award recognizes volunteers and organizations that are taking a leadership role in ensuring that patients and families are at the centre of patient safety initiatives. The prominent Award was presented at the National Health Leadership Conference in Vancouver, on June 12, 2017.
In September 2015, an Action Team from the National Patient Safety Consortium released the 15 "Never Events" for Hospital Care in Canada, based on adverse events that have been demonstrated to be reliably preventable. A never event is best described as patient safety incidents that result in serious patient harm or death, and can be prevented using organizational checks and balances.
North York General Hospital (NYGH) was quick to align its efforts to support the elimination or reduction of organizational never events, creating 15 Never Event Action Teams (NEATs) to lead the identification, measurement and documentation of strategies to mitigate and decrease the likelihood and severity of all 15 never events. In a phased roll-out strategy, beginning during Canadian Patient Safety Week in October 2016, and continuing until April 2018, each NEAT team is working on an action plan to identify, develop and implement innovative prevention and mitigation strategies for a prescribed never event. The progressive rollout strategy provides an opportunity to learn from each launch and make adjustments along the way.
One of the first initiatives out of the gate was an action plan for pressure injury prevention strategies. Consolidating work that had been underway since April 2015, this was an opportunity to implement a new approach to pressure injury prevention and care. Comprehensive in nature, the new care model was accompanied by the introduction of inter-professional staff education initiatives, targeted engagement of the patient and family in pressure injury prevention strategies, the adaptation of previously established risk assessment measures and processes, and the creation of an evidence-based, holistic pressure injury prevention plan. This work has been led by Anna Tupis, Director, Cancer Care and Ambulatory Care.
Quality Improvement initiatives associated with the new model of care delivery for pressure injury prevention include:
- A monthly Dashboard Report to facilitate the tracking of identified wounds.
- An education program, where 200 frontline nurses and 40 wound care champions have received in depth training in pressure injury prevention and care.
- A comprehensive bed surface survey facilitated the purchase of 286 new specialty bed surfaces.
- The launch of a health teaching pamphlet on pressure injuries for patients and families was developed in conjunction with the Patient & Family Advisory Council (PFAC).
- Corporate streamlining of wound care products to better facilitate the standardization of clinical wound care management.
"This pressure injury NEAT demonstrates how NYGH, through a quality lens, endeavours to keep our patients safe through an interdisciplinary approach to care," says Anna Tupis. In addition, work is now underway to pursue the development of a mattress selection algorithm, as well as engaging in a review of clinical electronic documentation forms. For more seamless transitions of care, the revised electronic documentation forms would allow for wound care summaries and care plans to be easily shared with community partners upon discharge.
"For our first never event, we wanted to choose one that was having the most impact on the patient experience," says Jennifer Quaglietta, Director, Patient Experience and Quality. "Looking at our incident reporting system and in collaboration with the PFAC, we had noted that hospital-acquired pressure injuries were a challenge that we were facing."
Stage III and IV pressure ulcers, or bed sores, can lead to serious complications, such as infections of the bone or blood (sepsis). NYGH has mandated the reporting of all incidents at stage III or IV pressure ulcers acquired after admission to hospital. Last year, double-digit incidents were recorded for pressure ulcers; however as the injury prevention strategies were implemented, no critical pressure ulcers have been reported since the first quarter of 2017.
"We wanted to handle this project in a way that would be sustainable. If we would have gone with all 15 NEAT projects in one go, I don't think we would have been able to manage it in a manner that would have been supportive to everyone involved," says Renee Blomme, Manager Patient Experience & Corporate Risk. "This is not a new process, it is something that our people are familiar with and builds on the work that teams have already done for our Enterprise Risk Management Program, where you look at a risk and identify strategies for prevention and mitigation."
A comprehensive governance structure has also been implemented. Each of the 15 NEATs is led by a program manager and a physician co-chairs the team. In addition, each NEAT is supported by a dedicated Patient and Family Advisor. The mandate of each team is to drive project completion, assess mitigation and prevention strategies, identify gaps and develop action plans to ensure that a protocol or standard of care is in place to prevent injuries or decrease the risk to patients. Jennifer Quaglietta, Renee Blomme and Katie Anawati act as the Secretariat for the project teams, to ensure the proper structure is in place and help the project teams to prepare reports that flow to the Steering Committee and Quality Committee of the Board. As quality and safety is a strategic priority of the organization, the program is managed under the leadership of Karyn Popovich, Vice President of Clinical Programs, Quality and Safety, and Chief Nursing Executive. Karyn acts as the key link between the work of the Steering Committee and the Senior Leadership Team (SLT) and Quality Committee of the Board. "We are committed to providing safe, quality care to our patients, and implementing NEATs builds a structure of accountability and proactive approach to patient safety," says Karyn Popovich.
All 15 NEAT leads sit on a NEAT Steering Committee that meets quarterly to discuss rollout plans, best practices and lessons learned. The NEAT Steering Committee provides updates to the NYGH Quality of Care Committee, who provides operational oversight for the quality, safety and risk of the organization. The Quality of Care Committee meets monthly to review progress, provide recommendations on issues and support various resolutions. The Quality of Care Committee, through Karyn Popovich, report up to the SLT, comprised of the CEO, all Vice-Presidents and the chair of the Medical Advisory Committee.
A Never Event dashboard tracks how many never events are occurring at NYGH on a quarterly basis. Once or twice a year, a report on never events is presented to the Quality Committee of the Board, which provides governing oversight of the quality, safety and risk of the organization.
"Patients come first in everything we do," says Jennifer Quaglietta. "To ensure the initiative remains grounded in patient experience, we have integrated Patient and Family Advisors at each level -- on each of the project teams, on the main Steering Committee and the Quality of Care Committee."
NYGH has shared their work with the Joint Centre for Transformative Healthcare Innovation, a consortium of six hospitals in the Greater Toronto area that provides an opportunity to learn from others, share best practices and spread a project's scale. They also hope to spread their work provincially, nationally and internationally by the end of the year.
"We are excited to receive this Award and the opportunity to really showcase the great work being done by the staff at North York General Hospital on a daily basis," says Katie Anawati, Patient Safety and Risk Specialist. "We have a wonderful inter-professional team and as a community hospital, we have taken a bottom-up, team approach to this initiative."
Congratulations, North York General Hospital! Your innovative approach to Never Events is truly inspiring.