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CPSI Share                                                  
11/15/2012 5:00 PM

An integrated plan to Learn-Act-Communicate-Improve

The Capital District Health Authority (CDHA) has developed a Patient Safety Plan, "Patients First – Learn-Act-Communicate-Improve", to promote a patient safety and quality improvement culture within the health authority in Nova Scotia

“With a strong commitment of the board and the Quality and Patient Safety Committee of the board, the Patient Safety Plan was developed with a focus on what the patient’s voice brings to quality and patient safety,” says Catherine Gaulton, Vice-President Performance Excellence and General Counsel. “Our commitment to quality and patient safety is the cornerstone of all strategies and priorities developed for patients and others that we serve, including families and the community.”

About 18-months ago, the Quality and Patient Safety Committee of the CDHA Board led a strategic initiative to look at what constituted good governance in terms of quality and patient safety, using the Canadian Patient Safety Institute Effective Governance for Quality and Patient Safety Toolkit as their guide. The board’s commitment to quality and patient safety was formalized with a list of recommendations and a “to do” list to ensure all obligations would be met. The committee now provides diligent oversight and the board dedicates at least 25 per cent of their monthly agenda to quality and patient safety, regardless if an issue is present at the time.

The guiding principles and philosophy of patient safety at CDHA are first organized following the six domains of the Canadian Patient Safety Institute Safety Competencies framework. The competencies are then overlaid on each of the Accreditation Canada Required Organizational Practices (ROPs) and both are further mapped to the Canadian Medical Protective Association “Good Practices Guide” to create a Practices Map.

“Our board is committed to fulfilling its mission, vision and values in a strategic, goal-oriented and measurable way,” says Dr. Daniel O’Brien, CDHA Board Chair. “Improvement in quality and patient safety are at the forefront of our work and, in our view, are simply non-negotiable. The Patient Safety Plan incorporates and aligns the Canadian Patient Safety Institute’s safety competencies, Accreditation Canada's required and respected parameters and our own strategies complete with their evaluation and accountability mechanisms. This plan overwhelmingly supports our work as governors and our full commitment to improving quality and patient safety.”

Gail Blackmore, Director, Performance Excellence Program at CDHA and her team, Beth Kiley and Kitty Grant (Risk Management and Patient Safety Leaders in Performance Excellence) are responsible for linking education, accreditation and physician engagement into the performance excellence framework. Mapping these levers together shows how each drives quality improvement and patient safety practices for better, more effective planning and without duplication of effort.

“The Patient Safety Plan links expectations, resources and education,” says Gail Blackmore. “It is a live document that we update regularly and use to continually track our progress. This truly is a team effort and the integrated approach reinforces that patient safety is a shared responsibility that requires a commitment from everyone in the organization.”

The CDHA has established quality and patient safety teams that meet regularly and report back to a district Quality and Patient Safety Council and a Physician District Advisory Quality Committee.  Much work is underway to engage with patients in patient safety and bring the patient’s voice to the table. Using a three-prong approach to foster meaningful engagement of patients and families, the CDHA is providing education sessions for quality leaders on how to engage patients, developing recruitment strategies for meaningful participation, and providing education and support for patients and families participating as Healthcare Experience Advisors.    

The CDHA Patient Safety Plan supports patient safety and reduces risk to patients by creating and sustaining a safe environment that ensures the recognition and acknowledgement of risks to patient safety; initiation of actions to reduce these patient safety issues and risk; internal reporting of patient safety issues and corrective actions taken; a focus on processes and systems; organizational learning about patient safety; and supporting and sharing knowledge about patient safety within CDHA and other healthcare organizations.

The CDHA Patient Safety Plan is available at  For further information, contact Gail Blackmore at