At Fraser Health, on an average day you will see 42 babies born, 1,208 Emergency visits, 457 patient surgeries, 630 homecare nurse visits and 740 clients accessing mental health services at one of 12 acute care hospitals and community sites or 80 residential care facilities. There are 10,000 patient beds, 25,000 staff, 2,600 physicians and 8,000 volunteers across the region, located in British Columbia's lower mainland.
#SuperSHIFTERS Kevin Hare, Executive Director, Clinical Quality and Strategic Priorities and Nicole Quilty, Director, Clinical Quality and Patient Safety share how quality indicators are reducing harm to patients and improving quality outcomes at Fraser Health.
Tell us about your project.
Starting in 2015, we moved from reactive harm response to proactive harm prevention through the implementation of evidence-informed practices focused on six indicators that have driven our focus and culture change.
As an organization, we took the time to look at our measures and what was going on, and from there identified where the harm is. When the hospital restructured in 2014, under the leadership of a new CEO, we moved from a programmatic management to site-based leadership model. The Quality, Patient Safety and Strategic Priorities portfolio was tasked to create a quality structure, and develop an integrated quality management plan and patient safety plan, and link both to the operational plan.
As a first step, we did a comprehensive literature review, led by our Library Services team, and created a monster list of indicators. From there we looked at our internal data and external data from the Health ministry and the Canadian Institute for Health Information (CIHI), to create an overarching list of indicators to review -- we found a daunting list of 150 indicators. We then sifted through the quality indicators and distilled them down further to identify patient safety indicators. At the same time we were doing our work on the safety indicators, CIHI was in the finals stages of the Hospital Harm Indicators (HHI) development. When the hospital harm indicators were released we used these as a benchmark to validate our list of indicators.
We were very pleased to find that our safety indicators were aligned with the hospital harm indicators. This validated that both processes really had the right focus - preventing avoidable harm to patients in our system. This also strengthened our utilization of the hospital harm indicators as we saw that there was direct alignment to our system and these were not just random indicators selected by a third party organization. We identified 18 patient safety priorities and from there, the Executive selected six that we would work on for two years. We then created strategic and operational imperatives to prevent harm with the creation of organizational patient safety priorities.
The six patient safety priorities identified were: hand hygiene, Clostridium difficile (C.diff), sepsis, medication reconciliation, urinary tract infections, and pneumonia. Initially, we set a target of 50 per cent improvement in each of the priorities. All priorities must stay on the plan for a minimum of two years to ensure sustainability.
What issue did your harm prevention initiative address and why?
CIHI research confirmed that one in 18 patients in acute care experienced a harmful event while in Canadian acute care facilities. That was way too many and a compelling motivator to do something different. As a follow-up to our Accreditation Canada survey in 2015, we embarked on a process that formed the overall quality plan. The plan called for better alignment between the education and training provided to our staff and the patient safety priorities to positively impact patient safety.
How was the process used innovative?
It was a robust process that changed staff awareness. The Safety Starts with Me program gets staff to make a pledge around the six patient safety priorities. The campaign evolved and moved to a call to action associating the priorities with the specific actions that staff can engage in to prevent harm; and we provided tools and resources to help make it happen. We assigned staff leads to specific indicators to move them forward. We formed Planning Committees with representatives from professional practice, infection prevention and control, and a mix of supports from an organizational perspective. Patient and family representatives were also included on all of the Committees.
We implemented progress monitoring and shared results with the staff at the unit level. We held large quarterly update meetings and spoke about where we were at and the work in progress. Teams presented on the work they were doing at those meetings.
The indicator data was built into the report cards at an organization, site and unit level. We shared results every reporting period, encompassing 28 days. Some indicators were reported quarterly, based on the numbers. Report cards were distributed to the quality teams, regional patient safety/quality steering committee, Clinical Executive Committee, Board Quality Committee and to the Fraser Health Board. A key factor in progress monitoring was that we shared the data at the site level, with the frontline teams and through the quality governance structure. This allowed for the creation of quality plans that addressed what the data was telling us.
Statistically, over two years, all indicators have shown significant improvement. There was also a decrease in process variation, which led to improved patient safety.
What was one major learning or take-away?
The time we invested in planning prior to improvement implementation was invaluable. Through a thorough, rigorous and engaging process, we created greater commitment to the patient safety priorities from our staff.
Three key takeaways – first it is important to have your data experts in the room to help deconstruct the data. This helps to create insight and gives depth to the conversation. People have the space to have the discussions they need to have. Second, the work will pull you. From the get go, create a groundswell of people who would be interested. Find the individuals who have a unique passion for the work and leverage them. Third, don't be afraid to invite people you don't traditionally include into the planning and improvement process. You'll be amazed at the value they bring to the table.
Can others replicate and adopt what you have done?
If your organization values patient safety, then you too can do this! Invest the time, review your data/indicators and truly understand it. Most organizations have some structure in place that they can use to work through the process. The CIHI hospital harm indicator was our starting point to begin the conversation -- Are these indicators a problem for us? What does our data tell us? Narrow your indicators down and keep them focused on patient safety.
How can we get more information?
Kevin Hare, Executive Director, Clinical Quality and Strategic Priorities
Nicole Quilty, Director, Clinical Quality and Patient Safety
Watch the webinar on how Fraser Health is using the Hospital Harm Measure to help inform their quality and patient safety priorities and initiatives: Hospital Harm Measure: Can it really be used for Improvement?