Inside this Issue:
A message from Hugh MacLeod
I have to say that I am impressed with the number of interventions happening in patient safety in Canada through Safer Healthcare Now!. As I said in the news release when I started in my Canadian Patient Safety Institute role I will get to witness and hear about brilliance. I will also get to hear about and see pockets of patient safety excellence in leadership delivered through passionate care providers who truly want to make a difference.
I will also see many areas that require continued transformation. The challenge ahead for all of us is to learn to lead, guide and coach others through a patient safety transformation process that goes beyond a system structural and program focus to one of individual behavior and organizational culture change.
From the book, Deep Change, “... Transformation requires more than the identification of the problem and a call to action. It requires looking beyond the scope of the problem and finding the actual source of trouble. The real problem is frequently located where we would least expect to find it – inside ourselves.”
Our current “mindset and behaviour circle” is our comfort zone. It is where we feel safe and secure HOWEVER, if we stay there too long, it is where we become; complacent about transformation, cynical about transformation, bored and unchallenged by transformation.
We know good things are happening and we need to be better at knowledge transfer to create a positive “ripple.”
As part of my orientation I want to hear from you and your organization how you have created behaviours and mindsets that have transformed patient safety in this country through Safer Healthcare Now! I plan on publishing these stories to share the ripple Safer Healthcare Now! is having.
Email me at firstname.lastname@example.org with the subject line “Celebrating You” and share your successes. These successes will assist in orientating me to where we are making advancements in our mandate to build a safer healthcare system.
I look forward to touching base at the Safer Healthcare Now! Pre-Conference in Toronto.
Hugh MacLeod, CEO
Canadian Patient Safety Institute
The Evolution of Safer Healthcare Now!
Celebrating five years and moving forward with vigour
Safer Healthcare Now! is the largest quality improvement and patient safety initiative ever undertaken in Canada, with almost 1150 teams from some 330 healthcare organization enrolled in one or more of 10 interventions to prevent adverse events. Today, more than 80 per cent of Canadian hospitals participate in Safer Healthcare Now!
When we asked Phil Hassen, former CEO of the Canadian Patient Safety Institute how Safer Healthcare Now! got its start he said, “at the outset no one knew who should do what, but we knew we had to do something.” The Canadian Adverse Events Study had been released in May 2004, estimating that 7.5 per cent of patients admitted to acute care hospitals in Canada had experienced one or more adverse events and 36.9 per cent of those were deemed to have been preventable. A group of patient safety leaders from Canada attended the Institute of Healthcare Improvement (IHI) Forum in December 2004, where the IHI launched its ‘100,000 Lives’ campaign with six interventions to target improvements in patient safety to prevent adverse events.
Once back in Canada, ,the group, including Ross Baker (University of Toronto), Peter Norton (University of Calgary) and Ward Flemons (Calgary Health Region), were joined by Phil Hassen and a number of people with an interest in patient safety, to talk about developing a Canadian campaign to promote improvements in patient safety. They would use the 100K Lives campaign as a model, tweaking the same six interventions with strategies to reflect Canadian content. On April 12, 2005, the group asked the Canadian Patient Safety Institute to launch Safer Healthcare Now! and in less than six months, 118 teams had signed up.
“We had an initial meeting of a number of individuals and organizations and from the outset there was a lot of interest,” says Phil Hassen. “The Canadian ICU Collaborative was already well-underway implementing evidence-based practices in critical care. Dr. Dean Sandham shared his expertise and the ICU Collaborative quickly came on board to lead those interventions. Other experts also wanted to get involved and everyone contributed, giving freely of their time, with a deep commitment to improve patient safety. Healthcare providers realized how important it was to do the right thing - they just needed help getting started and once they began to measure and see how well they were doing, they found it was the right thing do to for their patients.”
In April 2008, Phase II of Safer Healthcare Now! was launched with the addition of four new interventions to complement the original six. Teams continue to sign up to participate in the Safer Healthcare Now! interventions and apply what they learn into standard practice. To build on this momentum, there has been ongoing dialogue and consultation about the evolution of Safer Healthcare Now! as we move forward.
On Monday, April 12, 2010, Safer Healthcare Now! will celebrate its fifth year of improving patient safety in Canada. Teams will gather on that day in Toronto (Ontario) to celebrate this milestone and recognize those that have gone above and beyond in their achievements in the interventions. Teams will also learn about what’s new in Safer Healthcare Now! – watch for more detail in the May issue of this newsletter.
A Farewell tribute
Phil Hassen first became involved in and committed to Safer Healthcare Now! in 2005. Phil marked his last day with the Canadian Patient Safety Institute at the end of February and will transition into “retirement”, continuing in a leadership position as president of the International Society for Quality and Safety in Health Care (ISQua) and his work with The Canadian Network for International Surgery. Phil’s leadership and dedication are honoured by some of those who have had the opportunity to work with him:
I am one of the lucky ones at Safer Healthcare Now! having had the opportunity to get to know and learn from Phil Hassen over the past five years. It was clearly evident to me from early days in 2005 that Phil has many gifts including his ability to attract and surround himself with strong, talented people with great potential. I have watched as they grew and flourished under his leadership and as a result so too did the Canadian Patient Safety Institute and Safer Healthcare Now! We at the Central Measurement Team have benefitted from Phil's support, his vision, his ability to listen, stick to his guns or embrace other opinions. He has given us sage advice, and helped us celebrate our successes. He will be missed.
Virginia Flintoft, Central Measurement Team
It is a tribute to Phil Hassen that Safer Healthcare Now! and its success in Canada exist at all! Phil, along with Dr. Peter Norton and Dr. Ross Baker decided that Canada could and would be able to create a successful campaign and created a structure that enabled it to happen. No one knew more than Phil how complex it would be to take medication reconciliation beyond acute care. Even though implementation of medication reconciliation in long-term care was difficult, Phil knew that home care was a whole new ball game! More clients, more interfaces, less staff and reliance on the consumer. The great news is that Phil supported medication reconciliation in home care and now we have a model, are launching a kit and launching an e-learning series! Kudos to Phil for placing Canada in the forefront of medication reconciliation!
Marg Colquhoun, ISMP Canada
On behalf of the Atlantic Node Steering Committee and our 225 teams, a sincere thanks to Phil, for his Safer Healthcare Now! leadership over the past five years. Phil has been with us on the “Safer Healthcare Now! journey of discovery” from its inception and we have certainly learned lots from him. Leadership strengths that come to mind include, “constancy of purpose” and “sticking to the knitting”. Phil demonstrated that leadership is not about the achievement of individual results. Leadership is about one’s ability to effectively engage and influence followers and then set them free to align local and national patient safety imperatives to shape a preferred tomorrow. He has been successful on all counts. His support of Atlantic Province followers has challenged us collectively to stretch to new heights in inter-provincial collaboration, shared teaching and learning, strengthening the patient voice and standardization of patient safety evidence-based practices. We now know and appreciate the many ways to hardwire our systems for greater reliability in patient safety outcomes, across our islands, peninsulas, mountains, valleys and shorelines. We appreciate the difference between doing the right things and doing things right.
We anticipate that our paths will cross again from time to time and look forward to that. We also know that Phil will continue to do great things to further the patient safety field internationally as he takes on his next career challenge. We will be observing from afar as patient safety hearts and minds will always link, no matter what path our individual journeys take. In our eyes Phil Hassen is the “Patriarch of Safer Healthcare Now!” and its milestones and an energetic ambassador for strengthening the collective Atlantic voice at national patient safety tables. We cannot imagine having taken this amazing journey without Phil’s skilled leadership. Thanks so very much.
Theresa Fillatre, Safer Healthcare Now! Atlantic Node Leader/Atlantic Node Steering Committee
It’s been an exciting ride! I established an early connection with Phil Hassen when he was CEO of St. Joseph’s Health Centre in London, ON. “Over the years I have worked with Phil, his passion and commitment for quality and safety has never faltered.“During his time at St. Joseph’s, the Quality Healthcare Network (formerly The CQI Network) was fortunate to have Phil as our Chair. His energy in this role was endless, as was his interest in building leadership skills and capacity for improvement as we launched an innovative learning network in Ontario. It has been our pleasure to continue that relationship, in new capacities over the years - most recently in his role at the Canadian Patient Safety Institute and through his leadership in Safer Healthcare Now! On behalf of all of us in Ontario, our founding partners of QHN and our Members, we wish Phil the very best!
Cynthia Majewski, Executive Director of the Quality Healthcare Network (QHN) and Ontario Node Leader for Safer Healthcare Now!
The Western Node of Safer Healthcare Now! express their thanks and appreciation for Phil’s inspiration and vision for the evolution of Safer Healthcare Now! “The Western node staff has felt supported throughout the last five years and will miss Phil’s leadership as we move to our new iteration of Safer Healthcare Now! Phil listened to our challenges and consequently worked his magic at a strategic level. We look forward to crossing paths on the international patient safety journey!
Marlies van Dijk, Safer Healthcare Now! Western Node Leader
Phil Hassen is synonymous with patient safety in this country and internationally. Through his strong leadership and unwavering commitment, the Canadian Patient Safety Institute has raised the bar for safety in healthcare organizations across Canada.
Marie Owen, Director of Operations, Canadian Patient Safety Institute
Last Call! It’s not too late to Register!
Improving Safety across the Continuum
Canada’s Forum on Patient Safety and Quality Improvement 2010
Don’t miss this opportunity for thought-sharing, networking and celebration! Register now for Canada’s Forum on Patient Safety and Quality Improvement! The 2nd annual forum will take place from April 12 to 14, 2010 at the Westin Harbour Castle, Toronto (Ontario). Click on these links to access the Preliminary Program and Concurrent Session Guide.
Safer Healthcare Now!
Moving Forward with Vigour
Canada's Forum 2010 Pre-Conference Day
Join the one-day gathering of Safer Healthcare Now! teams on April 12th, for a pre-Conference workshop, held in conjunction with Canada’s Forum on Patient Safety and Quality Improvement. During this session we will provide you with tactics and strategies you need to boost your quality improvement efforts. This information-packed program highlights top speakers who will share best-practices in safer healthcare. Learn, network, brainstorm and get going on your quality improvement efforts by spending one-day dedicated to Safer Healthcare Now! Register today!
Click here to view the full program.
Safer Healthcare Now! Awards
Safer Healthcare Now! salutes two outstanding teams as recipients of the 2010 Safer Healthcare Now! Awards. These coveted awards set a benchmark for excellence in patient safety recognizing and celebrating the work of teams in implementing the Safer Healthcare Now! interventions. We recognize the tremendous strides these teams have made in making healthcare safer!
The Improving the Safety of Patient Care in Canada - Team Award sponsored by BD goes to Royal Jubilee Hospital – Vancouver Island Health Authority with their submission entitled “Medication Reconciliation – Implementation and Spread.” Congratulations go to Cynthia Turner and her team at Royal Jubilee Hospital.
The Healthcare Associated Infections Safer Healthcare Now! Award sponsored by Cardinal Health Canada goes to Eastern Health with their submission entitled “Safer Healthcare Now! and VAP.” Congratulations go to Sheena Leonard and her team at Eastern Health.
The Awards will be presented in Toronto (Ontario) on April 12, 2010, at Canada’s Forum Pre-Conference Day workshop. Our congratulations to Eastern Health and Vancouver Island Health Authority!
We thank all of the teams that took the time to submit their work for consideration. Without a doubt, there is a great deal of excellent work being done from all parts of Canada!
Ready, Set, Go! New Safer Healthcare Now! tools to get you started
Three new kits will be launched this month to help teams implement the Safer Healthcare Now! interventions:
The “New Approach to Controlling Superbugs” how-to guide will help your organization control healthcare-associated infections, using a behavioural change approach called positive deviance.
The Medication Reconciliation in Home Care provides a framework, processes and tools to support a formalized approach to medication reconciliation in the home care community. A webinar learning series is also being planned to help you get started!
The new Preventing Falls and Injuries from Falls Getting Started Kit provides information on how to reduce the incidence of falls across all sectors of the healthcare system. This Kit provides evidence-based strategies and tools to enhance patient safety in long-term care, acute care and home care.
STOP! Clean Your Hands Day
The Canadian Patient Safety Institute, Accreditation Canada and the Community and Hospital Infection Control Association-Canada (CHICA-Canada) invite you to participate in "STOP! Clean Your Hands Day"
The first ever, STOP! Clean Your Hands Day will take place on Wednesday, May 5, 2010. This national event will coincide with a global initiative of the World Health Organization, Save Lives, Clean Your Hands Day.
Register now to receive a package of tools and resources to assist you in promoting optimal hand hygiene practices in your organization. There are a number of opportunities available to get involved and results will be showcased and prizes awarded for participation:
- Hand Hygiene Observation: Auditing for Compliance - Organizations spend the day conducting hand hygiene observations in healthcare facilities. A variety of observation and surveillance tools will be available for use. Training in use of the Observation tool and analysis tool will take place in April.
- Peer to Peer Reviews - organizations seek out groups of healthcare workers interested in conducting peer reviews of hand hygiene practices.
- Patient and Family Engagement and Observation of Hand Hygiene Practices - a new Patient and Family Hand Hygiene Observation Card launched by the Canadian Patient Safety Institute can be used by any patient or family member to observe and report the hand hygiene activities of the individuals providing care. This postcard includes prepaid postage to the Canadian Patient Safety Institute and results will be reported back to the participating organizations. A new Patient and Family Guide will also be available. Click here for a copy of the new Patient Family Hand Hygiene Guide.
- Hand Hygiene Education Module for Healthcare Workers and Volunteers - healthcare workers and/or volunteers across the country can log into the Canadian Patient Safety Institute’s Discovery Campus Hand Hygiene Training Module to complete online training and receive a certificate of completion. Organizations are encouraged to register as many staff and volunteers as possible to complete the training.
Created in 2007, Canada’s Hand Hygiene campaign has been revised and updated to reflect latest research and leading practise. To support organizations in their efforts to improve hand hygiene practices among providers, a human factors toolkit has been developed and will be launched with the entire resource kit as ‘Canada’s Hand Hygiene Challenge’ and the "STOP! Clean Your Hands" website will be re-launched with a new look, renewed emphasis, new tools, information, and strategies.
Visit www.handhygiene.ca for more information on how you can participate and enrol in Canada’s Stop! Clean Your Hands Day.
Improving Acute Myocardial Infarction care:
Virtual Learning Collaborative
Safer Healthcare Now! in partnership with the Canadian Patient Safety Institute invites you to participate in an Acute Myocardial Infarction (AMI) Virtual Learning Collaborative- Time is Myocardium, designed to improve the timely administration of Thrombolytic agents.
Over the past year Safer Healthcare Now! teams have reported that between 44 and 70 per cent, or an average of 62 per cent of AMI patients who received thrombolytics had this myocardium-saving treatment delivered within 30 minutes of hospital arrival. For safer care, we need to improve the timely administration of thrombolytic agents!
Participants will attend four learning sessions and a closing congress scheduled over the course of the year, beginning in June 2010 and ending in February 2011. The learning sessions and team calls will be held using WebEx technology. Registration opens on May 17, 2010.
Shouting from the rooftops improves AMI care in Cape Breton
The Cape Breton Regional Hospital had to improve care for acute myocardial infarction (AMI) patients. To meet national standards, anyone presenting to Emergency with cardiac pain needs an ECG completed within 10 minutes of arrival and if required, thrombolytic within 30 minutes of arrival. In 2007, data for the hospital showed that 39 percent of ECGs were completed within 10 minutes and 75 per cent received a thrombolytic within 30 minutes. Their goal was to achieve 90 per cent in both measures by March 2010.
A team of 10 gathered to work collaboratively on this initiative. The team included a lead physician, the Emergency manager, two Emergency nurses, a cardiology manager and technologist, representatives from cardiac care and cardiology, the patient safety manager and a data analyst. Ad hoc members are added as required.
The team determined that a reliable work process was needed to maximize the timeliness of response for patients requiring an ECG and thrombolytic. It would be the responsibility of a dedicated person within Emergency to call to have an ECG completed and to clearly identify the location of the patient for the cardiology technologist. A data collection sheet was designed to collect concurrent data to measure their results.
The team learned that ensuring work is planned with clear deliverables and dates, and that everyone on the team participates in the planning and agrees on the results were factors that contributed to their success.
Improving communication within the team was also critical. “To build and maintain the momentum to implement these strategies, you must over-communicate,” says Anne Buchanan, co-lead of the Cape Breton Regional Hospital AMI Collaborative. “The vision and strategies need to be communicated to every level of the organization to maintain focus and to keep everyone working with energy and enthusiasm toward the goal.”
“Recognition is also important,” adds Anne. “Small steps are better than big ones by far. When your team makes small measurable headway, shout it from the rooftops and make your team know that their small efforts are recognized, as well as the large ones.”
Tuesday, May 18, 2010 – 12:00 EST - MedRec Ideas That Spread: MedRec Implementation Across a Region. Guest Speakers: Christine Foote, Safer Healthcare Now! Coordinator, Corporate Improvement - Central Health and Julie Johnson, Director, Quality Improvement - Regina Qu’Appelle Health Region