Patient Safety Framework

Overarching objective: The reduction of preventable harm to patients

Background:

The first goal of the Yukon Hospital Corporation (YHC) is to provide SAFE comprehensive patient care inclusive of a commitment to best practice standards for care and safety as required by Accreditation Canada. Many of the Required Organizational Practices (ROPs) and components within Accreditation Canada’s standards target system safety including but not limited to:

• Adopting client safety as a written strategic priority or goal
• Providing the governing body with quarterly reports on safety including recommendations arising out of adverse event investigation
• Establishing a reporting system for adverse events which includes appropriate follow up
• Developing a written policy and procedure for disclosing adverse events to patients
• Establishing an Integrated Quality Management Framework which includes the relationship between the key elements of the framework: Patient Safety, Quality
• Improvement, Risk Management, Utilization Management, Ethics and Strategic planning.
• Administering a Culture of Safety survey at least every three years and ensuring there are no unaddressed priority for action flags
• Inform patients and families on their role in patient safety (written and verbal)
• Perform Patient Safety Prospective analysis done at least once annually (project specific)
• Provide patient safety training at least annually to senior leaders, staff, service providers and volunteers (tailored)
• Clearly define the roles, responsibilities and accountabilities of leaders, staff, physicians and volunteers for patient safety and care
• Implementing clinical Required Organizational Practices i.e. medication reconciliation, VTE prophylaxis, Transfer of Information, Do Not Use Abbreviations list, Safe Surgery Checklist etc.
• To ensure these (and other) aspects of organizational and patient safety are met, the development of a Patient Safety Framework and strategy is required.

Assumptions:

The patient journey through the healthcare system is the central focus of the YHC patient safety efforts. Healthcare is an example of a complex socio-technical system that is not easily understood. There are always goal conflicts at all levels of the healthcare system (in other words, the safety of a patient is never the only priority, even at the provider-patient level of the system). Safety is not a commodity that can be counted but is an emergent property of the healthcare system. Enhancing the safety of patients receiving services in YHC requires transparency and honesty.

Our Approach

We have learned through a recent survey (2009) on patient safety that we must make some improvements to drive a positive cultural change. Directly engaging and changing the relationship the YHC has internally with its staff and that of the staff with patients and families will lead to culture change.

Culture change can change the quality of the climate towards learning, towards openness, transparency and accountability, which is a necessary precondition for changing the way we deliver care as a system and as individuals working within that system.

Team efforts towards the same direction require shared models, which are come to life through conversation/dialogue that is respectful, diverse and part of our day-to-day work. The ability to suspend our comfort with the way we’ve always done things and work towards new ways of being and acting in the healthcare system is essential for positive culture change.

Five key patterns in the culture of organizations that often strongly influence the organization’s ability to bring about whole-systems transformation are:

Relationships: Do the interactions among the various parts of the system generate energy and innovative ideas for change, or do they drain the organization? Decision-making: Are decisions about change made rapidly and by the people with the most knowledge of the issue, or is change bogged down in a treacle of hierarchy and position-authority?

Power: Do individuals and groups acquire and exercise power in positive, constructive ways toward a collective purpose, or is power coveted and used mainly for self-interest and self-preservation?

Conflict: Are conflicts and differences of opinion embraced as opportunities to discover new ways of working, or are these seen as negative and destructive?

Learning: Is the system naturally curious and eager to learn more about itself and about what might be better, or is new thinking viewed mainly as potentially risky and threatening to the status quo?

Transformational: whole-systems change will occur more naturally and more frequently when we learn to integrate changes across our departments and positions. We are in the process of improving structures and process to help us move towards a positive, safe organizational culture which includes honest dialogue about the five key patterns above and in finding ways to modify these to be supportive of transformation.

The Patient Safety Matrix

The YHC has adopted a quadrant system (from the Winnipeg Regional Health Authority) to identify key elements of patient safety components. The elements inclusive of activities completed or underway from 2009-2011 are listed below:

Using the 4 elements described above, a template for quarterly reporting to the board, management and front line staff will be implemented effective October 2010.