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Advancing Patient Safety-Canada’s Vision for the Future
IV International Conference on Patient Safety November 25, 2008
Philip Hassen, CEO Canadian Patient Safety Institute
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Overview
• Canadian Health System • OECD-Comparing Spain, Canada, Other
• Background CPSI • Concluding Remarks/Questions
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Canadian Population in 2006 was at 32.5 Million
Canadian health-care spending for 2007 will reach $160.1 billion.
Public-sector health care spending forecast projected to reach 70.6%.
Private-sector health-care spending forecast projected to reach 29.4%.
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Canadian Health System Key Differences Highlighted
• one fully socialized health care system • Federal government funds the provincial government
as long as they abide by the Canada Health Act whichexplicitly prohibits end user billing for procedures covered through the publicly funded system
• All provinces except Ontario have "mature" Regions • These are vertically and horizontally fully integrated
health and health care under one organization • Focuses as much on population as individual health
Canadian Government Involvement
Central structural difference is in health insurance
OECD Health Data 2007 3.8
3.4 2.8
4.0
0.0
1.0
2.0
3.0
4.0
ada France Italy Uni ted States
OE C D Ave
Acute Care Hospital Beds per 1000 Population
2004
3.9 4.1
6.8 5.7
0.0 2.0 4.0 6.0 8.0
anadaFrance Italy United States
OECD
Maternal and Infant Mortality Deaths per 1000 Live Births
2004
Canada Spain
Canada Spain
29 26 53
40
Health Employment Health Employment Practicing Physicians Practicing Nurses
Density per 1000 Population (Head Counts) Density per 1000 Population (Head Counts)
2005
16.0
4.7
15.0
0.0
9.9
France Italy United States
OCED Ave Spain
81
Canada
55
4.0 14.0 3.5 12.0 3.0 10.0 2.5 8.0 2.0 6.0 1.5 4.0 1.0 2.0 0.5 0.0 0.0
3.4 3.8
2.4
3.0
France Italy United States
OCED Ave
2005
Canada Spain
22
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OECD Health Data 2007, October 2007 Not Available
5
OECD Health Data 2007 Health expenditure as a share of GDP, OECD countries, 2005
15.3
11.1 10.7 9.8 9.2 9 8.9 8.3 8.2 7.5
0 2 4 6 8
10 12 14 16 18
United
States
Fran
ce
German
y Can
ada
Netherl
ands
OECD
Italy
United
Kingdo
m Spa
in Ire
land
%GDP
OECD Health Data 2007, July 2007
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• Patients for Patient Safety Patients for Patient Safety
• Global Patient Safety Challenges: • Clean Care is Safer Care (GPSC 1) • Safe Surgery Saves Lives (GPSC 2)
• Reporting & Learning • Classification • Research • Safety Solutions and High 5s
Alliance Programmes
Canadian Patient Safety Institute Mission
To provide national leadership in building and
advancing a safer Canadian health system
Vision We envision a Canadian health system where:
• Patients, providers, governments and others work together to build and advance a safer health system;
• Providers take pride in their ability to deliver the safest and highest quality of care possible; and
• Every Canadian in need of healthcare can be confident that the care they receive is the safest in the world.
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Patient Safety: Barriers to Action
• Access is more urgent in Canada
• Shortages of clinical professionals
• Concern about liability
• Jurisdictional conflicts
• Delays in building the Electronic Health Record
• Culture of patient safety is lacking
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A Culture of Safety 31,033 Pilots, Surgeons, Nurses and Residents Surveyed*
*Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: crosssectional surveys. BrMedJour, 3-18-2000.
% Positive Responses from: Pilots Medical Is there a negative impact of fatigue on your performance?
74% 30%
Do you reject advice from juniors? 3% 45%
Is error analysis system-wide? 100% 30%
Do you think you make mistakes? 100% 30%
Easy to discuss/report mistakes? 100% 56%
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Human Error – the New View
The point of an investigation is not to find where people went wrong.
It is to understand why their assessments and actions made sense at the time.
Sidney Dekker (2002); The Field Guide to Human Error Investigations
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Human Error – the New View
HUMAN ERRORS ARE SYMPTOMS OF DEEPER
TROUBLE
Sidney Dekker (2002); The Field Guide to Human Error Investigations
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A Systems Approach “The systems approach is not about
changing the human condition but
rather the conditions under
which humans work.”
J.T. Reason, 2001
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. Tools &
Resources Interventions & Programs
ResearchEducation
.
Influence Change
Measure & Evaluate
Communicate
Build Capacity
Engage Stakeholders
Understand the Issues
Examples of Collaboration & Partnerships
Canadian Institute for Health Information • Hospital Standardized Mortality Ratio (HSMR)
Institute for Safe Medication Practices • Canadian Root Cause
Canada and Saskatchewan Health Analysis Framework
Canada Health Infoway • Patient Safety and the Electronic Health Record
Community and Hospital Infection Control • Canada’s Hand Hygiene Association, Canadian Council on Health Campaign
.Services Accreditation, Public Health Agency of Canada
World Health Organization • Patients for Patient Safety Canada; High 5s
Ministère de la santé et des services • Projet de formation sur les facteurs humains sociaux (Québec)
Canadian Council on Health Services • Align efforts
Accreditation, HIROC
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CPSI Strategic Direction Education
Executive Patient Safety Series
Governance for Quality and Safety
Canadian Patient Safety Officer Course
Simulation
IHI Re-broadcast
Halifax Conference
Studentships
Patient Safety Competencies
Canada’s Forum on QI and Patient Safety.
Interventions & Programs World Health Organization High 5’s
Patients for Patient Safety Canada
Infection Control Hand Hygiene Campaign
Safer Healthcare Now!
Research Home Care
Long Term Care
Mental Health Services
Emergency Medical Services
Primary Health Care
Building Capacity through Research
Tools & Resources
Event Analysis
Electronic Health Record
Canadian Disclosure Guidelines
Canadian Adverse Event Reporting and
Learning System WHO Safe Surgery Saves Lives
Human Factors 20
Education
Governance for Patient Safety
• National leadership, coordination and collaboration with current provincial/territorial and regional initiatives
• Co-commissioned research - partnership with CHSRF
• “Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations” (Baker, Denis, Pomey & MacIntosh Murray, 2009)
• Development of a framework and supporting tools, resources and education to assist boards in their understanding of and efforts to improve patient safety
21 21
Education
Education
Simulation GOAL: • To establish a national coordinating group
to promote and endorse simulation andprovide a foundation for collaboration (or:“framework for the sharing of resources”)
• To facilitate the development of a national simulation strategy for healthcare throughfocused collaboration with stakeholders
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Education
Halifax Conferences • Annual National Patient Safety Conference
Patient Safety Officer Course- One week intense education/training session
Patient Safety Competencies • First edition released September 25, 2008.
Activities for dissemination and stakeholder engagement are underway
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Research
• Over 60 research and demonstration projects have been funded in the last three years, these will form the basis for new knowledge of Canadian patient safety challenges and solutions
• Work Collaboratively with Other Research Funding Groups
• Research Dollars Spent to date: $5.8Million
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Research
Building Capacity Through Research
• Development of Patient Safety background papers to identify the current state of knowledge, future research priorities, key issues, and strategies and opportunities for action and improvement:
• Mental Health Emergency Medical Services
• Primary Health Care
• Home Care
• Long-Term Care
25 25
Interventions & Programs
Patients for Patient Safety:
Why?
• More to offer than simply the ‘victims’ story of tragic medical error.
• Consumers offer the richest resource of information related to medical errors as many have witnessedevery detail of systems failures from beginning to end.
• Patients want to know the truth when things go wrongand be treated with honesty and openness rather than face a closed door of denial
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Health-care providers’ compliance with hand hygiene practices is less than 40% on average
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Interventions & Programs
Canada’s Hand Hygiene Campaign
Hand Hygiene Campaign Goals: • Promote the importance of hand hygiene in reducing the
occurrence of healthcare associated infections • Respond to the needs of healthcare organizations for
capacity building and leadership development by creating and providing them with tools to help promote good hand hygiene
SHN MRSA Intervention Goals: • Enable healthcare organizations and caregivers to
prevent patient harm from MRSA • Reduce MRSA infection rates
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Interventions & Programs
Canada
• 33 million people • 10 interventions + 2
pilots • 1035 teams enrolled • 80% of acute care
hospitals enrolled • All regional health
organizations outside of Quebec enrolled
Aim • Reduce adverse events
by 40-100% according to intervention
www.saferhealthcarenow.ca
Interventions & Programs
Campaign Structure
Partner Network
Peer Support Network
CAPHC
Measurement Working Group & CMT Education & Resource
Working Group
Clinical Support
Canadian ICU Collaborative
ISMP Canada
Operations
Teams
Other Canadian Faculty
Communications Advisory Group
Atlantic Node
Ontario Node
Western Node
Campaign Support SHN National Steering Committee
Secretariat - CPSI
Patients
CCHSA CIHI
Quebec Campaign
IHI
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Interventions & Programs
SHN Interventions Initial Interventions • Improve Care for Acute Myocardial Infarction • Prevention of Central Line Associated Bloodstream Infection • Medication Reconciliation • Rapid Response Teams • Prevention of Surgical Site Infection • Prevention of Ventilator-Association Pneumonia
New Interventions • Prevention of Adverse Drug Event
in Long-Term Care • Prevention of Harm from Falls in
Long-Term Care • Prevention of Harm from MRSA • Improve Care for Venous
Thromboembolism (VTE)
Pilot Projects • Prevent Adverse Drug Events
Related to High Risk Medication Delivery in Paediatrics
• Prevent Adverse Drug Events Through Medication Reconciliation in Home Care
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Interventions & Programs
Safer Healthcare Now! Teams Continue to Enroll
Total # of Enrolled Teams
Sep-05 Nov-05 Jun-06 Nov-06 Jan-07 Mar-07 Jun-07 Aug-07 Oct-07 Jan-08 Mar-08 Apr-08
May-08 Jul-08 Aug-08 Oct. 08
Safer Healthcare Now! Overview Total # Enrolled Teams September 2005 to September 2008
118
296
443
546 579 628
695 734
789 817 860
933 962 1004 1021
1050
0
100
200
300
400
500
600
700
800
900
1000
1100
Total at September 23, 2008
Month
13
Month
13
Interventions & Programs
SHN: End of Phase I – January 2007
Med Rec Results – Unintentional
discrepancies
È from 1.16 to 0.65 per patient (goal of 0.30)
1.4 1.2
1
0.8 0.6 0.4 0.2
0
Months in SHN!
Ventilator-associated Pneumonia
Central Line-Associated Blood Stream Infections �bloodstream infections 4.8 per 1,000 central line days
to 1.6
6
5
4
3
2
1
0
M o nt hs in SHN !
Rapid Response Team � in the national rate for VAP from a baseline of 19.88 per â 1,000 ventilator days to 3.76 after 13 months, (goal was 7.00)
Rat
e
18
16 10 14
812
10
8
6
4
2
0
6 4 2 0
national rate of Codes (occurring outside ICU) per 1,000 discharges from 7.46 to 4.61,
Months in SHN
Months in SHN
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Tools & Resources Event Analysis
• The French adaptation for the Canadian Root Cause Analysis Framework is completed and Failure Mode Effect Analysis is in progress
Electronic Health Record • Plans are underway to examine the role of EHR as it
relates to the process of medication reconciliation
Canadian Disclosure Guidelines • Are available on the CPSI website.
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Tools & Resources Canadian Adverse Event Reporting and Learning
System (CAERLS) • The CAERLS Consultation Paper is available on the CPSI
website. Planning for consultation meetings to be held throughout Canada are currently underway.
WHO “Safe Surgery Saves Lives” • An in-country working group has been assembled to adapt
the Safe Surgery Checklist for use in Canada
Human Factors • Development of educational strategies is being
contemplated to assist organizations to better understand this important area of patient safety
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Other Challenges and Key Issues
• Develop other indicators • Build patient safety expert capacity • Collaborate and Increase Engagement (F/P/T,
“patient safety” agencies/organizations) • Keep patient safety on the national agenda;
inform the public, patients, providers, policy-and decision-makers
• Misdiagnosis • Culture of Patient Safety
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Summary
Patient Safety
• CPSI is “leading without owning” resulting in significant and measurable patient safety improvements by many Healthcare organizations in just three years of operations
• Safer Healthcare Now! is a pan-Canadian success story – “changing the face of safety in the Canadian healthcare system”
• The success of CPSI will continue to be assessed with the emergence of Hospital Standardized Mortality Ratios and other measures
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Commitment to Our Patients
“…there are some patients
we cannot help,
there are none
we should harm...”
Dr. Ken Stahl
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