Potentially harmful mistakes can happen in a healthcare system. Human error cannot be avoided entirely, so we need to better support our physicians and employees, as well as improve our systems and processes, to eliminate preventable harm.
That is why Saskatoon Health Region is devoting its second 90-day initiative to safety, with the aim of achieving new breakthrough approaches to safety issues that have an impact on care and addressing the organizational challenges that impede us from preventing harm.
“Safety is everyone’s responsibility,” says Petrina McGrath, Team Co-Lead for the Safer Every Day 90-day initiative. “However, we know that our system and processes aren’t always set up to help us prevent harm to our patients and staff, or to catch mistakes. Zero human error is impossible in any system, but zero preventable harm is completely possible by building strong teams that support each other and designing safety into our processes.”
This 90-day initiative is another phase of a strategy to eliminate preventable harm by 2020.
Six initial teams will be working on areas of top concern identified by patients, residents, clients, physicians and employees, as well as from data collected from the Hospital Standardized Mortality Rate (HSMR) report and other reporting systems. These teams will be led by Petrina McGrath, Vice-President of People, Practice and Quality, and Dr. Susan Shaw with the Region’s adult and critical care division and the chair of the Health Quality Council. They will also be working with a group of physicians, department heads, Health Region vice-presidents and patient and family advisors, who will oversee all the teams’ work to ensure success.
“From our patients, physicians and employees, we heard that we need to talk about near misses and harmful events more openly in order to learn how to make the Region safer,” says Dr. Susan Shaw, Team Co-Lead. “When harm occurs, patients, families and their healthcare providers are all affected, and they all require support. The patient must come first, and we also need to ensure that our teams have the right skills, information and support to solve unsafe situations before harm happens and to provide the correct supports when it does.”
Currently the six main areas of focus are:
• Team Communication and Performance – This team will focus on developing and sustaining better communication among patients, families and healthcare professionals to anticipate and catch mistakes before they occur.
• Leadership and Management for Safety – This team will create a safety learning system to better respond to and learn from safety issues. The team will also look at how to close the information loop around safety concerns with patients, families, physicians and staff.
• Psychological Safety and Staff Support - This team will examine the impact that critical incidents have on staff and physicians and will examine the support required to build resilience.
• Building Capacity for Safety and Quality Improvement – This team will examine how to build stronger physician partnerships while developing staff and physician skills and capacity to lead improvements in safety and quality.
• Clinical Process Improvements – This team will test a new model of clinical improvement, involving multiple departments and professions, with a focus on early recognition and treatment of sepsis in patients already admitted to hospital.
• Mortality Review - This team will design and test a new process to review and learn from all inpatient deaths.
The goals for the Safer Every Day 90-day initiative are to:
• Create and test a model for team communication and performance that anticipates and catches mistakes before they occur.
• Equip physicians to enhance their leadership skills in safety and quality improvement through a training program with a focus on new physicians.
• Build a structured approach to provide opportunities for teams to identify and solve mistake-prone situations at the point-of-care and service.
• Standardize the leadership response to safety issues and design processes to learn from and implement improvements.
• Learn how to design and support interprofessional clinical improvements, beginning with early recognition and treatment of individuals who develop sepsis after admission to hospital.
• Develop a consistent approach to support patients, families, staff and physicians following a traumatic incident.
“If we are able to achieve these goals at the end of 90 days, then we’ll know we’ve made a difference,” says McGrath.
“This work is so important to guiding how we improve our practices and processes and to how we work together with our patients and staff in becoming safer every day,” adds Dr. Shaw.
For Safer Every Day updates, visit saskatoonhealthregion.ca/news
Everyone has a safety story to share. Watch Logan's here.