What about the patient’s perspective? Engaging patients and families in patient safety and incident management practices
Sharon Nettleton, former Senior Advisor, Health Outcomes (Calgary Health Region) and currently Co-Chair of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute) and Carolyn Hoffman, Senior Program Officer, Quality & Healthcare Improvement, Alberta Health Services reflect on the importance of patient and family engagement in advancing patient safety. Jack Davis, former President and CEO and Ward Flemons, former VP Patient Safety for the former Calgary Health Region also provide their perspectives.
Following a sentinel event in 2004, where two patients died as a result of a production error in the preparation of dialysate solutions containing potassium chloride instead of sodium chloride, the former Calgary Health Region (CHR) developed a Patient Safety Framework aimed at improving the safety of patient care by changing the culture of patent safety. The work involved consulting with world patient safety experts and leading practice organizations, frontline providers and leaders. Most importantly experiences, ideas and advice were gathered from patients and families.
“Patients and families told us about their safety experiences, about harm, and how they were treated by the organization afterwards,” says Sharon. “We really learned what we could do differently through the experiences of these very courageous individuals.”
“Some of the experiences were very troubling to us,” says Jack Davis. “The more we heard, the more we learned and reflected back on our policies and practices. We also understood that these experiences were not unique to the Calgary Health Region.”
The patient and family consultations used to develop the safety framework, policies and procedures were multi-factored - some were conducted in private settings, others in small groups. They included patients and families working on committees, working groups and councils that were already engaged in health-related teams.
The CHR formed a Patient/Family Safety Advisory Council in 2006 to help guide and further inform leaders, and frontline providers of areas where safety improvements could be made and to assist in education and implementation. The Council provided open and frank input and direction on the patient safety priorities and issues from a patient and family perspective. “The Council was very critical of our work - but in a constructive way,” says Ward. “They pointed out things we had missed in our design and processes from our biases as providers and managers - people working within the system. They helped us understand that were often using language that was provider-focused, terms that patients and families wouldn’t understand. They outlined important gaps in services that we had just plain missed. They suggested solutions, particularly around reporting, disclosing, and informing others about harm and patient safety issues. They had ideas about actions and ways to enable learning so that care could be safer for everyone. It wasn’t about blame it was what can we all do together. It quickly became apparent that patients and families were an important voice and essential collaborators in helping to improve care.”
During a public forum about patient safety, held in Calgary in the fall of 2006, many patients and families shared their experiences with the public, the media, health providers and leaders. The aim of the forum was to create greater awareness and transparency about patient safety issues. The forum was opened by the CEO and senior health leaders. It provided an opportunity for uncomfortable but important discussions about patient safety experiences from the patient perspective. Both the CEO and Board Chair spoke about their commitments to improving patient safety and expectations that this work involved everyone.
“The forum helped in setting the expectation that patient safety was extremely important,” says Jack. “It sent a strong message that open and transparent communication and collaboration was essential – that we needed to work together to make improvements.”
Since the formation of Alberta Health Services (AHS) in 2008, the work of the CHR, along with that of the other 11 formerly separate health entities in the province, has contributed to the development of a provincial patient safety and incident management system. In 2010, AHS formed a Patient and Family Advisory Group that is currently made up of 24 volunteer members from across the province, coming from various backgrounds and with varied experience. Their insight on organization-wide consultations brings the patient and family voice to bear on the development of strategic plans, major initiatives and policy development. Examples include consultation on an AHS Patient Safety Learning policy and procedures, as well as the AHS Patient First Strategy.
The AHS Patient First Strategy formalizes our commitment to quality patient experience, focusing on priorities that are important to patients and on building trust with patients and their families. Four themes guide the strategy: promote respect; enhance communications; support a team-based approach to care; and improve transitions in care.
“Continued engagement with all key stakeholders, especially patients and families, will strengthen patient safety and incident management practices from all perspectives across Alberta Health Services,” says Carolyn.