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CPSI Share                                                    
10/30/2015 2:00 AM

More than 500 sites and 1,000 viewers in five countries have tuned into Canada's Virtual Forum so far. Here's a recap of Day 2:


Helen Bevan from the NHS began the day by introducing five directions in transformational leadership in healthcare:

  1. Disruptive Change- change needs to happen more quickly.
  2. Digital Connection
  3. Healthcare work is becoming more complex
  4. Power of hierarchy is diminishing in healthcare organizations
  5. Change is moving to the edge- Research and innovation functions that are usually in the centre of an organization are now on the edge.

After explaining the approach to change between old power and new power, Helen concludes that change will happen more quickly in a new power world, where people are voluntarily connected through a shared purpose. "Be a rebel to inspire change."

Dr. Ward Flemons began his powerful presentation with Greg Price's story to segue into the topic of Patient Safety 101.

Dr. Ward proposes four big questions for patient safety and offers answers:

  • Why does healthcare break?
  • How do you make care safer?
  • How do you respond when healthcare breaks?
  • How do you create / promote a culture of safety?

Dr. Flemons says that healthcare providers need to be doing more. "Saying sorry is one thing but if you don't do anything to rectify the situation, you haven't done much at all."

He concludes with the powerful message "informed patients are safer patients."

Next up was a powerful panel driving home the message that adverse events don't only cause harm to patients and families, they have a dramatic and lasting impact on the care providers within our health system.  Often times the phenomenon of the second victim goes unnoticed causing dramatic personal and organizational consequences.  Dr. Katrina Hurley spoke about her experience with patient harm and the lasting impact this adverse event had on her personally and professionally.  Dr. Bruce MacLeod shared the journey that Alberta Health Services has undertaken to develop a framework to address this significant issue. Cheryl Connors, explained how to use the RISE Intervention (Resilience in Stressful Events -psychological support and emotional first aid) to support the recovery of healthcare workers suffering from second victim syndrome.

Our next presenter was Sabina Robin sharing her personal story of loss and learning from the death of her daughter in the health system. Sabin discusses the importance of patient and family involvement through the adverse event process, right from the time of an error, through to the disclosure and learning process. Sabina emphasizes the importance of accountability, transparency, and support when a health related error occurs. Sabina shares the lesson, that healing cannot occur and learning will not take place until patients, families and health providers work through adverse events together as partners.

We also heard three case studies focus on specific communication strategies implemented to improve patient safety and mitigate adverse events in medication management.

Debra Merrill outlined the experience of the Royal Victoria Regional Health Centre in using a variety of communication techniques to successfully implement a comprehensive medication management system. In communicating change,  it is imperative to answer three key questions: what's changing, what's staying the same and what's in it for me?

Lara Di Mambro explained how communication positively impacted patient safety during brand changes, backorders in medications or allocation changes at Huron Perth Healthcare Alliance. Communication strategies included the use of visual aids and electronic notifications.

Roberta Baker described how the Nova Scotia Health Authority implemented specific communication strategies to ensure alignment with Accreditation Canada medication focused required organizational practices (ROPs). The organization's four pronged approach in addressing high alert medication classifications is shared.

The next session was all about Nova Scotia. They recently underwent a significant change when the province brought nine health regions into one overall health region. This change impacted over 24,000 employees and meant a shift in how the delivery of care was provided. Throughout this time of significant change, Nova Scotia was able to sustain a consistent culture of safety and quality.

Tracey Barbrick outlined the collaborative process the ten authorities and the government undertook over the course of a year to action this change. Successes of the process included government commitment, landmark legislation focused on quality, co-leadership model, streamlined labour environment and an ability to plan as one province.

Catherine Gaulton identified that the focus in the early days of transition planning was to get the mission, vision, values (design principles) and the case for change clear. The importance of clear messages during times of change cannot be underestimated. In Nova Scotia those were "we cannot lose ground on patient safety and quality" and "don't stop doing anything you're doing for quality and patient safety."

Tara Sampalli spoke about keeping initiatives on innovation, quality and safety moving forward during the change process. The example of a clinical initiative which won a 3M quality award during this transition time exemplified the sustained focus on quality and safety.

Last up was Michel Tremblay delivering a French session on language barriers in healthcare and their impact on patient safety.