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CPSI Share                                              
4/26/2011 6:00 PM

​​This is the third article in a three-part series on how the Patient Safety Education Program – Canada  (PSEP – Canada) is helping to advance the patient safety culture at Bridgepoint Health in Toronto, Ontario.  Learn more from the participants and their work projects.

The PSEP – Canada train-the-trainer model is being used by Bridgepoint Health to revamp their approach to patient safety education. Using the PSEP – Canada framework, the Bridgepoint Health Patient Safety Education Program was developed to help participants learn about applying human factors in the workplace, scientific methods for improving safety, organizational culture and dealing with change, understanding teamwork, moving beyond blame to systems thinking, teaching others about patient safety, and implementing patient safety initiatives that will result in improvements. During the program, participants worked in teams to apply their learnings to a work-based project. Here are highlights of four of the projects and the impact the program has made in improving patient safety on the frontline.    

Addressing safety and quality issues

Respecting Bridgepoint’s no-restraint policy, one team looked at the use of transponders with patients experiencing changes in behaviour that include wandering or  being at risk of getting disoriented and lost. The team reviewed the literature, their current processes and policies, and reflected upon the characteristics of clients requiring a transponder. They then developed criteria to assess use of a transponder and validated why the restraint was required for the client. They came up with a decision tree/flow chart, case studies, an easy-to-remember mnemonic for staff to use, and training materials to provide guidance on what to look for when assessing the client and the things to do once the decision is made that a transponder is required. 

Richard Kellowan, an Occupational Therapist on the team says that the PSEP – Canada program has opened up an avenue to discuss things more freely with the frontline staff.  “It provides a structured platform to identify and address safety and quality, without the stigma associated with being a ‘whistleblower’,” says Kellowan.  “When reporting a risk or a problem, it is about being comfortable to speak up about it and engaging others to get their input.  The main thing is that it makes it easier to address issues of safety and quality without preconceptions and there is no blame with any of the issues.”

Learning from different perspectives

Patricia Ruiz-Skol, Patient Care Manager, found the Plan-Do-Study-Act (PDSA) cycle a practical and useful tool that provided concrete results and illustrated how it would impact behaviour.  Her team used the PDSA cycle to create a protocol and clear guidelines to follow on their unit when a patient requires a transponder.  An inter-professional approach provided knowledge and experience from different perspectives and she says they all learned from each other. 

“The program helped me to be more aware of patient safety and the importance of it and how everyone plays a role,” says Ruiz-Skol. “We are more organized, informed and aware so that we can always be vigilant and look for anything that may harm the patient so we can step in and correct it. To report near misses is a new way of thinking and this program reinforced that patient safety is a priority and not to be hesitant to report or identify issues that compromise patient safety.”

Effecting change for patient safety

In the fast-paced environment of the inpatient and outpatient neuro-rehab programs, the team focused on information that was important in terms of handover to outpatient services. Through interviews and a staff survey, they determined what information was frequently missing or undocumented on the referral form.  This project focused on whether the Ministry of Transportation (MTO) had been notified as to whether the patient’s condition could impact their ability to drive (in which case their driver’s license could be suspended). They found patients were sometimes driving to their appointments and the outpatient staff was unsure if a letter had been sent to the MTO, if their license had been suspended, what had been discussed while they were an inpatient, or even if it was safe for the patient to drive.

“We wanted to know what had been discussed on the unit so that we could better advise our patients for their safety and the safety of everyone on the road,” says Sandy Duncan, Occupational Therapist.

First they had to determine who was discussing what with patients and if the information placed on the record was difficult to find.  The process implemented now has the discussion taking place during the patient’s inpatient intake meeting, with their family and the full team present, and documented in a way that is very clear so that everyone knows that a letter has been sent to the MTO.  Unit Clerks and administrative support staff have been instructed where to file copies of the sent letter and the referral form has been updated, adding a box to check if the matter had not yet been discussed with the patient.

“The Bridgepoint Patient Safety Education program gave legitimacy to the changes we were making and having a program and tools behind the project really helped to push it forward,” says Duncan. “Often you feel you won’t be able to do anything that will result in change, but this program has changed the way I approach things.  I know I can effect change and it is important for the safety of the patient.”

Speak up! Patient safety is everyone’s role

As an Interprofessional Education Specialist, Elizabeth Hanna knows how incredibly valuable it is when people at different levels of the organization learn together.  She says that PSEP – Canada is a well-designed program where interaction was a priority and that it provided a good balance between didactic teaching, small group work and the work-based projects.

Elizabeth’s team focused on the transfer of information for clients with head injuries, to ensure that the Ministry of Transportation is appropriately notified. “There was confusion around the process with both staff and the patients,” says Hanna.  The group did a needs assessment and a survey before designing and implementing a tool, but recognized that they had to do more; they continue to do chart audits to ensure the new process is working.

“What resonated with me during this program is that it is as much about leadership as it is about patient safety and you need to speak up,” says Hanna.  “Do not think that it is someone else’s role to raise an issue, either small or large, about patient safety.  The program focuses on leadership, how you manage a project, involving your stakeholders and how you manage change.  These all go together and are important aspects to sustain change.”

Click here to link to the first article in the three-part series on how Bridgepoint Health has customized the Patient Safety Education Program – Canada to advance patient safety in their organization. To link to the second article in the three-part series which focuses on the perspectives of the participants and profiles of their work-based projects, click here.

For more information on the PSEP – Canada program offered by the Canadian Patient Safety Institute please click here.