The Quebec situation:
a view from the trenches
OCHU conference on The Epidemic of Medical
Errors, June 4th, 2012
Presented by Marc Pineault
Coordinator – Quality and Risk Management
St. Mary’s Hospital Center
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Disclaimer
• I have no vested financial interests in any
activity that promotes patient safety
• The views in this presentation are my personal
views and do not bind or represent my
employer’s views
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Outline of the presentation
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Introduction and Quebec context
Legislative measures
The good
The challenges
Future perspectives… or what we need to win
the war
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Introduction and Quebec context
• Quebec healthcare system in a nutshell
 Regulatory framework is based on Canadian Healthcare
Act – 5 conditions
 The government regulates the size of the coverage
basket of services (RAMQ)
 Hierarchy is centralized at the MSSS level, and regional
delegation through regional health boards (18)
 95 CSSS (85% of which have a hospital but also include
CLSC’s, LTC facilities), geographically based
 CHA, Institutes, and 4 University Hospitals
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Introduction and Quebec context
• Quebec healthcare system in a nutshell (continued)
 2000 private clinics and family medicine groups
 Over 3000 community organizations
 Long-term care facilities
 Rehabilitation centers
 Youth protection
 Private institutions (private long-term care, community
pharmacies, non-institutionalized resources, etc.)
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The Quebec Context
• In the world,
• To Err is Human
• Australian study
• UK study
• The Quebec stories and study
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Legislative measures adopted in
2003
Became mandatory to:
• Disclose accidents to patients and family
• Have a Board of Directors by-law for
disclosure
• Define support measures for patients and
family
• Report incidents/accidents
• Put in place measures to prevent recurrence
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Legislative measures adopted in
2003
• Create a risk management committee
• Create a local registry of incidents/accidents
• Follow an accreditation process (since 2011,
mandatory to be accredited)
• Transmit a summary of the report to
authorities (since 2011, made public)
• Annual report must contain risk management
activities conducted during the year
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Legislative measures adopted in
2003
• In addition to a local registry, a national
registry was to be put in place
• This took over 8 years to accomplish!!!
• And what did we learn? You’ll soon see…
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The good
Improvements were observed in increased transparency:
• With victims and families through the disclosure
process (CMPA, CPSI guidelines, etc.)
• Through the development of a structured reporting
system
• In institutions, through the accreditation process, the
reporting of results, and the obligation to report on risk
management activities in the annual report
Disclaimer: none of these claims are necessarily scientifically-based but are based on experience
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The good (continued)
• Focus on patient safety has increased in health
institutions through the local registry, through the
activities of the risk management committees, and
through the accreditation process that focuses on patient
safety
• The increase in expertise on patient safety within
health institutions has also increased the responsiveness
of organizations to correct and prevent adverse events
Disclaimer: none of these claims are necessarily scientifically-based but are based on experience
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The good (continued)
Some tools to support institutions:
• Training for risk management committees
• Purchase and adaptation of the Australian human
factors and patient safety program called ErroMed©
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The good (continued)
Infection control:
• Mandatory reporting and public disclosure of infection
rates for C-diff since 2005.
• Standardized ratio of infection control personnel per
hospital bed established
• Effort put into guidelines and methods of prevention
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The challenges
• Disclosure: despite efforts, telling patients that
something went wrong remains taboo in many areas
and with many professionals
• Accreditation process: the cycle has been increased to
4-years, posing a risk that institutions will not pay
attention to patient safety issues during 2 of the 4
years in the interval between visits
• Expertise in patient safety within institutions has not
been recognized by the Ministry (i.e. risk managers
and patient safety officers)
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The challenges (continued)
Reporting system:
• The focus on reporting and the birth of the national
registry has put emphasis on the management of
reporting forms, and less on prevention
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The challenges (continued)
“National” registry:
• 179,011 events were reported in 6 months
• 10% were incidents, 65% were accidents, and 25%
were undetermined
• Falls and medication were the 2 highest reported
events
• 1/5 events required only monitoring
• 1/10 events required non-specialized interventions
• 2/100 events required specialized interventions
• 4/1000 events required increased level of care or
increased the length of stay
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The challenges (continued)
“National” registry:
• But what does this mean?
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Validity of the data
25% undetermined severity!
Rates?
What do institutions report?
• What’s the purpose vs what was the legislator’s intent
10 years ago?
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The challenges (continued)
Tools to increase patient safety:
• Risk management committee training quickly outdated
and was finally upgraded in 2011; many senior
trainers dropped off
• Human factors training program was not sufficiently
supported and has lost momentum through high
turnover at the MSSS level
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The challenges (continued)
Infection control:
• Efforts seem to not be heard by some professionals
• Uneven attention to the risks involved
• Inter-institution transfers seem to remove ownership
of problem
Disclaimer: none of these claims are necessarily scientifically-based but are based on experience
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Future perspectives: what the
Ministry is hinting
• Continue presenting numbers; no communicated plan
as to how to improve the report
• Based on the frequency, create “expert groups” to
find solutions
• Human factors is still in limbo, after 7 years,
decisions based on erroneous information from the
Regional Health Authorities
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Future perspectives: what the
Ministry is hinting
• Support for training in Human Factors and patient
safety
• Data that is meaningful
• Recognition that some issues are solvable at the
Ministry level; but that most are at the institution
level
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Future perspectives: what the
true stakeholders need
• To stop looking at humans as being the problem; to
err is human; to implement a culture of why’s not
who’s
• Transforming Dr Seuss’s Whoville into Whyville
• Empower the front liners to be able to implement
change instead of implementing more centralized
control
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Thank you for your attention
Merci beaucoup de votre écoute
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