Muskoka Algonquin Healthcare Patient Safety Plan

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1 Muskoka Algonquin Healthcare Patient Safety Plan Muskoka Algonquin Healthcare s (MAHC) three year patient safety plan is designed to support and promote the mission, vision, and values of its organization, with a special focus on the delivery of safe care and continuous improvement for all patients. This plan defines MAHC s safety priorities as well as the organizational infrastructure to support the delivery of safe quality care, including the mechanisms to respond to patient safety concerns and make system wide improvements. The patient safety plan supports MAHC s: mission of providing outstanding care, people focused. vision to provide quality and safety through the provision of outstanding care and service. strategy to commit to patient and provider safety and quality outcomes by focusing on process improvement, technology and the incorporation of evidence based best practices on an ongoing basis. Plan Objectives: The objectives of the plan are to: Encourage and promote a culture of patient safety at all levels across the organization. Promote organizational commitment to and accountability for safety through the selection of priority initiatives that are aligned with the organization s quality and safety goals and objectives and provincial patient safety priorities. Articulate the organization s safety and quality goals and objectives to all staff and physicians. Support the effective disclosure and reporting of events/incidents to help create a culture of openness and improvement. Encourage the ongoing monitoring of risks within the organization. Engage patients and their families in understanding their role in promoting patient safety. MAHC participates in the three year cycle of accreditation through Accreditation Canada. This plan will address and identify strategies for MAHC to meet and exceed Accreditation Canada s required organizational practices and patient safety goals.

2 Scope: The Scope refers to the types of incidents that will be addressed by the organization s plan. At MAHC, the patient safety plan will address the following types of events/incidents (as per Safety Incident Reporting policy ADM V 03 v.0): Occurrence: as defined by JCAHO is an unexpected occurrence involving the death or serious physical or psychological injury or risk thereof (near miss). This would include any event that is not consistent with the normal or usual operation of the hospital. Note: Injury does NOT have to have occurred. The potential for injury and/or property damage (financial loss) is sufficient for an occurrence to be considered an incident. Critical/Sentinel Event: Identifies a rare, adverse or potentially avoidable occurrence that has the potential to result in: Significant threat to patients, residents, employees, volunteers or visitors Imminent litigation Significant financial loss Significant damage to the reputation. Patient Safety Events (as defined in Safety Incident Reporting policy) Minor event: an event involving no harm or very minimal temporary harm to the patient Moderate event: an event that causes discomfort sufficient to interfere with usual activity and requires additional specific therapeutic intervention, but poses no significant or permanent risk of harm to the patient Major Near Miss: an event that would have resulted in death or serious physical or psychological injury but did not because it was caught or because of good luck. Major event: an event involving death or serious physical or psychological injury. These events should not be considered stuff that just happens. Nor should they be considered inevitable. Investigation, Analysis and Reduction of Risks All serious occurrences/incidents that have safety or major risk concerns or which result or could result in injury/illness must be documented and reported on the patient/visitor safety incident/near miss form. Safety reporting is the responsibility of all staff and medical personnel and provides an opportunity to identify and trend events as well as track their follow up. Knowledge generated from the reporting and review process provides MAHC with the opportunity to make system wide improvements. MAHC Senior Leadership must continue to support a culture of patient safety and encourage the reporting and full disclosure of patient safety incidents/events as well as support improvement strategies to prevent recurrence.

3 In accordance with the incident reporting policy, once an incident report has been completed, Administration will be responsible for creating a consolidated report of the types of incidents on a monthly basis, which in turn is reported to the Quality Council and Quality Committee. Information from the incident reports are analyzed and integrated into the hospital s performance monitoring tool, Quality Matters Balanced Scorecard. Moderate and Major Incidents are reviewed by the Quality committee and recommendations are made to improve practices to prevent similar incidents and communication of the recommendations to frontline staff will occur. Effective Oct st, 20 MAHC will start reporting all critical incidents related to medication/iv fluid that occur to the Canadian Institute for Health Informations(CIHI)National system for Incident Reporting(NSIR). MAHC will have thirty (30) days to initiate the report after disclosing the critical incident to the MAC, an administrator and/or a patient. The initial report requires only minimal information; additional details can be added over the next 30 days. Plan Structure (Roles and Responsibilities): It is generally understood that in a culture that supports and encourages safety, there is shared ownership for patient safety. However, for ongoing sustainability and improvement, best practice suggests that overall accountability and leadership for the achievement of patient safety goals be maintained at the Board and Senior Management levels. Management & Oversight The Chief Executive Officer will provide general oversight of the effectiveness of the patient safety plan. The MAHC Quality Council is responsible for providing monthly reports on the achievement of performance measures or targets, as defined in the patient safety plan, to the Board Quality Committee. The Quality Council will also be responsible for monitoring progress, measures, and risks and identifying additional priority areas. All incidents discussed at Quality Council are protected, as quality of care reviews, under FIPPA(Freedom of Information and Protection of Privacy Act), 202. The Quality Committee of the Board of Directors, as defined through its Terms of Reference, is accountable for the quality and safety of patient care and service delivery. The Quality Committee, as per the Excellent Care for All Act will also be responsible for: Monitoring and reporting to the Board on quality issues and on the overall quality of services provided in the health care organization, with reference to appropriate data. Consider and make recommendations to the Board regarding quality improvement initiatives and policies.

4 Ensure that best practice information, supported by available scientific evidence, is translated into materials that are distributed to employees and persons providing services within the health care organization, and to subsequently monitor the use of these materials by these people. Oversee the preparation of and approve the annual quality improvement plans The Quality Council, as defined through its Terms of Reference, will: ) Provide leadership in identifying opportunities for improving quality of care 2) To promote the MAHC mission and strategic plan s goals and objectives in each of the hospital sites of MAHC and the CCAC 3) To gather, monitor and evaluate clinical quality indicator data 4) To gather, monitor and evaluate sentinel event reporting and track changes to systems and process to reduce the possibility of future occurrences 5) To initiate, monitor and evaluate cross functional CQI activities 6) Conduct risk assessments to identify potential risks and ways to eliminate them 7) To provide education to staff, physicians and volunteers to minimize and eliminate risk exposure 8) To carry on activities for the purpose of studying, assessing or evaluating the provision of health care with a view to improving or maintaining the quality of health care, or the level of skill, knowledge and competence of the persons who provide health care. Composition of MAHC Quality Committee ) The Vice Chair who may serve as Chair 2) One third of members must be voting members of the Board of Directors 3) One physician member of the Medical Advisory Committee 4) The Senior Director Patient Care, Clinical Services & Chief Nursing Officer 5) The Chief Executive Officer 6) One Member of a Regulated Health Profession 7) Other members as appointed by the Board of Directors 8) The Board Chair, the CEO, and the Chief of Medical Staff who shall be ex officio Composition of MAHC Quality Council

5 ) Chief of Staff* 2) Member of the Medical Staff 3) Chief Nursing Officer* 4) Chief of Professional and Diagnostic Services Officer* 5) OR Surgical Services Manager 6) Infection Control Manager 7) Health Records Manager 8) Acute Care Site Manager (rotate between three sites, starting with Burk s Falls) 9) Diagnostic/Therapeutics Middle Manager (one of DI, Lab, Pharmacy) 0) Nurse Manager, Complex Continuing Care, Long Term Care & Transitional Care ) CEO (ex officio) 2) Staff appointee from each site *eligible to be chair Implementation A designated executive or management lead will sponsor and be accountable for the achievement of a patient safety priority area. They will be responsible for ensuring the strategy is achieved and provide general oversight for any work plans or targets identified. Project leads for each initiative are identified and will be accountable to the executive/management lead. Board of Directors Medical Advisory Committee Quality Committee Chief Executive Officer Quality Council

6 Sustainability To ensure and support the sustainability of the patient safety initiatives implemented identified below, it is important that all staff and physicians understand the objectives of the plan and have a role to play in its implementation.

7 Patient Safety Initiatives Goal Objective Priority Support and engage the Board of Directors in promoting a culture of safety Develop and maintain a patient safety culture across the organization Review and refine the accountability structure for quality and safety at the Governance level Board approval of MAHC safety plan Formalize and develop Terms of Reference for Board Quality Committee (ensure alignment with the Excellent Care for All Act, requirements) Monthly patient stories presented to Quality Committee and to the Board, as a whole Provide quarterly reports to the Board and Quality Committee on patient safety indicators and critical incident data % of time at Board meeting focused on patient safety >5% of Board meeting time spent on quality/patient safety Y CEO 2 Provide patient safety education for Trustees (i.e. OHA courses; IHI Courses or by MAHC Certified Patient Safety Trainers) Participation rate Y Identify and measure a core set of big dot patient safety indicators approved by the Board Patient safety Indicator rates/big Dot Indicator (i.e. falls, pressure ulcer) 0% annual reduction in # of injurious falls by year 3 Y Y3

8 Goal Objective Priority Integrate patient Refine strategic plan to safety into the include patient safety as a strategic planning written strategic process priority/goal** Support and engage staff and physicians in developing a culture of patient safety and quality improvement Conduct Accreditation Canada patient safety culture survey** 3 Define staff members patient safety roles and responsibilities in all job descriptions and align with CPSI patient safety competencies Include safety checklist in all job descriptions Strategic plan approved by Board of Directors Accreditation Canada Patient Safety Culture Instrument Results % job descriptions updated with safety responsibilities and checklist included. January 202 Y Meet Accreditation Canada targeted response rate >25% all descriptions completed in Y >75% completed at Y3 Y Y Y3 Rob Hughes 3 Integrate patient safety into staff performance review process using CPSI patient safety competencies. % performance reviews completed with patient safety competencies >25% reviews include safety competencies Y2 Rob Hughes 2 Provide at least annual education for management/staff/physicians about patient safety including education on effective disclosure and reporting of incidents. % of staff who attended patient safety education session(s). >40% staff participation at education sessions Y Y3 Dawn Major Support the identification, reporting and management of patient safety events Revise incident reporting policy to reflect amendments to Regulation 965 under the Public Hospitals Act Incident/event reporting rates At least 0% reduction in events causing harm Y2

9 Goal Objective Priority Review the analysis of aggregate data/adverse events and provide summary with action plans to Quality Council with a plan for reporting to Quality Committee Implement safety briefings at the unit level to promote an open dialogue about patient safety/risks between staff and physicians. Summarize the safety issues identified and follow up on critical issues. 3 Continue to conduct executive walkarounds and provide a summary of safety concerns or issues identified. Develop a repository of safety issues and improvement strategies identified through briefings, walkrounds, incident reporting, FMEAs, RCA. Integrate improvement strategies into QIP as appropriate. Communicate improvements to staff (i.e. safety newsletter; , huddleboard postings) # of safety briefings conducted # walkarounds conducted At least briefing conducted on each area (both patient care units and non patient care areas) by end of Y >5 walkarounds conducted per year >2 safety issues identified during each walkaround Y Y Y3 Project Leads: Clinical Managers CEO

10 Goal Objective Priority Educate patients and their families about their roles in promoting patient safety** Engage and partner with patients and the community to advance patient safety 2 Develop patient and family guidelines regarding patient safety 2 Involve patients in transfer of care reporting (hand offs with patient involvement). Patient/family participation on councils/committees as appropriate # of patient contacts made during hand offs At least committee has patient representation in Year. (South wing Patient Council presently in place) March 3 st, 202 Y Y Y2 Quality Council Protect patients and staff and reduce the rates of health care associated infections Promote the use of PIDAC best practice guidelines to reduce the rate of C.difficile 2 Include Your Health Care Be Involved and Clean Hands Protect Lives materials in all patient admission packages/ posted material, as well as patient safety brochure. ED visits to be included. Establish a transparent patient relations/complaints process across the entire organization for Quality/Patient Safety issues and ensure the process aligns with requirements from the Excellent Care for All Act Ensure that patients are screened for CDI in timely manner and access to lab results Review procedures to prevent transmission (e.g. adequate isolation rooms) within the confines of our # of patients/families informed of their roles in Patient safety via intermittent audits of patient safety brochure being given to each patient/family at the time of their admission # of patient/family complaints Time to resolution/follow up C. difficile/000 patient days March 3 st, 202 >50% complaints resolved within one month Equal to or better than the provincial rate based on organizational 2 month rolling rate. Y2 Y March 3 st, 202 Dawn Major

11 Goal Objective Priority physical infrastructure Formula: HDMH+SMMH hospital acquired CDI cases/total MAHC inpatient days Comply with PIDAC Best Practices Perform Audit to ensure appropriate environmental cleaning best practices are being met >90% compliance with high touch surfaces cleaned at least once daily in clinical areas. Ongoing annual report to Board, monthly/quarterly reports to SLT, departments on HAI rates quarterly audits 50 per site per month MRSA(bacteremia)/000 patient days VRE(bacteremia)/000 patient says 90% compliance TBD Ongoing Annual training for staff (i.e. IPAC Core Competencies) Percentage compliance with best practices Maintain compliance with hand hygiene protocols Conduct HH audit to monitor compliance with hand hygiene protocols** Identify educational opportunities to promote effective hand hygiene practices for staff and physicians Educate patients/visitors on effective hand hygiene practices by utilizing Clean Compliance rates (moments and 4) by professional/clinical group. Provincial rate plus 5% March 3 st, 202

12 Goal Objective Priority Implement Safer Healthcare Now Initiatives hands Protect Lives brochure and MAHC Patient Safety brochure. 3 Reduce rate of CLI, SSI and VAP CLI bloodstream infections(/000 line days SSI bundle compliance Decrease or maintain Mar 3 st, 202 Improve the delivery of safe and evidence based care Falls risk reduction Implement a falls prevention strategy** Revise policy and procedure Implement assessment protocol Evaluate protocol and monitor compliance through chart audits of screening tool compliance VAP/000 ventilator days Fall rate Reduce injurious falls by 0 %) Y Y2 Diane Veitch Prevent pressure ulcer development** Provide ongoing education to all staff and physicians on MAHC s fall risk prevention policy Provide education to patients and family members about how to prevent falls Conduct risk assessment for patients at admission and at regular intervals throughout the patient s care Develop and implement organizational protocol for the prevention of pressure ulcers, including standardization of products, Pressure ulcer prevalence % risk assessments completed % patients at risk with a preventive skin care protocol Reduce pressure ulcers by 0% over Q4 20 data ccc Population only for 20/2. Acute care to Y Y3 Patti Connick/ Diane Veitch

13 Goal Objective Priority Prevent Venous Thromboembolism** Reduce surgical errors equipment, treatment protocols Provide education to staff on pressure ulcer prevention Sessions for staff by wound care champions. Provide education and information to patients and families about the risks of developing pressure ulcers and prevention strategies Patient and family brochure Identify patients at risk for VTE and provide appropriate thromboprophylaxis. Develop written policy for the use of thromboprophylaxis and audit use of appropriate thromboprophylaxis Provide education to all staff and physicians about the risks of VTE and organizational policy Provide education to patients about the risks of VTE and prevention Implement the Safe Surgical Checklist** % pressure ulcers present on admission # staff attending workshops/education on pressure ulcer prevention/management % of at risk inpatients receiving appropriate venous thromboembolism prophylaxis % compliance with surgical checklist be added 202/3 % of patients screened for VTE risk per month Maintain compliance rates over three years of >90%. Y Y2 Ongoing Karen Moore/ Kathleen Vom Schiedt/ Diane Veitch Noreen Chan

14 Goal Objective Priority Improve the safety and efficiency of medication administration Reduce medication errors Implement medication reconciliation process Develop a policy for independent double checks in the administration of medications to patients 2 Finalize the implementation, communication, and education on use of Open Source Order Sets. Develop policy and protocol for medication reconciliation at admission/assessment; discharge and/or transfer. Develop a protocol to involve patients in reconciliation process. Audits Mars for number of IDC s % patients with medications reconciled at admission Greater than 90% compliance with IDC s >60% Ongoing Ongoing Harold Featherston Cheryl Dakin Catherine Racine Develop a plan and process for implementing medication reconciliation in ER (utilize Best Possible Medication History). % of patients who have the best possible medication history completed >80% Eliminate the use of dangerous abbreviations** Evaluate and limit the availability of heparin products** 2 Develop a list of dangerous abbreviations (reference ISMP Canada), symbols and dose designations and communicate this broadly through education across the organization. Revise forms and organizational processes as required. Complete an audit of heparin storage. Remove and standardize the number of parenteral heparin concentrations available. Monitor compliance with appropriate use % compliance with storage recommendations and standardization across the organization with parental narcotic below 25% of abbreviations utilized are dangerous Y >80% Y

15 Goal Objective Priority Evaluate and limit the availability of narcotic products** Complete an audit of narcotic storage area. Standardize and limit the number of narcotic concentrations available. concentrations Monitor compliance with standardization of narcotic concentrations across the organization >80% Y

16 MAHC Patient Safety Initiatives (timelines and priorities) Timeline Planned Initiative Priority Ongoing Develop a policy for independent double checks in the administration of medications to patients Develop policy and protocol for medication reconciliation at admission/assessment Develop a plan and process for implementing medication reconciliation in ER Implement a falls prevention strategy Provide ongoing education to all staff and physicians on MAHC s fall risk prevention policy Provide education to patients and family members about how to prevent falls Implement the Safe Surgical Checklist Ensure that patients are screened for CDI in timely manner and access to lab results Review procedures to prevent transmission (e.g. adequate isolation rooms) Perform Environmental Audits to ensure appropriate environmental cleaning best practices are being met for high touch surfaces Ongoing annual report to Board, monthly/quarterly reports to SLT, departments on HAI rates Annual training for staff (i.e. IPAC Core Competencies) Conduct HH audit to monitor compliance with hand hygiene protocols** Identify educational opportunities to promote effective hand hygiene practices for staff and physicians Educate patients/visitors on effective hand hygiene practices Involve patients in transfer of care reporting(focus on shift handoffs) 2 Finalize the implementation, communication, and education on use of Open Source Order Sets 2 Maintain or decrease rate of CLI, SSI and VAP Review and refine the accountability structure for quality and safety at the Governance level Identify and measure a core set of big dot patient safety indicators approved by the Board Refine strategic plan to include patient safety as a written strategic priority/goal Conduct Accreditation Canada patient safety culture survey` Support the identification, reporting, and management of patient safety events Implement safety briefings at the unit level to promote an open dialogue about patient safety/risks Establish a transparent patient relations/complaints process for Quality/Patient Safety issues, across the entire organization and ensure the process aligns with requirements from Bill 46 Conduct pressure ulcer risk assessment for patients at admission and at regular intervals throughout the patient s care Develop and implement organizational protocol for the prevention of pressure ulcers, including standardization of products, equipment, treatment protocols Provide education to staff on pressure ulcer prevention Provide education and information to patients and families about the risks of developing pressure ulcers and prevention strategies Identify patients at risk for VTE and provide appropriate thromboprophylaxis.

17 Timeline Planned Initiative Priority Provide education to all staff and physicians about the risks of VTE and organizational policy Provide education to patients about the risks of VTE and prevention Complete an audit of heparin storage Remove and standardize the number of parenteral narcotic concentrations available Complete an audit of narcotic storage area Standardize and limit the number of narcotic concentrations available Provide at least annual education for management/staff/physicians about patient safety including education of effective disclosure and reporting of 2 incidents Develop patient and family guidelines regarding patient safety 2 Develop a list of dangerous abbreviations, symbols and dose designations and communicate this broadly 2 Define staff members patient safety roles and responsibilities in all job descriptions and align with CPSI patient safety competencies Identify and measure a core set of big dot patient safety indicators approved by the Board Provide patient safety education for Trustees 2 Provide at least annual education for management/staff/physicians about patient safety including education on effective disclosure and reporting of 2 incidents Include Your Health care Be Involved and Clean Hands Protect Lives materials into all patient admission packages and/or post information 2 Define staff members patient safety roles and responsibilities in all job descriptions and align with CPSI patient safety competencies 3 Integrate patient safety into staff performance review process using CPSI patient safety competencies 3 Conduct executive walk arounds and provide a summary of safety concerns or issues identified Identify and measure a core set of big dot patient safety indicators approved by the Board Provide at least annual education for management/staff/physicians about patient safety including education on effective disclosure and reporting of 2 incidents Define staff members patient safety roles and responsibilities in all job descriptions and align with CPSI patient safety competencies 3 Conduct executive walk arounds and provide a summary of safety concerns or issues identified 3

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