Nova Scotia Public Reporting Serious Patient Safety events? Advancing Patient Safety & Quality?

Size: px

Start display at page:

Download "Nova Scotia Public Reporting Serious Patient Safety events? Advancing Patient Safety & Quality?"

Marshall Ramsey
5 years ago
Views:

1 Nova Scotia Public Reporting Serious Patient Safety events? Advancing Patient Safety & Quality? Catherine Gaulton, Chair Health Achieve November 3, 2014

2 Agenda Who we are? The Mandate The Language we Use Errors versus Patient Safety Events The Context of Disclosure, Informing and Reporting Why Report? The Nova Scotia Experience What We ve Learned The Future

Who We Are The Quality and Patient Safety

related to quality and patient safety of care

3 Who We Are The Quality and Patient Safety Advisory Committee (QPSAC) is mandated to provide advice and make recommendations to the Minister of Health and Wellness on matters related to quality and patient safety of care across the continuum of Nova Scotia s health care system.

4 QPSAC Strategic Plan ( ) Bring a provincial perspective to patient safety and quality improvement activities by making quality a systems strategy Facilitate the building of capacity and expertise in Quality & Patient Safety (QPS) through educating leadership Prioritize areas of QPS for improvement Demonstrate transparency and accountability to patients and the public for the quality of care provided in Nova Scotia by defining and reporting on QPS results

5 Errors/Adverse Events/Patient Safety Events What are They? Errors denote: individual mistakes ; someone is at fault ; and if only that someone could do better; Continued use of the language inhibits the culture which enhances patient safety; Adverse Event N.S. uses the defn. of a patient safety event but can be wider and could include adverse events arising as a result of the disease process or the treatment for it. Patient Safety event an event or circumstance which could have, or did, result in unnecessary harm to a patient; Serious Reportable Event an adverse health event which results in serious disability or death and includes, but is not limited to, the actual or potential loss of life, limb, or function

6 How we Communicate Disclosure Informing Reporting

7 Disclosure Disclosure: advising those impacted about a patient safety event; Disclosure has a rich history, literature and associated evidence of the benefits of disclosure (CPSI, Nova Scotia, Provincial Quality councils across Canada) Nova Scotia has been at the forefront of disclosure Disclosure policy in some health organizations in 1992 before the patient safety movement took off and before the IOM (To err is Human) report in 1999; Department of Health & Wellness policy has meant consistent and comprehensive disclosure policies in the province since 2005

8 Informing Informing advising the public (those who are not directly impacted by the patient safety event) Also has a significant history in Canada Alberta, British Columbia and Ontario cases Nova Scotia history sterilization of instruments; CJD; unnecessary mastectomy Most Canadian jurisdictions now have experience in relation to informing the public about to individual patient safety events

9 Reporting Advising others (regulatory authorities, governments, health councils, accrediting bodies and sometimes the public) generally about adverse events Sometimes legislatively required Saskatchewan first Que, Ontario, B.C., Alberta, Manitoba followed Quebec legislatively required reporting to the public

10 Public Reporting Why? IT IMPROVES QUALITY AND SAFETY External reporting Provides for central analysis and reveals trends and leading practices Alerts about new hazards Disseminates information Public reporting Raises the level of system accountability Demonstrates a commitment to transparency and openness Allows our patients and public to be informed so they know that their questions, their participation in their care; their collaboration with us is key to improving quality and safety

11 Public Reporting Why? Over the last two decades, public reporting has evolved due to Increased commitment to improvement Public accountability expectations Improvement in data systems AND We knew it was the right thing to do BECAUSE IT WILL IMPROVE QUALITY AND SAFETY

12 Reporting in Nova Scotia Plans were already under way to develop a comprehensive IT solution for patient safety internal and external reporting Government had shown its commitment to transparency and accountability with the Patient Safety Act (defined reporting indicators) Incidents of informing had inspired the public to clarify their wish for transparency Serious Reportable Event policy developed as an interim solution

13 What We ve Learned The reasons for reporting may still be misunderstood this is about improving care and not about finding fault or liability Focus on the system We have much work to do with our public, media to ensure we get the objectives right Our internal stakeholders may still not appreciate the extent of the patient safety vulnerabilities

14 What We ve Learned Our public wants more detail and we need to find the right balance Disclosure is well established Still work to do on informing and reporting There is no one fix it incremental improvements are key

15 Nova Scotia s Plan Ensure Quality Improvement and Patient Safety continue as our top priorities Engage the passion and commitment of our citizens Adverse Events Reporting System provincial IT solution implementation by 2017 Add to the system indicators Patient Safety Act

16 Nova Scotia s Plan Ensure patient safety events are properly identified and managed and used to drive improvement and safety Explore opportunities for greater preventative practices Capitalize on the change we are experiencing in our system to enhance quality and to reduce preventable harm

17 Questions?

18 Selected References Alberta Health Services Performance Report Q4 2012/13. Retrieved from pub pr performance report.pdf Leape, L. L., M.D. (2002). Reporting of adverse events. The New England Journal of Medicine, 347(20), Retrieved from ?accountid=10406 Wallace, Jack, Teare, Gary F., and Verrall, Tanya. Public Reporting on the Quality of Healthcare: Emerging Evidence on Promising Practices for Effective Reporting. Ottawa, ON, CAN: Canadian Health Services Research Foundation, ProQuest ebrary. Web. 29 October CPSI, Canadian Disclosure Guidelines, Being Open with Patients and Families, 2011.

Therapeutic Recreation Regulation in Canada 2015: Comparison of Canada s Health Professions Acts

Therapeutic Recreation Regulation in Canada 2015: Comparison of Canada s Health Professions Acts Report prepared by: Dianne Bowtell, Executive Director, Alberta Therapeutic Recreation Association, May