National Patient Safety Consortium
The National Patient Safety Consortium has fulfilled its mandate, however to keep building momentum of large scale change, the remaining actions will transition to PATIENT SAFETY RIGHT NOW. Some 16 actions identified by the Consortium are complete; implementation and endorsement of the Never Events report will be carried over to the 2018-19 fiscal year.
Through several summits and roundtable meetings, the Consortium Steering Committee, comprised of healthcare organizations and patient/family members from across Canada, governed the development of the Integrated Patient Safety Action Plan to drive a shared action plan for safer healthcare for Canadians. The Integrated Patient Safety Action Plan includes activities led by Lead Groups and Action Teams in five priority areas: medication safety, home care safety, infection prevention and control, surgical care safety, and patient safety education.
One of the outputs of the Consortium was the development of the Engaging Patients in Patient Safety: a Canadian Guide, a valuable resource for organizations across the country working to advance patient engagement.
The National Patient Safety Consortium held its fifth and final meeting in Toronto, in October 2017. The five Lead Groups met on October 11, with 54 participants. On October 12, the Lead Groups were joined by the Consortium representatives, with 104 participants in total. Many common themes emerged from the presentations and numerous small group discussions and question and answer periods were built into the program. These included:
- The fundamental importance and value of involving patients, families and stakeholders in all aspects of the work of the National Patient Safety Consortium and the Integrated Patient Safety Action Plan.
- Widespread support for the National Patient Safety Consortium approach for advancing patient safety in Canada.
- Acknowledgement of the need to bring more focus to the work of the National Patient Safety Consortium and support a smaller number of initiatives that can have more impact.
- Concern about the ongoing lack of public and patient awareness of patient safety as a significant issue within the Canadian healthcare system.
- The need to better align patient safety initiatives with the priorities and work of provincial and territorial governments.
A comprehensive, independent evaluation of the Consortium and the Integrated Patient Safety Action Plan was conducted; the final report was released in August 2018. The evaluation includes findings from a document review, key information interviews, focus groups and an online survey.
The key learnings of this large-scale collaboration, including the evidence-based outputs from the Integrated Patient Safety Action Plan and recommendations from the independent evaluation, will inform the next steps of this work in making patient safety a priority and the global culture of safe care a reality.
Government relations outreach
The Canadian Patient Safety Institute’s government relations outreach works to ensure all federal, territorial and provincial governments see patient safety as a priority and use that understanding in the development of health policy to improve patient safety. In 2017-18, over 30 meetings were held with policy leaders in government, including Ministers of Health, Deputy Ministers and elected officials from federal and provincial governments. In addition, the Canadian Patient Safety Institute was invited to the House of Commons Standing Committee on Health to provide expert testimony on the Committee's study on Antimicrobial Resistance (AMR); and provided Members of Parliament with information on medication safety and the patient’s perspective.
The Canadian Patient Safety Institute brings together experts from across Canada to provide strategic advice and direction for regional and government relations, health policy, and legal and regulatory affairs. The Policy, Legal and Regulatory Affairs Advisory Committee provides strategic advice that enables the Canadian Patient Safety Institute to be a catalyst that influences patient safety issues and directions as they relate to federal, provincial and territorial health priorities and policy, health law, legislation, and regulatory systems and processes.
Integrated Patient Safety Action Plan
Our vision to drive a shared action plan for safer care has made a collective impact to raise the bar on quality improvement and advancing the patient safety agenda. This work concluded at the end of the 2017-18 fiscal year. The Integrated Patient Safety Action Plan was built on a shared leadership model with unprecedented collaboration and partnering with patients/families as guiding principles. Some 58 actions were complete as of March 31, 2018. Participation included 106 organizations contributing to the Integrated Patient Safety Action Plan. Eleven in-person meetings were held, involving 270 leaders from more than 100 organizations and 27 patient and family members.
Over 25 outputs were developed, such as environmental scans, literature reviews, and published resources and tools. Many of these resources have been made available through the Canadian Patient Safety Institute, national and international conferences, and various partner websites.
The Canadian Patient Safety Institute presented highlights of the Integrated Patient Safety Action Plan to the International Forum on Quality & Safety in Healthcare (London, England; April 2017); Health Quality Ontario Heath Transformation Conference (Toronto, Ontario; October 2017); and the Institute for Healthcare Improvement (Orlando, Florida; December 2017).
Going forward, implementation of the outputs of the national safety improvement projects and further knowledge translation of the evidence and impact achieved through this transformational change initiative will be advanced.
Patient Safety Forward with Four
The Integrated Patient Safety Action Plan was the foundation of Patient Safety Forward with Four, and with the shared purpose stemming from the Consortium, it drove all commitments and communication. The five pillars supporting the Integrated Patient Safety Action Plan include surgical care safety, medication safety, home care safety, infection prevention and control and patient safety education.
Four strategies were identified to move patient safety forward In the Canadian healthcare system:
- Provide leadership on the establishment of a National Integrated Patient Safety Strategy.
- Inspire and sustain patient safety knowledge within the system, and through innovation, enable transformational change.
- Build and influence patient safety capability (knowledge and skills) at organizational and system levels.
- Engage all audiences across the health system in the national patient safety agenda.
Surgical Care Safety
The Surgical Care Safety Action Plan had a total of 12 actions completed at the end of the 2017-18 fiscal year. Over the past five years, three face-to-face meetings were held to advance the Action Team’s priorities.
Through a partnership with Patients for Patient Safety Canada, the Canadian Anesthesiologists’ Society and the Operating Room Nurses Association of Canada, a number of surgery-related patient engagement tools were compiled and posted on the Canadian Foundation for Healthcare Improvement’s Patient Engagement Resource Hub, a collection of more than 300 resources to help with patient and family engagement initiatives that will improve health and healthcare.
Under the leadership of the Operating Room Nurses Association of Canada, Canadian Anesthesiologists' Society and Doctors of BC, a report has been developed by a team at Ryerson University that synthesizes the current literature on communication and teamwork in surgical settings. Communications and Teamwork in the Perioperative Setting was published in March 2018.
Through a collaboration led by the Canadian Institute for Health Information, a 17-member working group from across the country identified a set of eight surgical indicators that would have broad applicability in Canada. The Common Set of National Surgical Safety Indicators is now under review by provincial and territorial health ministries to determine alignment of these indicators with those being collected currently.
A Joint Position Statement outlining the advocacy and support for use of a Surgical Safety Checklist has been adopted by the Canadian Patient Safety Institute, Alberta Health Services, Canadian Anesthesiologists’ Society and the Operating Room Nurses’ Association of Canada. The purpose of the statement is to convey the commitment of these organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist. Support for the Joint Position Statement in the surgical community is widespread. The Joint Position Statement also acknowledges "never events" and empowers providers in their use of available preventative measures.
The work of Enhanced Recovery Canada on surgical safety best practices will be rolled into the Canadian Patient Safety Institute’s 2018-2023 Business Plan. Six working groups have been established to adapt and adopt existing evidence based guidelines and an implementation strategy is being planned for 2019-20.
The 10 actions identified in the Medication Safety Action Plan are now complete with many of the initiatives continuing in 2018-19 to expand the use of the 5 Questions to Ask About Your Medications, patient-centred tools for opioid safety, and the Med Safety Exchange webinar series. Medication Safety Action Team partners attended three face-to-face meetings to foster completion of their initiatives.
Through the Joint Statement of Action to Address the Opioid Crisis, the Canadian Patient Safety Institute, Institute for Safe Medication Practices Canada and Patients for Patient Safety Canada are working to empower patients and improve their knowledge about the use of opioids and options for non-medication treatment of pain. Two new tools are now available, including an information card that provides guidance on the safe storage and disposal of opioids in the home. The second is a handout to assist patients who have recently been prescribed an opioid following surgery. Common questions are addressed to ensure that patients, families and caregivers have a thorough understanding of how to take these medications properly and safely.
Promotion, endorsement and support for the 5 Questions to Ask About Your Medications tool continues to increase across Canada and internationally. Over 70 organizations and regional health authorities have formally endorsed the tool for use within their organizations and the tool has been translated into over 15 languages.
In partnership with ISMP Canada, a national interactive webinar series was delivered to facilitate shared learning from medication incident analyses and safety initiatives. The Med Safety Exchange delivered six one-hour webinars between September 2017 and February 2018. On average, there were 237 attendees at each of the webinars. Frontline practitioners from organizations across Canada shared key learnings to encourage participants to identify similar vulnerabilities and safety opportunities in their own systems and contribute their own strategies for dealing with identified medication safety issues. The series will continue in 2018-19, with a focus on topic areas of the WHO Global Medication Challenge: Medication without harm.
As the Canadian coordinating body responsible for leading planning and implementation of the WHO 3rd Global Patient Safety Challenge Medication Without Harm, the Canadian Patient Safety Institute contributed to several expert consultations related to the development of several technical reports
(polypharmacy, transitions of care, high-risk situations) and the overall implementation and measurement strategy. The Canadian Patient Safety Institute also led a number of initial discussions and garnered support from stakeholders and partners to coordinate Canada’s contributions to the Challenge, beginning in 2018-19.
Home Care Safety
The Home Care Safety Action Plan focuses on incorporating new and emerging evidence in medication safety and falls prevention into home care delivery. A total of 12 actions were completed at the end of the 2017-18 fiscal year. The Home Care Action Team held three face-to-face meetings to advance the Home Care Safety Action Plan.
Seven teams from across the country participated in Wave Two of the Home Care Safety Collaborative to better understand measurement and quality improvement (QI) principles, and to apply the QI methodology to a local issue in order to improve safety for their clients. During the course of the Collaborative, 14 virtual learning sessions were hosted, each with a range of 25 to 90 participants. The 14-month Collaborative wrapped up in February 2018 with a final symposium where teams reported on their progress and lessons learned. An independent evaluation of Wave Two of the Collaborative is now in the works.
Am I Safe? provides tools and resources to support conversations about safety in the home. The publication was highlighted in a poster presentation displayed at the Institute for Health Care Improvement (IHI) National Forum on Quality Improvement, held in December 2017.
Going forward, the Canadian Patient Safety Institute will build on the Home Care framework to develop a learning series and resource toolkit using Canadian Institute for Health Information data.
Infection Prevention and Control
The Infection Prevention and Control Action Plan had six actions completed as of March 31, 2018. A total of three face-to-face meetings were held to complete the actions.
Key highlights for the year include: an environmental scan of infection prevention and control, and behavioural change campaigns that helped to inform the annual STOP! Clean Your Hands Day, held May 5, 2017; development of a knowledge translation and implementation science module that can be utilized with any Canadian Patient Safety Institute patient safety improvement project and existing curriculum; and the delivery of an interactive webinar series to create awareness of barriers to knowledge translation principles and assist in identifying barriers to uptake of the knowledge.
Collaborative partnerships have been developed that support the measurement and surveillance of healthcare-associated infections (HAI) to improve consistency of surveillance practices within both acute and long term care settings. IPAC Canada and the Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada) have been leading the work to promote the wide-spread adoption and application of a pan-Canadian set of common HAI indicators. A meeting of key provincial, territorial and national stakeholders is being planned to help advance the pan-Canadian adoption of these definitions. The Association for Medical Microbiologists Canada (AMMI Canada), Canadian Nosocomial Infection Surveillance Program (CNISP), Canadian Patient Safety Institute, Canadian Institute for Health Information (CIHI), Infection Prevention and Control Canada (IPAC Canada), and the Public Health Agency of Canada (PHAC) are collaborating to develop a proposal and implementation plan for pan-Canadian collection, analysis and reporting of healthcare associated infections.
With the support of the Knowledge Translation and Implementation Science Faculty, a six-part webinar series has been developed that is designed to build capacity in the basic principles of knowledge translation and implementation science. Each session builds upon one another and is ideally suited to those who can participate in the full series. The first two sessions were delivered in February and March 2018; the remaining four sessions will take place between April to June 2018.
Patient Safety Education
The Patient Safety Education Action Plan completed two actions to accelerate a consistent approach to patient safety and quality improvement education. The Action Plan team participated in four face-to-face meetings to discuss strategies and outcomes.
The Patient Safety Culture Bundle for CEOs and Senior Leaders, launched in February 2018, has been widely distributed and presented at multiple forums. The bundle is a key resource that provides useful guidance for senior leaders on the critical knowledge and actions needed to support improvements in safety culture and outcomes. The key components required for a Patient Safety Culture are identified under three pillars: enabling, enacting and learning. Within each pillar are links to valuable tools and resources to help healthcare leaders establish and sustain a patient safety culture.
The Hidden Curriculum refers to the influence that attitudes and ideas current in a practice setting can have on new team members and students who quickly learn how things are really done outside the classroom. A one-pager was developed by the Royal College of Physicians and Surgeons of Canada to highlight this phenomenon within healthcare. In the next phase tools and resources will be identified to support healthcare providers and leaders.
Work continues with academia and health professional regulators to embed safety competencies into health professional education and licensing/credentialing so that these are a core competency of all healthcare providers and leaders. Development of Curriculum Mapping has commenced; with an aim to simplify the proposed curriculum map relevant to its stakeholders.
The Patient Partnership in Curriculum initiative will identify tools and resources for teaching students, faculty/educators, and healthcare providers on how to have important conversations and partner with patients and families. A guide will be developed to integrate curricula on Partnering and Engaging with Patients and Families.
Case for Investing in Patient Safety in Canada
The Canadian Patient Safety Institute funded an independent study on the Case for Investing in Patient Safety in Canada. The report estimates that over the next 30 years, 12.1 million Canadians will be harmed by a patient safety incident (PSI) within acute and home care settings. This is equivalent to such events occurring in Canada every one minute and 18 seconds. Further, deaths due to PSIs occur every 13 minutes and 14 seconds. PSIs have the potential to cause serious illness and even death, with patients who experience harm having a higher mortality than those who do not. There could be roughly 40,000 average annual deaths due to PSI in Canada over the next 30 years. The statistics produced by RiskAnalytica drive our new strategic plan as we hope to curb the trend of patient safety incidents and educate the public, healthcare providers, and healthcare leaders on the universal importance of patient safety.
In 2017-18, there were 80 page views and 435 downloads of the Case for Investing in Patient Safety in Canada report.
Patient Safety Right Now
In February 2018, the Canadian Patient Safety Institute rolled out a new Business Plan for 2018-2023, PATIENT SAFETY RIGHT NOW. This call to action focuses on demonstrating what works and strengthening commitment to patient safety in Canada....right now!
The new direction rationalizes, focuses and aligns our efforts. The Business Plan includes an updated Vision, Mission Statement and Strategy:
- Vision Statement: Canada has the safest healthcare in the world.
- Mission Statement: To inspire and advance a culture committed to sustained improvement for safer healthcare.
- Strategy: Lead system strategies to ensure safe healthcare by demonstrating what works and strengthening commitment.
Mechanisms to implement the strategy include these guiding principles:
- Implement – Implement safety improvement projects in priority areas to demonstrate what works.
- Evaluate – Embed evaluation in all Canadian Patient Safety Institute activities to assemble evidence of what works.
- Share with Purpose – Develop concrete strategies to share evidence and improvement knowledge.
- Raise the profile – Increase the profile of patient safety to raise expectations for improvement.
- Transparency – develop a comprehensive framework that addresses rights and obligations for transparency at all levels.
- Commitment – Strengthen commitment to safe care through policy regulation and accreditation.