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Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.

The healthcare system is comprised of many sub-systems operating at different levels (e.g. outside of the organization, organization and/or program level, point of care) each with specific goals, resources (human, financial, equipment) and processes (formal and informal.) Maintaining a system perspective and regularly assessing the sub-systems and their connectivity is critical in identifying how they influence each other which in turn can inform actions to strengthen patient safety and incident management. 

Assess key system factors and understand how they relate to patient safety and incident management.

  • Outside the boundaries of the organization:
    • public and community awareness of and engagement in patient safety
    • healthcare legislation, standards, policies, regulations and accreditation requirements
    • healthcare infrastructure and resourcing (fiscal, human, facilities and sites, equipment)
    • education of healthcare providers, labour agreements, and workforce trends
    • social determinants of health, societal trends (income, social status, education, employment, housing, culture, etc.)
    • health trends, issues and challenges (e.g. disease outbreaks, population health)
    • political environment (local, provincial/ territorial, national), economic, technological, and trends influencing the healthcare industry (e.g. through a PESTLE analysis)
    • infrastructure, trends, and funding for patient safety research, evaluation and improvement
    • trends in other sectors that might intersect with healthcare (e.g. technology, social media)
    • geographic location and regional characteristics (remote vs. rural vs. urban)
  • At the organizational and program/service levels:
    • commitment and governance at the leadership team and board levels, including knowledge of patient safety science and best practices
    • visibility and engagement of leadership in patient safety
    • the prioritization of patient safety by leadership - whether it’s at the top of meeting agendas and allocated at least 25% of the meeting time
    • accountability for patient safety performance by organizational leadership, alignment with incentives (formal and informal)
    • inclusion of the patient/family perspective at board and leadership meetings, in decision-making and in the design of care processes and patient safety initiatives
    • leadership team stability, experience, and style
    • organizational patient safety culture
    • organizational experience, current performance/progress with patient safety 
    • funding and financial status of the organization including infrastructure and technology investment needs
    • proactive design or redesign of  policies and practices related to safety
    • expertise and skill of workforce related to patient safety  
    • alignment between patient safety, quality improvement, risk management
  • At the point of care:
    • patient/family partnership in care and safety
    • team communication, feedback, culture, composition, hierarchy
    • comfort and ability to report incidents, concerns, successes
    • competencies, skill, experience of staff, professional requirements regarding patient safety and incident management
    • access to resources to manage safety and incidents
    • staff turnover, staffing levels protected time for projects

Identify actions to strengthen patient safety and incident management

  • Respond – Monitor and anticipate system factors that influence and impact patient safety (e.g., changes in regulations, workforce shortages, changes to health funding), ensure patient safety remains at the forefront of decision making (e.g., regular updates at key meetings, assigning responsibility to stay informed to key leaders) and take action to respond as appropriate.
  • Align – Use internal and external system factors in assessing priority of patient safety and incident management initiatives. Initiatives that align at different system levels create multiple wins, which will accelerate uptake and spread, and promote best practices known to reduce harm.
  • Leverage – Take advantage of system  factors to improve patient safety and incident management (e.g., use Accreditation Canada’s Required Organizational Practices as a lever to implement best practices known to improve patient safety.)
  • Partner/collaborate – Work with others to make changes that can positively impact healthcare in your setting; support or endorse the work and successes of others.
  • Advocate – Promote learning from patient safety incident management to shape system factors for the benefit of your healthcare organization and providers, as well as others (e.g. work with advocacy groups to change public policy, engage funders in addressing known safety issues.)