Quality & Patient

Safety TOH
Linda Hunter
Director, Quality and Patient Safety
2011
 Champlain LHIN

Deep River & District Hospital

Ottawa Area Hospitals

- The Ottawa Hospital
Pembroke General Hospital - Royal Ottawa
- CHEO
- Montfort
- Bruyere Continuing Care Hawkesbury & District General Hospital
- Queensway-Carleton 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 Cornwall General Hospital

Hotel Dieu Hospital

Perth & Smith's Falls District Hospital

 The Ottawa Hospital
Facts and Figures

Capacity Activity
• ~$1B Operating • 46,000 Admissions
Budget
• 49,000 Surgical Cases
• 1,172 Inpatient Beds
• 127,000 ED Visits
• 12,000 Staff
• 1,200 Physicians
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
Access Effectiveness Efficiency Safety Satisfaction
Outcomes Wait Times: Re-admission rates ALOS-ELOS HSMR Overall
DI, Hip/Knee, Surg. Site Infections CPWC Hospital Infections: Pain
Cancer & ED MRSA, VRE & C- Transition
Difficile

Culture Create a culture of compassionate people, world-class care

Service Excellence Performance Physician Engagement &
Milestones Measurement Accountability
& Tactics
Patient Experience
Enabling environments

Clinical transformations

Staff Engagement
Our Patients Quality Plan
Research Plan
Our Staff Human Resources Plan
Our Finances Operating Plan
Our Capital Plan
Environment
Information Services Plan
Our Partners Communication & Community Outreach Plan
Respect
Values Commitment to Working Together for the Individual Compassion
Quality
 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)
SATISFACTION
Health services are respectful and
responsive to user needs,
preferences and expectations
(HQCA)
SAFETY
Patients should not be harmed by
an accident or mistakes when they
receive care (OHQC)
APPROPRIATE
Efficient: The hospital should continually
look for ways to reduce waste, including
waste of supplies, equipment, time,
ideas and information (OHQC)
Effective: Patients should receive care
that achieves the expected benefit and
is based on the best available scientific
information (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)
Appropriate
Effective
Ottawa Model for Diabetes (Q)
Inpatient satisfaction with pain control (Q)
•Medicine
•Surgery
•Obstetrics and Gynecology
•Emergency Department
•Rehabilitation
 - Data currently available Central Line Infection rate (Q)
A - Reported annually
Q - Reported quarterly
Efficient
Cost per weighted case (A)
% clinical pathways revised (Q)
# new clinical pathways /
program (Q)
Safety
Ventilator Associated Pneumonia rate (Q)
Surgical Site Infection rate (Q)
Hand Hygiene compliance rate (Q)
Hip fractures receiving surgery < 48
hours (Q)
C Difficile rate (Q)
MRSA rate (Q)
VRE rate (Q)
HSMR (Q)
Satisfaction
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: For MOH Public Reporting:
• Percentage of patients • CLI rate
receiving medication
• VAP rate
reconciliation at admission
• MRSA
• MRSA infection rate
• C. Diff
• C. Diff infection rate
• VRE
• Rate of post surgical infections
• SSI antibx
• Rate of timely administration of
prophylactic antibiotic • HH compliance
• HSMR
Submitted quarterly in each three • SSCL
year cycle
Submitted quarterly to annually
 2010/2011 Public Reporting Indicators
Jun-10 Q1 Q1 Q1 Q1 Q1 Q1 Mar-10 Mar-10 FY08-09

Institution/Health Centre Campus HH % HH %

C Diff MRSA VRE CLI VAP SSIP SSCC Before Pt. After Pt. HSMR
Env. Env

TOH Civic 0.46 0.03 0 1.03 2.63 91.8% 99.6% 65.26 83.44
94
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

Sunnybrook 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 92

Hamilton Health Science Centre 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 0 103

London Health Science Centre 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 95.5% 99.9% 37.15 65.89 77

UHN Princess M 0.3 0 0 100.0% 56.26 79.83

Not Eligible

Updated Jan 2011

 Reporting:
Infection Rates
Central Line Bloodstream Infections / 1,000 Line Days

3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Nov-09

Nov-10
Jul-10
Jan-10

Jun-10
May-
Dec-09

Feb-10

Mar-10

Apr-10

Aug-10

Sep-10

Oct-10

Dec-10
10
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 Maximal Barrier Precautions Used
100%
97% 97% 98% 97%
100% 96% 100%
93% 92% 92%
95% 90% 77% 73% 73% 76%
80% 68% 69% 71%
90% 62% 64% 64%
85% 60% 47%
80% 76%
73% 71% 40%
75%
70%
20% 6%
65% 5%
60% 0%
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 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

Hand Hygiene Target Full barrier precautions Target

Chlorhexadine Skin Antisepsis Optimal Catheter Site Selection

100% 100% 100%
98% 97% 98% 98% 97% 98% 98% 98%
100% 97% 97% 98% 100% 97%
96% 96% 97% 95% 94% 94%
94% 95% 91%
95% 93%
91% 90%
89%
90% 85%
80%
85%
75%

80% 70%
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 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

Skin asepsis Target Optimal site selection Target

 Reporting:
Ventilator Associated Pneumonia
Head of Bed Elevation Over 30 Degrees Use of EVAC ETT
100.0% 100.0% 100.0%
99.0% 99.0% 98.3% 96.4% 96.0%
100% 97.5% 98.2% 98.2% 97.7% 100% 94.5% 93.6% 94.4%
92.8% 91.7% 93.0% 92.4%
96.0% 95.8% 90.0% 89.9%
95.3% 87.8%
90%
95% 81.4%
80%
90%
70%

85% 60%
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 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

HOB Elevated Goal EVAC ETT Goal

Use of Oral vs Nasal Tubes Daily Sedation Vacation

95.0% 94.8% 93.1% 95.3% 95.3% 95.8% 100.0% 96.7% 96.5% 96.6%
100% 92.9% 92.3% 92.6% 91.8% 96.0%
87.9% 94.6% 94.8% 94.5% 94.4% 94.2%
90% 95.0% 92.6%
79.6%
73.8%
80% 90.0%
85.0% 85.0%
70%
85.0%
60% 79.6%
50% 80.0%
40% 75.0%
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 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

OG Tube Goal Sedation Vacation 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
 Focus on how we can
Response prevent and intercept
errors
Analysis  Statistical data that can be
analyzed to determine
trends
Detection
 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
Voluntary reporting
Ongoing Electronic triggers
Surveillance
Identify

Patient Safety
Learning System
Report/
Record

TOH Risk Management

Quality Coordinators
Analyze/ Data Warehouse
Patient Safety
Classify Department Head/Clinical
Learning
Experts TOH Critical Incident
System Severity of risk or Policy & Procedure
AE will determine
Department & Escalate
work flow
Division Front
Line Staff Department/Function
QI Internal Process
System
Improvement Causal
Analysis
Safety Rounds
M&M Rounds
Data Warehouse AE Analysis
Corrective
Action

Learn &
Educate
 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. Determine the team
2. Organize the meeting
3. Gather information and the facts of the incident
 Who, What, Where, When but not the Why
4. At the meeting
 Review the information gathered and determine what did
happen compared with what should have happened
5. Determine contributing factors and root causes
 Keep asking “why” until the contributing factors and root
causes are found
6. Develop actions and determine performance measurements
7. Implement the actions
8. 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?