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Canadian Patient Safety Institute

Safe care....accepting no less​

The Canadian Patient Safety Institute (CPSI) has over 10-years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum.​

SHIFT to Safety

Improving patient care safety and quality in Canada requires everyone’s involvement—SHIFT to Safety gives you the tools and resources you need to keep patients safe, whether you are a member of the public, a provider, or a leader.

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Our Programs​

 CPSI Latest News



Canadian Red Cross shares key learnings from the Home Care Safety Falls Collaborative23613Patient Safety News In late 2015, the Canadian Patient Safety Institute, the Canadian Home Care Association and the Canadian Foundation for Healthcare Improvement launched the Home Care Safety Falls Collaborative. Organizations providing care in the home participated in a series of online virtual meetings and received individualized coaching and support to prevent falls in the home. Teams from the Canadian Red Cross, Eastern Health, Saint Elizabeth Health Care, VHA Home HealthCare and the Winnipeg Regional Health Authority participated in the six-month Collaborative. In this article, The Canadian Red Cross shares their key learnings from the Collaborative. The Canadian Red Cross (Ontario Community Health & Wellness programs) used a two-prong approach in setting the goals they wanted to achieve as it relates to the Home Care Safety Falls Collaborative. One of their measures focused on a specific targeted client population at high risk for falls and the other was to develop a service planning tool related to the outcome of the InterRAI Community Health Assessment (CHA), which is a standardized tool that is a mandated requirement of all Ontario community support service programs. "The Service Planning Tool helps frontline workers to identify action items that engage both the client and the caregiver in the care process, and promotes the understanding that clients and/or their caregivers have a responsibility to be actively involved in their care," says Jody Hales, Director of Quality Assurance & Risk, Canadian Red Cross Community Health & Wellness programs. "It is not just about providing a service; the client and/or their caregiver need to be engaged, and take on a role of responsibility as it relates to their own well-being." In developing and evaluating the Service Planning Tool, one of the key findings was that many caregivers are a family member or significant other of the client, who work outside of the home and therefore are most often not present for the client's assessment (assessments are done during the regular work day, most often when the caregiver is working). "That was quite a finding for us," says Hales. "Even though we are a 24/7 service, our supervisors work nine to five, Monday to Friday and are on-call for emergencies, we don't plan after-hour home visits and we may need to consider that. We need to understand our client population; you can't put everyone into one basket." This pilot project was affiliated with the Canadian Red Cross assisted living and attendant care programs in Cornwall, Ontario focusing on the use of the InterRAI Community Health Assessment (CHA) tool. This involved using the electronic validated assessment tool (as mandated in Ontario), where information is auto-populated into clinical assessment protocols (CAPs), which help identify specific risks to each individual client, which in turn, informs the care planning process. "One of our key findings was with connectivity issues at the point of care, being in the client's home – connectivity was very sporadic," says Hales. "This led to the completion of a provincial survey which identified that connectivity was a huge challenge across the province, not only in outlying areas, but in apartment buildings, basements suites and other geographic areas. Before you employ anything electronically, you really need to conduct foundational work to determine its feasibility and identify what effect it will have on both the provider and the end user." The connectivity issues resulted in the Canadian Red Cross supervisors and care coordinators having to print off the forms and manually completing them during the assessment at the point-of-care, then returning to the office and entering the data electronically (where there was good connectivity) which in turn would then auto-populate the risks for each specific client – clinical assessment protocols (CAPs). The supervisors and care coordinators would then travel back to the client's home to discuss the identified risks to inform the care planning process, in collaboration with the client. It is a huge, time-intensive process that requires duplicate effort resulting in additional workload. The Canadian Red Cross is now looking at options to address the identified connectivity challenges. Another key learning was related to client engagement. Understanding what is important to the client, rather than relying on worker perception. The Canadian Red Cross had a client representative join their Falls Collaborative team. "Our client representative was invaluable," says Hales. "She reviewed existing support documents and provided open and honest feedback. What was really interesting and important was to be cognizant of the level of information that we are providing. It is critical to understand our audience when delivering information. We must make it relevant and understandable for our clients and caregivers. We need to identify what is most important to our end user - our clients and focus on that." Jody Hales explains that they don't service just one client population. "As a service provider, it is vital that we understand the unique needs of all our client populations and although it is predominantly the senior, frail population that most often uses our services, we also have an attendant care population -servicing adults with physical disabilities." "Our quality improvement work is a continuous process," says Hales. "You can't just develop something and leave it. You need to engage clients, their caregivers and our frontline staff – those that are using the tools to ensure they continue to be relevant and responsive to the needs of our client population(s). We recognize that clients and their caregivers are critical partners in their plan of care. As we move forward with our client/caregiver engagement journey, our commitment is to creating the best possible client experience in partnership with our clients, families and the broader community." ​30/08/2016 4:00:00 PMIn late 2015, the Canadian Patient Safety Institute, the Canadian Home Care Association and the Canadian Foundation for Healthcare Improvement30/08/2016 3:40:51 PM
PSEP – Canada to help St. Michael’s build patient safety capacity23618Patient Safety News St. Michael's Hospital in downtown Toronto has embarked upon a renewed patient safety program to embed safety into the forefront of everything they do. Policies have been revamped and new tools, roles and supports have been created around the elements of a strong safety culture. "St. Michael's has been committed to patient safety in a fulsome way since 2004," says Dr. Chris Hayes, Medical Director, Quality and Performance. "We have now reached a point where we want to take patient safety to the next level and we are investing more in it as the science improves. It is a corporate commitment to advance our approach to patient safety in our journey to being a highly safe organization." St. Michael's already has a program in place that trains people in quality improvement skills; and now they are embarking on the same capacity building for patient safety by using the Patient Safety Education Program – Canada (PSEP – Canada) as the catapult. As a trained Master Facilitator for PSEP – Canada, Dr. Hayes knows how the PSEP – Canada program can help St. Michael's build that capacity. Rather than using the traditional approach where a few individuals are selected to take the PSEP – Canada training and bring their new knowledge and skills back to their organization, St. Michael's is bringing a PSEP – Canada workshop to their home front, training 30 people from their organization at the same time. They have strategically partnered with their corporate education portfolio to train individuals as patient safety educators, providing patient safety knowledge and pedagogical approaches so that they can be patient safety champions at the unit level. "The difference with bringing the program in-house is that we can apply the PSEP – Canada training into our contextual framework and align it with our messaging and corporate priorities," says Dr. Hayes. "The role of our educators is to translate knowledge and skills to the clinical units. We are augmenting our clinical educators with patient safety content so that they can embed it into what they already do. They will now have the language, the nomenclature and the capabilities to more easily translate patient safety examples and science, and human factors with confidence." St. Michael's worked with the PSEP – Canada team to choose the modules that are aligned with the hospital's strategic plan and patient safety program. A two-day PSEP – Canada workshop will be delivered at the hospital on September 20 to 21, 2016. Master Facilitators have been secured, patient representatives have signed up, the room is booked and they are ready to learn. "At the conclusion of the PSEP – Canada "Become a Patient Safety Trainer" workshop, we will have immediately created a large network of patient safety educators in our own building that we can connect with, and we will work with them to share the PSEP – Canada content hospital-wide," adds Dr. Hayes. "We are really excited about this big step in capacity building all at once." ​30/08/2016 4:00:00 PMSt. Michael's Hospital in downtown Toronto has embarked upon a renewed patient safety program to embed safety into the forefront of everything they30/08/2016 4:01:50 PM
RESEARCH VOLUNTEERS NEEDED!23548Patient 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?  23/08/2016 2:26:07 PM235
Measurement: a look back and a new approach374Patient 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. 04/08/2016 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,03/08/2016 3:56:42 PM240
Quarterly Update National Patient Safety Consortium29422Patient 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. 03/08/2016 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 of04/08/2016 7:08:28 PM334

 Upcoming Events



Nominations deadline: 2016 Champion Awards4693 12:00:00 AM01/09/2016 11:59:00 PMHealthCareCAN and the Canadian Patient Safety Institute (CPSI) 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 demonstrated exemplary leadership and collaboration to champion change and achieved safer care through patient/family engagement. 22/06/2016 5:47:26 PM38 Event
World Sepsis Day29465 6:00:00 AM14/09/2016 5:00:00 AMWorld Sepsis Day is a concept developed by The Global Sepsis Alliance ; a collaborative effort of organizations and individuals wanting to increase awareness regarding Sepsis and its treatment.10/08/2016 9:02:20 PM27
Become a Patient Safety Trainer Conference [Winnipeg, MB] 4673Winnipeg, MB 12:00:00 AM15/09/2016 11:59:00 PMThe Manitoba Institute for Patient Safety (MIPS) with support of the Canadian Patient Safety Institute (CPSI) is excited to offer the "Become a Patient Safety Trainer" education conference for both healthcare faculty and clinical teams from healthcare organizations. 13/04/2016 5:53:37 PM42;Workshop
Early Bird Deadline: Become a Patient Safety Trainer Conference [Sioux Lookout, ON] 4691 12:00:00 AM14/09/2016 11:59:00 PMThe Canadian Patient Safety Institute (CPSI) in collaboration with the Sioux Lookout Meno Ya Win Health Centre, the Northern Ontario School of Medicine (NOSM), and the Ontario Hospital Association (OHA) are pleased to announce that the Become a Patient Safety Trainer conference, a high impact, 2-day comprehensive patient safety education program will be offered in Sioux Lookout, Ontario.13/06/2016 3:43:00 PM26;Conference
Patient engagement in medication safety at the point of care – roles, responsibilities 7917Webex 2:00:00 PM15/09/2016 3:00:00 PMDesigned by patient/family champions for champions this interactive webinar is offered by the World Health Organization Patients for Patient Safety Programme in partnership with Patients for Patient Safety Canada.29/08/2016 4:45:07 PM3