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5/23/2018 6:00 PM

As Executive Director of the Canadian Mental Health Association's Kenora, Ontario branch, Sara Dias has incorporated a framework where checks and balances are in place to report harmful incidents and to ensure the appropriate follow-up is completed. Patient safety incidents in a community health setting are very different from the acute care sector. #SuperSHIFTer Sara Dias and her team work hard to consider all potential client risks in the eyes of community mental health.


Can you tell me about your work in patient safety and community mental health?

Our journey around patient safety first began in conjunction with the accreditation process, where client safety was one of the domains and a strategic direction for the Canadian Mental Health Association's Kenora Branch. When I took over as the administrator for the Kenora branch in 2014, we continued that focus, but in a different capacity. Client safety needed to be embedded at all levels of the organization, starting with governance right through to the client. I wanted to ensure that everyone was talking the same language; that they felt comfortable around disclosure of client safety incidents in community mental health; and that the culture was embedded into the day-to-day activities that we do.

We developed a Client Safety Committee to look at a cross-representation of programs that would help us have a meaningful conversation on client safety incidents. We did not want to just go through the motions of here is an incident; this is what we did to follow-up; and move on.

Everyone comes with a different lens when examining client safety incidents. We have a variety of individuals who sit on the Client Safety Committee and bring a lot of interesting perspectives through their conversations. What we needed was a tool to guide us, so that we could learn where to take the conversation in order to have an informed dialogue. We wanted to change the culture to ensure that our people understood that client safety is an organizational priority, as well as a requirement of the day-to-day activities that they do with clients.

We looked at a number of tools and liked what we saw in the Patient Safety Education Program – Canada (PSEP – Canada). We have since adopted the patient safety incident management process and Incident Decision Tree that is part of that training. We have committed to have one person a year complete the PSEP – Canada program; I completed the training first, followed by the Client Safety Committee Chair. Last year, we trained one of our clinicians. We are a small organization, and it is very costly to provide training across the entire organization, so we commit to training one person annually going forward.

How has this process addressed client safety?

The Incident Decision Tree is a very interesting tool to help walk us through our incidents. At every Client Safety Committee meeting, an incident is identified, the action steps are discussed, and there is open dialogue as to whether the Committee feels all action steps address the incident. The Incident Decision Tree is then used to walk us through whether the incident was a result of staff or the client in terms of the processes in place, or a larger system issue that needs to be addressed by the administration or the Board. This approach has resulted in us thinking at a more systemic level.

The methodology that we have implemented allows full organizational input; it is a holistic approach to incident management across the organization, with clients and families at the centre of the process.  An incident report analysis form is completed when an incident occurs, the Executive Director or team lead automatically reviews the process, and starts identifying action steps. The Client Safety Committee then meets to do a risk severity assessment using our risk management framework that assesses the probability of the problem continuing, the impact on the client for seriousness, and the recommended action to reduce the risk or system issue. Quality Improvement does an audit every quarter to ensure that all of the follow-up recommendations are completed. All incident reports are compiled monthly for the Board of Directors. For anything that is identified as a harmful incident, a disclosure process is in place to discuss the incident with the client or their supporting network to help mitigate any similar incidents from happening.

Each year, the Quality Improvement Coordinator identifies the top three trends in client incidents and our Client Safety Committee embarks on a quality improvement initiative.

How is this work innovative?

The built-in, continuous evaluation is the biggest innovation and a critical piece of this process. The incident is not just written up and dealt with by administration. We have checks and balances in place to ensure that the action steps taken have actually mitigated the potential risk. We also look at gaps in the system and move those issues forward either locally or provincially. 

As well, it is building a just culture within the organization. Taking what we have learned and having staff learn from the incident that was reported help to ensure that we can learn from these errors.

Are there any major takeaways that you can share?

As an administrator, when I took the PSEP – Canada training, everything seemed to work in my mind. However, we are now questioning if the Incident Decision tree is the right tool for a community health organization. We are reaching out to the Canadian Patient Safety Institute to have that conversation and to determine what tools other community mental health organizations are using. We will see where that conversation takes us.

Currently, everything is paper-based. We are looking at streamlining the incident reporting process and the potential of developing an online dashboard.

Is what you have implemented replicable?

Yes. We have had a lot of calls from other Canadian Mental Health Association branches and we have done a number of presentations on how this works. The feedback we have heard is that they like the structure, accountability, and checks and balances embedded into the process. They like that there are other groups internally looking at the work and providing information around the analysis. 

PSEP – Canada was the foundation for this work. Without that foundation, we would not have been able to create something so robust. In addition to the framework adopted for incident analysis, on an annual basis we share a module from the PSEP – Canada training with our staff. It is helping to build an organizational foundation around client safety.

Who can we contact to learn more?

Contact Sara Dias at sdias@cmhak.on.ca
@CMHAKenora
For more information on PSEP – Canada, email psepcanada@cpsi-icsp.ca or call 1-866-421-6933.