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CPSI Share                                                  
6/14/2010 6:00 PM

​​Inside this Issue:

A reflection on Canada’s Forum on
Patient Safety and Quality Improvement


Photo caption: Canada’s Forum 2010 — (left to right) Top Row: Jim Easton, UK National Health Service; an engaged audience. Bottom row: Stephen Lewis, Moderator; Doug Cochrane, Canadian Patient Safety Institute Board Chair; Hugh MacLeod, CEO Canadian Patient Safety Institute; Keynote speaker Dr. Michael Leonard; and the Honourable Deb Matthews, Ontario Minister of Health and Long-term Care


Over 400 delegates attended the 2nd Canada’s Forum on Patient Safety and Quality Improvement, held in Toronto (ON) from April 12 to 14, 2010.  With five keynote speakers and 60 presentations provided in six streams during the concurrent sessions, delegates left the Forum energized and informed on patient safety and quality of care.

The Conference was opened by the Honourable Deb Matthews, the Ontario Minister of Health and Long-term Care, reinforcing the shared challenges to improve patient safety and how demography is an underused tool in the opportunity for change. Dr. William Jarvis provided insight on the challenges with healthcare-associated infections. In his inaugural address as the new CEO of the Canadian Patient Safety Institute, Hugh MacLeod outlined a vision for patient safety transformation. Presentations from Jim Easton (UK National Health Services) and Jason Leitch (Scotland National Health Service) provided an international perspective that resonated with the Forum delegates. Dr. Michael Leonard focused on how to engage people in patient safety. And, Rahaf Harfoush gave an insightful presentation on social media.

“The Forum provided the perfect blend between valuing and seeing the great things that are happening in Canada, but at the same time being exposed to different ways of thinking from an international perspective and it was that combination that delegates found useful,” says Christina Krause, Forum Co-Chair and Executive Director of the British Columbia Quality and Patient Safety Council. “The international presentations really resonated with the Forum delegates. They could see the connection, in that if we really improve safety and quality of care, it can lead to sustainability in the system. We are doing some great things on a local level and the Forum provided an opportunity to celebrate what is happening around the country, share information and learn from each other.”

"The quality of the speakers was the real highlight of the Forum and we were thrilled to have the insight from Jim Easton and Jason Leitch as to what is happening from an international perspective," says Marie Owen, Director of Operations at the Canadian Patient Safety Institute and Co-Chair of the Planning Committee for the Forum. "I think participants heard that message loud and clear that we need to focus on spread and went back to their organizations with this reinforced message of stepping up our efforts to really get to where we want to be in patient safety in Canada."

Canada’s first STOP! Clean Your Hands Day (held on May 5, 2010) was launched at the Forum, with remarks from Wendy Nicklin, President of Accreditation Canada and Anne Bialachowski, President of CHICA-Canada (partners with the Canadian Patient Safety Institute on this initiative), and Hugh MacLeod, CEO of the Canadian Patient Safety Institute inviting delegates to be part of this global challenge. This partnership reinforced that while hand hygiene is one of the simplest things to do and something everyone understands, system changes are required well beyond this one day event to affect real change. A special area was set up as the Hand Hygiene marketplace where delegates congregated to discuss their hand hygiene strategies and review materials from the STOP! Clean Your Hands challenge. The Ontario Hospital Association and Vancouver Coastal Health also shared the specific hand hygiene tools they use within their facilities at the marketplace.


Keynote Presentations

Audio recordings of these presentations are posted at


Re-framing Hospital Acquired Infections as a Patient Safety Issue: A Key Challenge

Keynote address: Dr. William Jarvis, Jason and Jarvis Associates

Dr. William Jarvis is well acknowledged as a world expert in infection control. He provided an overview of the challenges and strategies undertaken to control healthcare-associated infections (HAIs) in Canada and the United States.

In summary, Dr. Jarvis reinforced that: 

  • Healthcare-associated infections are frequent occurrences.
  • HAIs have a major adverse impact on patients and cause considerable morbidity, mortality and are costly.
  • HAI prevention/control programs are cost-effective.
  • Most HAI prevention interventions are low technology and not expensive.
  • Implementation of evidence-based HAI prevention interventions should be a high priority for all healthcare facilities.
  • Evidence-based (not politically based) recommendations should be implemented or consumers or legislators will mandate it.
  • HAI prevention is an essential patient safety issue.
  • Infection control, quality assurance, and administrative personnel should make zero tolerance of HAIs an institutional priority.


Healthcare Improvement in a Tough World

Keynote address:  Jim Easton, UK National Health Service

Leading the drive to achieve £15 billion (CDN $23 billion) efficiency savings while improving the quality of services for 51 million people in England, the National Health Service (NHS) has committed to tackle this financial challenge while doing things that are important to drive quality up.  Jim Easton, the National Director for Improvement and Efficiency, says this presents the opportunity to tackle problems that were put aside as un-attackable – things that are deeply counter-cultural and against the grain. To get more quality and redesign the system, the NHS asked two questions: what would you do? and, if you knew what to do, how would you do it? Here are highlights of what the NHS is doing to improve efficiency:

  • Care outside the hospital – to reduce the need for inpatient facilities they need to increase and manage conditions outside acute-care facilities.
  • Standardization is a safety issue – doctors need the ability to think creatively, but it is a balance not to provide too much variation in ad hoc care and equipment.
  • Technology – talking to a lot of people about using technology to drive change.
  • Saving time – people are busy – that is not the same as using time well.
  • Reducing clinical error – most expensive patients are the ones we harm the most.  Need to look at end-of-life care.
  • Reducing waste – it is the system itself that is wasteful.


The Canadian Patient Safety Institute into the next decade

Presentation by Hugh MacLeod, CEO – Canadian Patient Safety Institute

As the new Chief Executive Officer of the Canadian Patient Safety Institute, Hugh MacLeod touched on a number of areas in his inaugural address, “a call to action, a call for visionary and committed leadership.” Topics included: unpacking complexity, relationship patterns, power of a question, new conversations, patient rights, team, leadership, culture, truth not blame, transformation, accountability and responsibility, and a new future.

In summary, MacLeod noted, “we can create the safest healthcare system in the world – if we are prepared to change.”  MacLeod committed to bring innovation and creativity to the table and work in collaboration with those that are prepared to make a difference to advance the patient safety agenda.

If you would like to share how you are improving patient safety, please send an email to


“Never assume safety”

Keynote address: Dr. Michael Leonard, Pascal Metrics

The one lesson that Dr. Michael Leonard wanted delegates to learn from his keynote address was ‘never assume safety.’ These are highlights from Dr. Leonard’s 60-minute presentation on how to engage people in patient safety:

  • Leadership needs to be involved.  Define a goal, not what to do, but how to do it.  Treat everyone with respect; give them the tools and flexibility to do the job; acknowledge it.
  • Culture is key – make it safe to learn. Teach people – focus is not who did it, but how did it happen?
  • Teamwork and communication need to be consistent – make your message clear, simple, repetitive and non-redundant. 
  • Implement reliable processes of care – make it simple to do the right thing.
  • Learn to improve through continuous process improvement – if you can’t measure it, you can’t improve.  Ask three questions – What did we do well? What did we learn? What will we do differently next time?
  • Transparency of data – it is not what you measure, but what you do with the data. Look for patterns and be proactive on communicating how to improve. Publicly report your data.


Healthcare Quality Lessons from the best small country in the world

Keynote address:  Dr. Jason Leitch, Scotland National Health Service

In 2008, the Scottish Government initiated a five-year plan to reduce mortality across all acute care settings by 15 percent over five years; achieve a 30 per cent reduction in adverse events, as measured by a trigger tool; and build a quality improvement infrastructure across the country to change the culture in their hospitals. To build long-term sustainability, the NHS is focusing on five work streams:  critical care, wards, medicine, theatres and leadership; and using the fundamental elements of the Plan-Do-Study-Act (PDSA) Cycle to drive changes. After two years, the NHS is now committed to provide zero per cent preventable harm. Their goal is to make Scotland a world leader in the quality improvement and to do so in a way that is meaningful for all.

Dr. Jason Leitch outlined lessons learned in their effort to tackle patient safety country-wide and their aim to deliver safe and reliable care for every patient, every time:

  • Have a relentless focus on data and results.
  • Build capabilities very quickly. Use resources of existing infrastructure.
  • Rationalize measurement.  Don’t count every patient, use a random sampling.
  • All improvement is local where the patient meets the care.  That is where the change happens.
  • Build a guiding coalition in your context – get the mainstream to believe in this agenda.
  • Patient voice is critical – be very conscious of patient-centered aims and measures.
  • Enjoy it!


Yes We Did: Strategic Insights and Social Media from the Campaign that Changed History

Rahaf Harfoush, New Media Expert

Social media is a powerful instrument that is here to stay and will change the way we interact. Rahaf Harfoush, a member of President Barack Obama’s Social Media Team, gave an insightful and entertaining presentation at Canada’s Forum on how to apply some of the new social media tools that are emerging that can support an organization’s strategic objectives. She provided a basic overview of existing platforms and practical tips to identify and act upon opportunities to create great content.

To learn how to use social media to advance patient safety, Rahaf invited delegates to participate in a broader conversation and share their main strategic challenge - what is the biggest problem you are facing; and what is the biggest thing holding you back from using social media tools to address these problems.

“The more I learned about the work of your organization, the more grateful I am there are people out there ensuring our healthcare system is safe, says “Rahaf Harfoush. “I am very appreciative of your efforts.”

The questions received ranged from marketing to the logistics of planning a campaign. “My answers are only my impression from reading an email, so should be taken as a point of departure or a good way to think about moving forward,” says Rahaf. Ultimately, campaigns need a strategic approach that is aligned with the goals of the organization. Many factors come into play, including familiarity with the space, resources, timing and budget. Every initiative is going to look a little bit different; this is a reflection of the unique organizations that operate in this space.

Some overall tips to help you when planning your campaigns:

  1. Be very specific about your audience. If you know who they are, it is easy to identify WHERE they are on the web. This knowledge will be the foundation of your strategy.
  2. Have a clear plan with a start and end date.  Before you create the first piece of content, make sure the entire team understands when the campaign is going to end. This will help you set the pace of how often and when to post certain pieces of content. 
  3. Have a contingency plan in place.  Digital Media is fast-paced and your reactions need to be as well, especially when something unexpected pops up. You may not be able to predict everything that might happen (from offensive comments, to lack of response on a site) but having an agreed upon processes can help minimize reaction time and make or break a campaign.

The questions received and Rahaf’s responses are posted to the Canada's Forum section of the website under Presentation Downloads.  Clic​k here to download the responses directly.


Key lessons from Steven Lewis

Using his wit and wisdom, the moderator Steven Lewis, summarized key lessons learned from the Forum:

  • We know how to be safe, we just don’t know how to be safe everywhere. The challenge in this country is to find the way!
  • We can no longer delude ourselves that knowledge transfer or information availability is the problem.  It is not that hard to find good information and people are outstandingly generous in sharing information to speed things up.
  • Subtext of all presenters is that this is not going fast enough – we can’t get it right all of the time for some things. Canadians need to hear the quality improvement and patient safety message. We can’t let ourselves be complacent with the pace of change.
  • We need to talk about policies and mandates. Change is not impossible and we need to start demanding at the policy and mandate level, the things that must be done.  Change has been too slow.
  • Clinical autonomy without accountability is the enemy. Canada has history of people doing what they want, when they want regardless of information and plans.
  • Social media is here to stay. Emerge in the conversation and find a way to harness social media for the good of the public and patients.
  • Change via demography and technology will not come by so quickly. Use technology as a reactive but positive influence in making the world a better place.


Concurrent Sessions

Over the two-day Forum, 60 presentations were offered and delegates self-selected six sessions they would attend. The Concurrent Sessions were organized around six streams:

  1. Building Skills in Quality and Safety
  2. Infection Control and Prevention
  3. Medication Safety
  4. Partnering for Patient Safety
  5. Learning from Adverse Events
  6. Building a Culture of Quality and Safety

Copies of the presentations are posted at

Thank you to all who participated in and contributed to make Canada’s Forum on Patient Safety and Quality Improvement a success!