​​Alberta’s roadmap to an integrated provincial patient safety and incident management system

Alberta Health Services (AHS) has developed a robust approach to patient safety and incident management that is built on collaboration and engagement with patients and families, and health providers. The approach includes monitoring, measuring and evaluating performance that is aligned with patient outcomes and experiences.

This summary was prepared with valuable input from Carolyn Hoffman, Senior Program Officer, Quality & Healthcare Improvement, Alberta Health Services and 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). Carolyn and Sharon reflect on the development of a patient safety and incident management system that is still being advanced and improved in Alberta.

Prior to the formation of AHS in 2008, the province’s nine health regions, and three other separate health entities, were developing their own approach to improving patient safety, including enhancing a process for appropriately managing incidents. For the former Calgary Health Region (CHR), it was 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 that provided a platform for leadership to focus attention on the safety of patient care.

Beginning at the leadership level with a commitment from the Board of Directors and CEO, the CHR began a journey to improve the safety of patient care and develop a culture of patient safety. The commitment focused on a new organizational structure, leadership and accountability, and resources and infrastructure. It included a culture of reporting, disclosure, and informing the public; and a culture that is just and trusting, flexible and emphasized learning and improvements. Communication and education would be paramount, as new policies and procedures that focused on critical areas of patient safety were implemented.  

The CHR’s Safety Framework became the roadmap for this work and helped in outlining how the organization would build this foundation and a lasting structure for patient safety. The CHR consulted with world patient safety experts and leading practice organizations.

As new patient safety policies were drafted by multidisciplinary teams, extensive consultation processes were used to gather critical input from care providers, managers, administrators and other major stakeholders including health educational centres, unions, regulatory and professional groups. Most importantly, the consultations included hearing from a variety of patients and families who had experienced harm.

Safety policies and procedures were developed in five key areas – just and trusting culture; reporting harm, close calls and hazards; disclosing harm to patients; informing principal health partners and stakeholders about safety hazards, failures and fixes; and adverse event management.

Once the new policies and procedures were approved, educational site-based forums were held (Leading the Way), to explain and discuss new practices that were aimed at teamwork and create the urgency and shared understanding of why patient safety was so critical. Each forum was opened by the CEO and members of the Patient and Family Advisory Council.

“Leading the Way set the expectation that this was extremely important and sent a strong message that this was way we were going to work together from here on in – that we would collaborate with patients and families in making improvements,” says Sharon. “It modeled a new way of providing care through engagement, collaboration and participation. And, it started to catch on like wildfire across the entire health region.”

The formation of AHS in 2008 brought together 12 formerly separate health entities in the province, including the nine geographically-based regional health authorities and three provincial entities working specifically in the areas of mental health, addictions and cancer. This change provided an unprecedented opportunity to establish an integrated Alberta healthcare system.

In the area of patient safety, it was realized that the work developed by the CHR was leading edge and could provide a strong foundation, in collaboration with the work in the other former health entities, to build an AHS integrated provincial patient safety and incident management system. 

The integrated provincial patient safety and incident management system now includes the following:

• Disclosure Policy – a formalized disclosure policy was implemented, building upon work that was collectively underway previously.
• Reporting and Learning System – a single reporting and learning system was developed using Datix web-based patient safety software. The system includes three components:  healthcare provider reporting of close calls, hazards and adverse events; quality assurance recommendation tracker (Rec Tracker) to monitor the implementation of recommendations; and tracking patient concerns and commendations across AHS.
• Patient and Family Advisory Group (PFG) – formed in late 2010 the PFG is a partnership with patients and families to improve quality, safety and the patient experience.
• Patient Safety Strategic Plan (2013-2016) – a three year-plan that puts patient safety into context for staff, physicians, patients and families. Five overarching areas of focus have been established to achieve the goal of working together to eliminate preventable harm: understand and incorporate the patient’s perspective; build a cultural foundation for patient safety, foster meaningful engagement to improve patient safety; enhance continuous learning as a system; and strengthen leadership focus and attention for patient safety. (See Figure 2: AHS  Patient Safety Plan Overview)
• Systems Analysis Methodology (SAM) – a standardized approach to system analysis, based on work of the Health Quality Council of Alberta, and the Canadian Patient Safety Institute’s Canadian Incident Analysis Framework, to improve and spread capability and capacity for the analysis of adverse events and development of effective recommendations for improvement.
• Safety Alerts and Safer Practice Notices – have been compiled and shared across AHS since 2008. AHS recently joined the Canadian Patient Safety Institute’s web-based Global Patient Safety Alerts and is sharing their Safety Alerts and Safer Practice Notices broadly so that other organizations can learn from their experiences, rather than through the harm of their patients.
• Patient First Strategy – the focus is now shifting to incorporate a better understanding of the patient and family experience, working back from that partnership to identify any gaps and ensure everything now in place aligns for the best quality of care, including safe care. AHS is reviewing their patient safety and incident management strategies to ensure that patient and family-centred care is at the forefront of delivering seamless and effective health care to Albertans. 

Safety is an AHS value that is endorsed and supported at all organizational levels. To ensure AHS is on the right track and know that care is safer, strategic performance measures are in place to track a number of indicators, set goals and compare progress to the national average, including patient satisfaction and adverse events.  Key performance indicators are reported on the AHS website at www.albertahealthservices.ca/performance.asp

AHS is collaborating with the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI) as well as other organizations across Canada to develop a harm indicator based on the health records of hospitalized patients. CIHI’s first public report is planned for the fall of 2015 and CPSI will release a resource library of evidence and tools. This objective source of information will further help healthcare organizations to better understand where patients are experiencing harm and more effectively target improvement strategies.

A patient safety culture survey is currently undertaken every four years.  With two cycles now complete, data is available across the system, including in many cases at a unit level, to better understand how the perception of safety varies across the organization and to inform an open dialogue with staff and physicians on this topic. “When it comes to safety, we know that important knowledge comes from the frontline providers” says Carolyn.

The recommendation tracker provides a good mechanism for monitoring the implementation of all Quality Assurance recommendations. Tracking now includes Fatality Inquiry recommendations as well.  “A just culture is essential for staff and physicians to effectively participate in the reporting and learning system,” says Carolyn. “The number of reports we are getting on adverse events, close calls and hazards continues to grow overall and that is an important indicator of progress in quality and patient safety.”

Many of the health regions were involved with Safer Healthcare Now! and after AHS was launched many hospitals, long-term care facilities and other areas continue to participate. One example where significant progress has been made is medication reconciliation on admission and work is well underway for transitions and discharge. “Harm from not completing medication reconciliation is often invisible unless you talk to patients and families about their medication issues and the impact to their health,” says Carolyn.  “We are bringing forward patient stories as an incentive and encouragement to move this work forward and we can show how this is spreading as we track progress. You would not think of that as a report, yet it is major area where harm is occurring and we are increasing awareness to make it more visible.”

AHS recently asked their Internal Audit team to evaluate the implementation of Disclosure policies and procedures to ensure that the process is working for patients, families and providers. “Engagement and collaboration at all levels is necessary,” says Carolyn. “Truly partner with patients and families and do nothing to jeopardize that partnership.”