Quality & Patient
Safety TOH
Linda Hunter
Director, Quality and Patient Safety
2011
Champlain LHIN
Deep River & District Hospital
Ottawa Area Hospitals
- The Ottawa Hospital
- Royal Ottawa
- CHEO
- Montfort
- Bruyere Continuing Care
Hawkesbury & District General Hospital
- Queensway-Carleton Hospital
Pembroke General Hospital
St. Francis Memrial Hospital
Renfrew Victoria Hospital
Arnprior & District Memorial Hospital
Glengarry Memorial Hospital
Almonte General Hospital
Winchester District Memorial Hospital
Carleton Place & District Hospital
Kemptville District Hospital
Perth & Smith's Falls District Hospital
Cornwall General Hospital
Hotel Dieu Hospital
The Ottawa Hospital
Facts and Figures
Capacity
Activity
• ~$1B Operating
Budget
• 46,000 Admissions
• 1,172 Inpatient Beds
• 12,000 Staff
• 1,200 Physicians
• 49,000 Surgical Cases
• 127,000 ED Visits
Patient Volumes
Vision
To provide each patient with the world class
care, exceptional service and compassion that we
would want for our loved ones
To Become a Top 10% Performer in Quality and Patient Safety in North America
Outcomes
Access
Wait Times:
DI, Hip/Knee,
Cancer & ED
Effectiveness
Re-admission rates
Surg. Site Infections
Culture
Safety
HSMR
Hospital Infections:
MRSA, VRE & CDifficile
Satisfaction
Overall
Pain
Transition
Create a culture of compassionate people, world-class care
Service Excellence
Milestones
& Tactics
Efficiency
ALOS-ELOS
CPWC
Performance
Measurement
Physician Engagement &
Accountability
Patient Experience
Enabling environments
Clinical transformations
Staff Engagement
Quality Plan
Our Patients
Research Plan
Our Staff
Human Resources Plan
Our Finances
Operating Plan
Our
Environment
Capital Plan
Information Services Plan
Communication & Community Outreach Plan
Our Partners
Values
Commitment to
Quality
Working Together
Respect
for the Individual
Compassion
Quality and Performance
Measurement
•
•
•
•
•
Define
Align
Prioritize
Measure
Report
Definition of Quality
Providing the patient with appropriate
consistent health care in a clean and safe
environment in which the patient is treated
with respect.
- TOH Board, January 2003,
reconfirmed 2008
Defining the Quadrants
ACCESS
Patients should be able to get the
right care at the right time in the
right setting by the right
healthcare provider (OHQC)
APPROPRIATE
Efficient: The hospital should continually
look for ways to reduce waste, including
waste of supplies, equipment, time,
ideas and information (OHQC)
SATISFACTION
Health services are respectful and
responsive to user needs,
preferences and expectations
(HQCA)
Effective: Patients should receive care
that achieves the expected benefit and
is based on the best available scientific
information (OHQC)
SAFETY
Patients should not be harmed by
an accident or mistakes when they
receive care (OHQC)
OHQC: Attributes of a High-Performing
Health System, Ontario Health Quality
Council
HQCA: Quality Matrix for Health, Health
Quality Council of Alberta
Alignment
With:
• TOH Strategic Direction
• Best Practice
• Legislation
• Accreditation Recommendations
• Ministry of Health Mandated Requirements
• Future Trends
• Others?
Corporate Quality Plan Prioritization
• Corporate in scope
• Aligns with TOH mission and vision
• Aligns with at least one of the following:
– Addresses issues occurring frequently or to a high
volume of patients
– Addresses high risk for patient safety issues
– Addresses accreditation or regulatory requirements
• High probability of impact on outcomes/process
measurement/indicators
Reporting
•
•
•
•
•
Scorecard
Workplan
Colour coded – green, yellow, red
Trend charts
Others
…to different end stakeholder groups
The Ottawa Hospital
Corporate Quality Plan
Balanced Scorecard
Access
Emergency Offload (Q)
•90th percentile CTAS 1
90th percentile CTAS 2-5
Emergency Access Times (Q)
•% admitted ED LOS < 8 hrs
•% non-admit waiting < 8 hrs for
CTAS 1&2
•% non-admit wait < 6 hrs, CTAS 3
•% non-admit wait < 4 hrs, CTAS
4&5
Number of cancer surgeries (Q)
Number of knee surgeries (Q)
Number of hip surgeries (Q)
Number of cataract procedures (Q)
Number of hours MRI delivered (Q)
Number of hours CT delivered (Q)
Safety

A
Q
Ventilator Associated Pneumonia rate (Q)
- Data currently available Central Line Infection rate (Q)
Surgical Site Infection rate (Q)
Hand Hygiene compliance rate (Q)
- Reported annually
Hip fractures receiving surgery < 48
- Reported quarterly
hours (Q)
C Difficile rate (Q)
MRSA rate (Q)
VRE rate (Q)
HSMR (Q)
Appropriate
Satisfaction
Effective
Efficient
Ottawa Model for Diabetes (Q)
Inpatient satisfaction with pain control (Q)
•Medicine
•Surgery
•Obstetrics and Gynecology
•Emergency Department
•Rehabilitation
Cost per weighted case (A)
% clinical pathways revised (Q)
# new clinical pathways /
program (Q)
NRC-Picker Pt Satisfaction Results (Q)
•Medicine
•Surgery
•Obstetrics and Gynecology
•Emergency Department
•Same Day Surgery
•Rehabilitation
•Ambulatory Care
Infection Control Dashboard
Hand Hygiene by Unit – Selection Criteria
Statistics Table by Campus
Indicator Assumptions
Selection criteria for indicators:
– Data is available
– Data is timely
– Indicator is valid and reliable
– Indicator is actionable
– Impact on high volume, high cost and high risk
Focus on the vital few versus the trivial many
Mandatory Indicators
For accreditation:
• Percentage of patients
receiving medication
reconciliation at admission
• MRSA infection rate
• C. Diff infection rate
• Rate of post surgical infections
• Rate of timely administration of
prophylactic antibiotic
Submitted quarterly in each three
year cycle
For MOH Public Reporting:
• CLI rate
• VAP rate
• MRSA
• C. Diff
• VRE
• SSI antibx
• HH compliance
• HSMR
• SSCL
Submitted quarterly to annually
2010/2011 Public Reporting Indicators
Jun-10
Q1
Q1
Q1
Q1
Q1
Q1
Mar-10
Mar-10
FY08-09
C Diff
MRSA
VRE
CLI
VAP
SSIP
SSCC
HH %
Before Pt.
Env.
HH %
After Pt.
Env
HSMR
TOH Civic
0.46
0.03
0
1.03
2.63
91.8%
99.6%
65.26
83.44
TOH General
0.51
0
0
1.04
4.12
98.1%
99.7%
52.12
68.92
TOH HI
0
0
0
0.52
5.54
96.6%
79.31
85.83
TOH
TOH Rehab
0
0
0
91.94
93.33
SMH
SMH
0.42
0.08
0
1.98
0.74
99.5%
99.1%
33.6
56.71
83
Sunnybrook
0.23
0.02
0
0.29
5.69
92.6%
87.9%
61.03
81.61
88
Ortho
0
0
0
0
97.1%
100.0%
53.16
80.13
McMaster
0
0.04
0
7.52
0
47.1%
61.84
78.76
Hamilton
0.19
0.06
0
1.22
1.61
34.4%
66.67
82.34
Henderson
0.14
0
0
0
0
100.0%
64.1%
49.21
71.16
University
0.61
0.2
0
1.48
1.76
98.4%
62.2%
51.64
83.48
South St.
0
0
0
Victoria
0.63
0
0.03
2.8
0.78
81.3%
62.1%
57.65
79.91
Mt. Sinai
Mt. Sinai
0.21
0.06
0
1.45
1.44
96.9%
97.2%
61.68
75.8
92
Kingston
Kgn General
1.33
0.03
0
0.75
4.37
88.1%
96.0%
33.72
48.42
111
UHN General
0.72
0.03
0
1.77
4.22
76.7%
51.26
76.93
Western
0.31
0
0
0.71
3.77
99.9%
37.15
65.89
Princess M
0.3
0
0
100.0%
56.26
79.83
Institution/Health Centre
Campus
94
Sunnybrook
Hamilton Health Science Centre
London Health Science Centre
UHN
92
103
95.5%
77
Not Eligible
Updated Jan 2011
Reporting:
Infection Rates
Central Line Bloodstream Infections / 1,000 Line Days
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Civic
0.00
0.00
0.00
1.54
0.00
1.63
0.00
1.40
1.92
1.63
0.00
1.51
1.68
0.00
General
2.85
1.51
1.38
0.00
0.00
0.00
3.01
0.00
0.00
2.99
1.55
0.00
0.00
0.00
Target
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
TOH
1.42
0.75
0.71
0.77
0.00
0.74
1.56
0.81
0.88
2.34
0.87
0.74
0.83
0.00
Ventilator Associated Pneumonia per 1,000 Ventilator Days
8
7
6
5
4
3
2
1
0
Jan - Mar 09
Apr - Jun 09
Jul - Sep 09
Oct - Dec 09
Jan - Mar 10
Apr - Jun 10
Jul - Sep 10
Oct - Dec 10
Civic
7.59
3.48
3.76
3.23
1.53
2.63
0.00
0.00
General
3.01
3.96
2.55
2.62
1.75
4.12
0.73
1.60
Target
3.00
3.00
3.00
3.00
3.00
3.00
3.00
3.00
Reporting:
Central Line Infection – Line Insertions
Hand Hygiene for CLI Insertion
100%
100%
95%
97%
97%
96%
98%
Maximal Barrier Precautions Used
97%
100%
93%
90%
92%
92%
77%
80%
90%
85%
60%
68%
76%
73%
69%
71%
62%
64%
64%
47%
76%
80%
75%
70%
73%
40%
71%
20%
65%
60%
5%
6%
0%
Jan-10 Feb-10 Mar-10
Apr-10
May-10 Jun-10
Jul-10
Hand Hygiene
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Jan-10 Feb-10 Mar-10
Apr-10 May-10 Jun-10
Target
97%
100%
98%
98%
96%
96%
94%
95%
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Target
Optimal Catheter Site Selection
100%
97%
Jul-10
Full barrier precautions
Chlorhexadine Skin Antisepsis
100%
73%
97%
100%
100%
97%
98%
98%
98%
97%
95%
91%
98%
97%
94%
95%
93%
98%
94%
91%
90%
89%
90%
85%
80%
85%
75%
70%
80%
Jan-10
Feb-10
Mar-10
Apr-10
May-10 Jun-10
Jul-10
Skin asepsis
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Target
Jan-10 Feb-10 Mar-10
Apr-10 May-10 Jun-10
Jul-10
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11
Optimal site selection
Target
Reporting:
Ventilator Associated Pneumonia
Head of Bed Elevation Over 30 Degrees
100%
99.0%
97.5%
100.0%
100.0%
98.2%
99.0%
Use of EVAC ETT
100.0%
98.3%
98.2%
90.0%
95.8%
95.3%
96.4%
100%
97.7%
96.0%
90%
95%
96.0%
92.8%
94.5%
89.9%
87.8%
91.7%
93.6%
94.4%
93.0%
92.4%
81.4%
80%
90%
70%
85%
60%
Jan 10 Feb 10 Mar 10
Apr 10 May 10 Jun 10
Jul 10
HOB Elevated
Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11
Jan 10 Feb 10 Mar 10
Apr 10 May 10 Jun 10
Goal
92.9%
73.8%
95.0%
94.8%
92.3%
87.9%
92.6%
Aug 10 Sep 10 Oct 10
EVAC ETT
Nov 10 Dec 10 Jan 11
Goal
Daily Sedation Vacation
Use of Oral vs Nasal Tubes
100%
90%
80%
70%
60%
50%
40%
Jul 10
91.8%
93.1%
95.3%
95.3%
95.8%
100.0%
94.8%
94.6%
96.7%
96.0%
92.6%
95.0%
79.6%
90.0%
85.0%
85.0%
94.5%
94.4%
94.2%
Sep 10
Oct 10
Nov 10
96.5%
96.6%
Dec 10
Jan 11
85.0%
79.6%
80.0%
75.0%
Jan 10
Feb 10 Mar 10
Apr 10
May 10
Jun 10
Jul 10
OG Tube
Aug 10 Sep 10 Oct 10
Goal
Nov 10 Dec 10 Jan 11
Jan 10
Feb 10
Mar 10
Apr 10
May 10
Jun 10
Jul 10
Sedation Vacation
Aug 10
Goal
Patient Safety Indicators on the Infonet
Quality Monitoring
Insanity is doing the same thing over and
over again and expecting a different result.
-Albert Einstein
It’s not the data.
It’s what you do with it.
Model of a work system
UW-Madison Systems Engineering Initiative for Patient Safety (SEIPS)
Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P. Alvarado, C. J., Smith, M., and Brennan, P. F. (2006). Work system
design for patient safety: the SEIPS model. Quality and Safety in Healthcare, 15(Suppl I), i50-i58.
Definitions
• Patient safety is defined as the reduction and
mitigation of unsafe acts within the health care
system, as well as through the use of best practices
shown to lead to optimal patient outcomes.
• Patient Safety Culture is defined as a commitment
to applying core patient safety knowledge, skills, and
attitudes to everyday work.
(CPSI, 2008)
CPSI – The Safety Competencies
Framework which includes 6 core domains that provide for safer patient
care:
Domain 1: Contribute to a Culture of Patient Safety
Domain 2: Work in Teams for Patient Safety
Domain 3: Communicate Effectively for Patient Safety
Domain 4: Manage Safety Risks
Domain 5: Optimize Human and Environmental Factors
Domain 6: Recognize, Respond to and Disclose Adverse Events
Visit CPSI – Safety Competencies www.safetycomp.ca for complete
framework information.
Fostering Patient Safety Culture at TOH
Need:
•
•
•
•
•
•
A vision of where we want to go
Senior leadership buy-in
Actions to get us there
Passionate clinicians and support staff
Accountabilities defined
An action plan to move forward
Patient Safety Culture Surveys at TOH
The Survey on Patient Safety Culture (AHRQ) was launched in August 2006, and offered to
all staff, physicians and volunteers at TOH.
A second survey, the Patient Safety Culture in Healthcare Organizations Survey, a tool
developed by Stanford and modified by York University and supported by AC was run
on four TOH inpatient units the following year. Further surveys were done in 2010 and
2011.
There were six survey items where the large majority of staff members responded the same
way in both surveys. (i.e. there was very little variation in responses); these include:
•
•
•
•
•
•
Asking for help is a sign of incompetence (93% disagree)
If I make mistake, and nobody notices, I do not tell anyone (95% disagree)
I will suffer negative consequence if I report a patient safety problem (86%
disagree; 9% neutral)
I engage in unsafe practices in order to get the job done (95% disagree)
I report the errors I make (86% often/always; 11% occasionally)
I learn from errors made by my colleagues (81% often/always; 16% occasionally)
Develop a Culture of Safety
•
•
•
•
•
•
•
•
•
•
•
Relay safety reports at shift changes
Create an adverse event respond team
Re-enact adverse events
Appoint a patient safety champion for every area/unit
Simulate possible adverse events
Involve patients in safety initiatives
Create a reporting system (PSLS)
Designate a patient safety officer
Conduct safety briefings
Provide feedback to frontline staff
Conduct patient safety walkabouts (rounds)
Comparison of Patient Safety Culture Surveys
Survey on Patient Safety Culture (n 738)
Both sets of survey
results reflect staff with
direct patient interaction
only.
Patient Safety Culture in Healthcare Organizations Survey (n 109)
Required Organizational Practices
Adverse Event Reporting
Response
Analysis
Detection
 Focus on how we can
prevent and intercept
errors
 Statistical data that can be
analyzed to determine
trends
 Understand and improve
practices that promote a
safe care environment for
patients
Definitions
A reportable incident is … any unusual occurrence that is inconsistent
with the routine care of a patient; or that adversely affects patients,
volunteers, visitors or hospital property; or an unexpected negative
treatment outcome.
e.g. falls, med errors, equipment problems, lab incidents
Injury does not have to occur for an event to be reportable
(“near misses”)
More definitions
As defined in TOH Critical Incident Review Policy and in accordance with the
Public Hospitals Act a “Critical Incident” means any unintended event
that occurs when a patient receives treatment in the hospital:
(a) that results in death, or serious disability, injury or harm to the patient,
and
(b) does not result primarily from the patient’s underlying medical condition
or from a known risk inherent in providing the treatment.
As defined in TOH Patient / Visitor Incident Reporting Policy a “Serious
Incident” is one that results in a fracture, haemorrhage, aspiration, serious
drug variance/reaction or death, transfer to a critical care area, increased
length of stay or admission to hospital.
Patient Safety Learning System (PSLS)
Event
Ongoing
Surveillance
Voluntary reporting
Electronic triggers
Identify
Patient Safety
Learning System
Report/
Record
Patient Safety
Learning
System
Department &
Division Front
Line Staff
System
Improvement
Analyze/
Classify
Escalate
TOH Risk Management
Quality Coordinators
Data Warehouse
Department Head/Clinical
Experts
Severity of risk or
AE will determine
work flow
TOH Critical Incident
Policy & Procedure
Department/Function
QI Internal Process
Causal
Analysis
Data Warehouse AE Analysis
Corrective
Action
Learn &
Educate
Safety Rounds
M&M Rounds
Disclosure
Disclosure is a professional, ethical, moral and legislative requirement
“Disclosure” refers to the communication of information regarding an
adverse event, adverse outcome or critical incident.
Public Hospitals Act directs that the disclosure conversation must include:
(a) the material facts of what occurred with respect to the critical incident;
(b) the consequences for the patient of the critical incident, as they become
known; and
(c) the actions taken and recommended to be taken to address the
consequences to the patient of the critical incident, including any health care
or treatment that is advisable.
Documentation of the disclosure discussion is also a legislative requirement.
TOH Disclosure Toolkit available
Goals of Root Cause Analysis (RCA)
To find out:
•
What happened
•
Why it happened
•
What can be done to reduce the likelihood of a
recurrence?
Resources: CPSI RCA Toolkit & TOH RCA Lite Toolkit
Steps of a RCA
1.
2.
3.
4.
5.
6.
7.
8.
Determine the team
Organize the meeting
Gather information and the facts of the incident
 Who, What, Where, When but not the Why
At the meeting
 Review the information gathered and determine what did
happen compared with what should have happened
Determine contributing factors and root causes
 Keep asking “why” until the contributing factors and root
causes are found
Develop actions and determine performance measurements
Implement the actions
Measure and evaluate the effectiveness of the actions
Common Root Causes
Rules, Policies, Procedures, Protocols and Processes:
 Lack of awareness of what protocols, policies and procedures are available
 Lack of standardization of processes
Communication Issues:
 Breakdown in communication primarily at the point of transition, both
internally and externally
 Lack of information in the patient health record
Equipment Issues:
 Lack of available equipment (department specific requirements)
Staff Factors (Knowledge, skill)
 Incomplete & inaccurate documentation across all disciplines
 Lack of ongoing education related to policies, procedures and protocols
CPSI/TOH
Patient Safety Culture Project
Questions?