FREE WEBINAR "Improving Patient Outcomes and Experience: How to Include the Patient and Family"

If you are interested in patient and family engagement in safety or other areas of health care, this looks like just the webinar and it is free registration.

Improving Patient Outcomes and Experience: How to Include the Patient and Family

The Agency for Healthcare Research and Quality tells patients that "The best way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results.” The Joint Commission encourages patients to be active participants through its SPEAK UP Campaign.

Unfortunately, the public mostly learns about patient safety through negative media stories. This thought-provoking presentation will teach you how it can be celebrated and how to encourage the patient's family takes some of the responsibility for safe care. Through storytelling and comparisons, Ms. Corina will leave you eager to include your patients and their families in patient safety.

But what exactly can the family do to be part of the team? How can they better understand their role in the patient's safety such as reducing falls, medication errors and hospital-acquired infections? Attend this webinar to learn how to communicate with families to make their presence work for you.

Participants will learn how to:

• Talk about patient safety with patients and their families to help ensure the best outcomes
• Teach patients’ guests about safety including falls, infections, medication safety, surgery safety and health literacy
• Reduce readmissions and injuries through clear, critical communication
• Get tips to develop a Patient Safety Advisory Council in your facility and learn how to choose the best representatives

Presenter

Ilene Corina, President and Founder of PULSE of New York

Selected as one of Modern Healthcare’s 100 Most Powerful People in Healthcare of 2009 and a Fellow of the AHA’s Patient Safety Leadership Training, Ilene Corina is a nationally recognized advocate for patient safety. She is the president and founder of PULSE of New York, a grassroots patient safety advocacy group that was formed in 1997. She runs support groups for survivors of medical injuries and develops patient safety programs for medical professionals and consumers of healthcare.

Ms. Corina has appeared as a patient-safety expert on CNN, Fox News and other television and radio news shows, and is a popular lecturer and author. She discusses the patient’s role in patient safety and the changing culture to form partnerships to improve outcomes. She also helps healthcare professionals work with patients and their families after a medical injury or death has occurred, and has developed curriculum on disclosure of medical errors.

Ms. Corina is a board member of the Joint Commission and the National Patient Safety Foundation, and has won numerous awards, including the 2010 MITSS HOPE award, presented by RL Solutions.

Optimizing Patient Safety Through IT Solutions: A Case Study

David Mosher presented to SickKids Patient Safety Symposium a personal case study titled "Optimizing Patient Safety through IT Solutions" based on his experience as the father of a child with complex care needs and a parent volunteer on SickKids family council and as a health care expert tasked with large scale mobile health care initiatives.

David describes his daughter as complex medically both in needs and in treatment concerns.

She also has an extremely wide circle of care extending to more than 10 sites at more than 5 different institutions.

As a father and IT professional, David then offers research and thoughts as to how technology adoption will improve the quality of information at the heart of patient safety.

Quality Information is Critical to Patient Safety

• “The majority of the key informants believed that the fundamental issue in patient safety and primary care is patient care information.”
(Kinston-Reichers et al., Cdn Patient Safety Institute)

• “During 32% of ER visits, missing information delays care”
(Stiell et al., 2004)

Increased Patient Safety Risk Factors

Can my wife and I get the answers right when under extreme stress?

What if we’re not there?

Very complex medical history/rare condition

My child cannot provide verbal feedback

Outbursts increase clinician stress, distracts and interrupts communication

Electronic Health Records are part of the solution

An E.H.R. provides a cross-provider, trusted healthcare record

But……….

• Is the info accessible at the point of care?
• Does it slow down the treatment process in E.R.?
• Is the information used to its potential?

Next Generation Mobile Devices Overcome the Access Barrier

- Light
- 10 hour battery life
- Intuitive user interface
- High resolution
- Built in cameras
- WiFi and 3G/4G
- Secure (no patient data on the device)
- Fast application deployment

Mobile Device Adoption is an unstoppable force in Healthcare

Clinical adoption of mobile devices is rising

• 72% of US Physicians use smartphones (Manhattan Research 2010)
• 52% look up patient information several times a day (Manhattan Research 2010)
• 50% of US physicians will have iPads by 2012 (Chilmark Research)
• 70% of Healthcare respondents plan to buy an iPad or similar device in the next year (HIMSS/BoxTone 2010 CompTIA 2010)
• 86% of Physicians with smartphones are interested in accessing EMR data by them (PwC 2010)

Conclusion

• The right information being available at the right time is crucial to patient safety

• E.H.R.s must be combined with mobile devices to have a meaningful impact

• IT can reduce the likelihood of errors that outside factors could introduce

David, thanks for sharing your presentation with us and for contributing to patient safety and family centered care at SickKids.

Canadian Paediatric Trigger Tool

The just published "Description of the development and validation of the Canadian Paediatric Trigger Tool" is a ground breaking contribution to pediatric patient safety co-written by Dr Anne Matlow, Medical Director of Patient Safety and Infection Prevention and Control at SickKids Hospital and member of the CAPHC Patient Safety Collaborative.

The CPTT is the first valid and reliable TT [trigger tool] for detecting harm in children and youth of all ages hospitalised in acute care. This 35-trigger tool is reliable and robust, and can be used in quality-improvement initiatives and for more rigorous research agendas. Future research should focus on improving the efficiency of the CPTT and investigating the differences between nurse and physician assessments of AEs [adverse events]... Such studies will enhance current efforts to raise the profile of paediatric patient safety issues.

...an AE was defined as an unintended injury or complication that results in disability at the time of discharge, death, prolonged hospital stay or subsequent hospitalisation, and is caused by healthcare management.... ‘Healthcare management’ included the actions of individual hospital staff, as well as the broader systems and care processes, and included acts of omission and commission.

Additional resources:

• Reducing Harm in Paediatric Care: Learning about Adverse Events using a Validated Canadian Paediatric Trigger Tool (Matlow: 2007) 
• Incidence and Types of Adverse Events in Children in Large Community Hospitals (Matlow: 2008)
• Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children's Hospitals (Takata: 2008) 
• video of trigger tool in use 
• trigger tool resources from the CAPHC Patient Safety Collaborative:
  "We know that we cannot prevent all Adverse Events, but if we eliminate or mitigate the harm from those that are preventable, we will greatly increase the safety of our healthcare delivery.  In order to do so, however, we must first be able to identify these events, a process that has been hampered to date by the lack of an appropriate paediatric tool."
• Adverse Events in the Neonatal Intensive Care Unit: Development, Testing, and Findings of an NICU-Focused Trigger Tool to Identify Harm in North American NICUs (Sharek: 2006)
• Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit (Silas: 2010) 

6th Annual Patient Safety Symposium is on Thursday June 10, 2010 8:00 AM - 4:00 PM: "Partnering in Patient Safety for a Better SickKids"

SickKids Patient Safety Symposium shines a spotlight on the work to keep patients safe from harm, to learn from adverse safety events and to create a culture of safety that includes the family and leads to effective changes by the bedsides and in the operating rooms.

In preparation for Accreditation Canada 2010, this year’s symposium will focus on enhancing awareness of the required organizational practices (ROPs) that organizations must have in place to enhance patient safety and to minimize risk. By highlighting presentations and activities underway throughout our organization, staff will have an increased awareness of ROPs focusing on the following patient safety areas: patient safety culture, communication, medication use, worklife, infection prevention, fall prevention and other risks. (Event details).

The Accreditation 2010 online resources include a full list of these required organizational practises in the ROP Handbook (PDF, 719Kb).

The Symposium includes three parent speakers, a rep on the Families as Partners in Patient Safety Committee and two reps on the Family Centred Care Advisory Council.

7:30 AM - 8:15 AM	Registration
8:15 AM - 8:30 AM	Welcome/Introductory Remarks
8:30 AM - 9:15 AM	Leadership’s Role in Patient Safety Joseph D’Cruz Professor of Strategic Management, Rotman School of Management
8:30 AM - 9:15 AM	Role of Leadership at SK’s Dr. Lawrence Roy Interim Vice-President, Medical and Academic Affairs
9:15 AM - 10:00 AM	Safe Surgery Checklist Dr. Chris Hayes Medical Officer, CPSI; Medical Dir. Quality & Patient Safety, St. Michael’s Hospital
9:15 AM - 10:00 AM	SickKids Safe Surgery Checklist Dr. James Robertson Staff Anaesthetist, SickKids
10:00 AM - 10:30 AM	Coffee Break/Posters
10:30 AM - 11:15 AM	"Disclosure Policy" Janice Campbell Risk Manager, SickKids
10:30 AM - 11:15 AM	Presentation on 'Just Culture' and 'Accountability' Aileen Killen Director, Patient Safety Program, Memorial Sloan-Ketting Cancer Centre, New York, NY
11:15 AM - 12:00 PM	Adverse Events related to narcotics Dr. Conor McDonnell Associate Staff; Anaesthesia, SickKids
11:15 AM - 12:00 PM	Medication Management- Accreditation Emily Musings Executive Director of Pharmacy, University Health Network
12:00 PM - 1:00 PM	Lunch
1:00 PM - 1:45 PM	Family Related Topics 1) FCCAC (Family-Centred Care Advisory Committee) Denise Clayton (Family Rep.) Jonathan Blumberg (Family Rep.) 2) FPPS (Families as Partners in Patient Safety Committee) Jane Ford (Family Rep.)
1:45 PM - 2:15 PM	Infection P & C topic (TBD) Rick Wray Director, Infection Prevention & Control, SickKids
1:45 PM - 2:15 PM	Virox Study: Knowledge, Attitudes & Behaviours of PSA’s Dr. Anne Matlow Medical Director, Patient Safety and Infection Prevention and Control
2:15 PM - 2:45 PM	Poster Awards/Presentations
2:45 PM - 3:00 PM	Coffee Break
3:00 PM - 3:30 PM	Safe Environment Initiative: - Safe Sleep - Falls/Entanglement Prevention Pam Hubley Associate Chief of Nursing, Practice; SickKids Rita Damignani QA/Patient Safety Coordinator, SickKids
3:30 PM - 4:00 PM	Team Capacity Building: Report on SCOPE project Michael Rothstein Infection Control Practitioner, SickKids
4:00 PM - 4:15 PM	Closing Remarks

NICU practise change to dedicated stethoscopes

Poster in a neonatal intensive care unit classroom, March 2010, describes the practise change to dedicated stethascopes after discovering the prevalence and persistence of microorganisms on the stethoscope bells. Each infant will now have its own stethoscope by the bedside.

Disclosure of medical error

One of the worst scenarios a family can face is a serious medical error. Having been at the bedside for months, I knew that the risk of an error grew with the expanding number and complexity of interventions and time in the hospital. Having met and been greatly impressed by several hospital staff working to improve patient safety, and the manner that they are including parents on committees, I found the following abstracts focusing on systems and patterns of disclosure of error to be quite interesting. The final article suggests that if there is a gap between policies and practise of open disclosure, explicit focus is needed not just on education but also on uncovering the barriers to implimentation of open disclosure policies.

A System Of Medical Error Disclosure (2002): Such a system can result using clear disclosure policies and procedures sensitive to patient and family needs, open communications with concerned, committed, and compassionate system representatives, and use of mediation methods that foster communication, allow for venting, and are flexible in their approach to resolving conflict, including using apology. Although a system may also result in conflict resolution costs, more importantly it may foster and solidify a team approach to reducing errors and promoting patient safety.

What Makes An Error Unacceptable (2004): Results. While the severity of the outcomes of errors remains the most important single factor in the choice of actions to be taken, the professional’s approach to the error is regarded as essential in the overall evaluation of errors and the consideration of consequences. In errors with a severe outcome, an honest, empathic, and accountable approach to the error decreases the probability of participants’ support for strong sanctions against the physician involved by 59%. Judgments were only marginally affected by respondents’ characteristics.

To Tell Or Not To Tell (2006) One published study [1] disclosed that only 50% of house staff physicians who admitted making serious clinical errors disclosed their errors to medical colleagues, and only 25% disclosed them to the patients or their families. In another published survey of laypersons, only a third of respondents who had experienced medical error said that the physicians involved in the error had informed them about it [2]. Still another survey asking European physicians whether they would disclose a medical error to patients found that although 70% responded that physicians should provide details of such an event, only 32% would actually disclose the details of what happened [3]. A similar percentage of American physicians, 77%, echoed the same opinion [2]. A British researcher explains this reluctance to disclose by pointing out that physicians who commit medical errors frequently question their own competence and fear being discovered; they know they should confess but "dread the prospect of potential punishment" [4]. These reactions are "reinforced during medical training; the culture of medical school and residency implies that mistakes are unacceptable and point to a failure of effort or character." Why physicians may choose to cover up rather than disclose an error was illustrated in a letter to the editor published in the Journal of the American Medical Association [5]. The letter described an incident in which a medical resident's employment in a Chicago hospital was summarily terminated after he voluntarily reported committing an error that led to the accidental exposure of a patient to HIV. The letter writer speculated that the resident's career would have remained intact and unblemished had he chosen to remain silent about the error and voiced concern that this incident would encourage an atmosphere that rewards lying. Certainly, many physicians believe that admitting mistakes invokes the so-called shame and blame mentality [6], thereby precipitating medical malpractice litigation [7-9] and leading to loss of referrals, hospital admitting privileges, preferred provider status, and even licensure [10, 11]. Other researchers [12] have emphasized that being subjected to a malpractice lawsuit is "an extremely powerful punishment that strikes at the heart of the professional's self-image as a caring and competent physician." The question of whether mistakes or errors committed by physicians should be disclosed to patients affected by them is no longer debatable. The preponderance of legal opinion, regulations of federal and state agencies, and policies of professional organizations all favor the physician's complete disclosure of all facts and information relevant to a patient's health, including complications of medical procedures and iatrogenic errors and injuries [13-16]. But the question of what physicians should say to patients as part of the disclosure of an error—in other words, whether they should apologize and, if so, what that apology should include—warrants further discussion.


Health Care Professionals' Views Of Implementing A Policy Of Open Disclosure Of Errors (2008): Results: Health professionals are positive about open disclosure and are applying the model to patient–clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals.

Conclusion: Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.

Learning from the life and death of Annie Farlow

Parents of children with severe medical conditions face many fears about their children's quality of life and long term prospects and open communication with a skilled and empathetic medical team is an anchor support. Parents of children with severe cognitive deficits may face another fear, however, that hospital care priorities or individual staff prejudices (however benevalently framed) will impact their child without being transparent in the care discussion.

Annie Farlow arrived in this world to a loving family, aware of and prepared for the cognitive and developmental impacts of her condition. Barbara and Tim Farlow's journey to understand the circumstances of Annie's death in an unnamed Toronto pediatric ICU challenge us to look at one of the most disturbing fears of parents of seriously challenged children:

"Do some doctors play God with disabled kids? Are treatable but possibly fatal problems, such as digestive obstructions or respiratory difficulties, sometimes left to take their course when a child has a condition like cerebral palsy or Down syndrome or, in Annie's case, Trisomy 13? Do some medical professionals mask their own quality-of-life opinions by giving parents only the worst-case scenario, leading to what Farlow calls "misinformed consent"? What can families do to change things?... As a member of the Canadian Patient Safety Institute and Patients for Patient Safety Canada, part of the World Health Organization's Alliance for Patient Safety, Farlow says she wants to bring more accountability and respect for life to the system. This is not about advocating prolonging life at any cost, she emphasizes. It's about patient-centred care in which the family is included in an informed decision-making process. Some families may feel comfortable knowing they will be giving birth to a child with disabilities; others may not, she says. Either way, their wishes should be respected through a process that is transparent and accountable."

You can read the full article by Helen Henderson and view the family website that remembers Annie and reminds us all that the ultimate test of patient and family centred care is its application to the most vulnerable of our developmentally challenged children.

2008 Patient Safety Symposium - Communication is Key

Sickkids Hospital's 4rth Annual Partners in Pediatric Patient Safety Symposium organized by Dr Anne Matlow and Polly Stevens on June 11 offers much to anyone interested in effective patient and family and staff partnership. The Sasha Bella Fund is thrilled to support the collective work of the patient safety committees. Registration deadline is May 16, cost is $150 (some bursaries available) and here is the exciting list of speakers.

COMMUNICATION IS KEY!

7:15 am Registration & Breakfast

8:00 am WELCOME Mary Jo Haddad, CEO The Hospital for Sick Children

8:05 am HEALTHIER CHILDREN. A BETTER WORLD: USING COMMUNICATIONS TO IMPROVE THE HEALTH OF CHILDREN IN THE THIRD WORLD Gord Martineau CityTV, Toronto

9:00 am COMMUNICATION FOR INFECTION CONTROL: THE WORDS WE USE Anne Matlow, MD SickKids

9:45 am Break

COMMUNICATING BETTER WITH OTHER PROVIDERS

10:15 am THE IMPACT ON TEAMWORK Lorelei Lingard, PhD SickKids Learning Institute

11:15 am THE IMPACT OF USING STANDARDIZED COMMUNICATION TOOLS (SBAR) FOR PATIENT SAFETY Karima Velji, RN, PhD Toronto Rehabilitation Institute

12:00 pm Lunch

1:00 pm WE NEED TO TALK: SAFETY AND COMMUNICATION Robert Buckman, MB, PhD Princess Margaret Hospital, Toronto. Toronto Book author, “How to Break Bad News”

2:00 pm I AM THE VOICE OF MY CHILD Elaine Tal-El, MA A.V. Israel

2:30 pm “WHO” ARE WE? LEARNING FROM THE LIVED EXPERIENCE Katarina Stanisic, RN, BN Toronto Rehabilitation Institute WHO, World Alliance for Patient Safety

3:00pm QUALITY / PATIENT SAFETY ACHIEVEMENT AWARD AND PRESENTATION

3:15 pm FAMILIES AS PARTNERS IN PATIENT SAFETY AWARD AND PRESENTATION

3:30 pm WRAP-UP AND CONCLUDING REMARKS

Speaker Biographies:

Robert Buckman, MB, PhD, FRCPC Professor, Department of Medicine, University of Toronto Oncologist, Princess Margaret Hospital, Toronto Book author, “How to Break Bad News”

Lorelei Lingard, PhD Associate Professor & Scientist, University of Toronto SickKids Learning Institute, The Hospital for Sick Children, Toronto

Gord Martineau Anchor, "CityNews at Six", CityTV 2007 Gemini Award, Best News Anchor; 2007 Radio and Television News Directors' Lifetime Achievement Award

Anne Matlow, MD, FRCPC Director, Infection Prevention and Control Medical Director, Patient Safety The Hospital for Sick Children, Toronto

Katarina Stanisic, RN, BN Patient Safety Officer Toronto Rehabilitation Institute, Toronto World Health Organization, World Alliance for Patient Safety, Patient Safety Champion

Elaine Tal-El, MA Chief Executive, Auditory-Verbal Israel, Jerusalem, Israel Parent

Karima Velji, RN, PhD Vice President, Patient Care and Chief Nursing Executive Toronto Rehabilitation Institute, Toronto

Download or View 2008 Sickkids Hospital Patient Safety Symposium Brochure (PDF, 107KB)

Patient Safety - Ryan Sidorchuk at SickKids

[This is based on my notes without a review of the detailed presentation so I am solely responsible for any errors. Should you see mistakes, please let me know.]

On January 16, 2008, Ryan Sidorchuk (Patient Voice Facilitation at the Winnipeg Regional Health Authority and advocate within WHO World Alliance for Patient Safety "Patients for Patient Safety" movement) spoke to about 50 SickKids staff on Patient Safety Rounds. The talk was titled Families to Improve Patient Safety, Satisfaction with Quality of Care, and Clinical Outcomes.

Ryan's 45 minute powerpoint presentation on parents as patient safety experts and communication strategies for staff was focused, useful, heartfelt with plain talk anecdotes, context and stories punctuating his slides.

Ryan remembered the call from his wife telling him that his daughter at age two had been diagnosed with cancer. Worse, and what started a new life for Ryan, was that the wrong diagnosis for cancer subjected her little body to poisonous doses of chemotherapy. As he puts it bluntly: "She spent the last month of her life in ICU with her belly open."

In addition to the mis-diagnosis, Ryan's careful research and presentation of several treatment options were ignored by hospital staff. More than one of these experimental treatments are now routine. Ryan and his wife divorced, each reminding the other of their child's horrible death. After experiencing first hand a wrong diagnosis leading to unnecessary pain, suffering and death, Ryan accepted a position as a patient safety representative in Manitoba.

On a positive note, "Ontario is leading the way with Interprofessional Practise." Much of the talk focused on elements that constitute trust in a care-family partnership. Respect, sharing uncertainty, truth telling, plain speaking, forging partnerships. There is a power dynamic seen in a very simple observation: how often do you see patients asking doctors to wash their hands on entry to their room? "Health care is only slightly harder to change than the Vatican."

I loved his reference to my childhood hero Saul Alinsky who went out into communities to help grassroots organizing. With their first parent safety committee Ryan admits that, with their mandate, "we left it open-ended and that was a mistake". Despite work, "The process to lodge complaint against a physician is a very disjointed process". Taking up matters with the Patient Rep is retroactive, the damage has already been done.

It was good to hear that Canada is a world leader on Patient Safety. [That also means we take seriously perceived gaps between rhetoric and practice.] At a conference in San Francisco in 2005 he recalled how the North Americans focused on technical and organization solutions while he was struck by the South American focus on the care process itself and how it could be humanised.

He delved into how measurement can be sufficient to promote quality. There is an old saying (Dennings?) that you can only measure 3% of what matters. Important is not to focus only on the numbers as much as the process and the dynamic. Capra, Bohm, Plsek suggest to look at patterns and not outcomes to effect change. Relationships, decisionmaking, power (who has, who has less), how manage conflict. How learn. He also differentiated simple, complicated and complex tasks and notes, from Plsek: "Healthcare is a complex adaptive system."

He differentiated Quality (the degree of excellence) from Safety (freedom from danger or risks and reduction of preventable harm) and pointed out that attempts to improve quality of life can inherently put the patient at risk. Safety is a core value, not a commodity and safety shows itself by events that do not happen.

Ryan also referred to Deborah B Gardiner's Ten Lessons in Collaboration from Online Journal of Issues in Nursing (January/2005). (They are so interesting I reproduced, from the appendix, the Table 1 Summary of Collaboration Lessons below).

"Those that will get along will usually get out alive" and, later: "We all know the patient better than the care-givers." An issue grappled with by safety advocates is when does safety trump privacy?

Ryan then showed a film with several parents speaking about tragic deaths due to medical error. Each of them described what their kids went through. "As parents, we see medical error from start to finish. Few others will." These voices he reminded us are not only sad stories but powerful reminders and powerful learning opportunities. For Ryan it was as simple as: "Noone told me jaundice can cause brain damage with cerebral palsy". For an Irish mom it was that "Doctors dont realize that whey they treat us poorly, they create another patient. We go away sick." Another talked of being blacklisted by the top pediatrician in her state from getting medical coverage.

Others touched on a very interesting reality. When a child dies in ambiguous circumstances, there is a tension between hospital staff being transparent and empathetic and growing concern about liability. Most parents natural inclination is to be satisfied with genuine efforts at remedy that protect other patients. Parents described staff responses in the immediate aftermath as heartfelt, with apologies and offers to remedy. Where the discussion about specific remedies break down and parent's still persist, hospitals can draw up the wagons and the initial empathetic nurse or administrator is replaced by hospital lawyers facing off against parent's lawyer in a no holds barred legal struggle.

I have come to realize that patient safety work is a key hubs of family centred participation. Working within their own organization, associated with the World Health Organization, patient safety committees are impacting hospitals, providing commitment, protocals and pressure from outside the hospital. They meet with ethicists, geneticists and themselves become expert on patient processes. Often they develop this expertise because they are shut out from any remedy at the hospital where the tragedy happened.