National Patient Safety Consortium Patient Safety Education Action Plan

National Patient Safety Consortium Patient Safety Education Action Plan Patient Safety Education for Leaders Working Group Environmental Scan Patient Safety & Quality Culture Bundle for CEOs & Senior Leaders October 2017

2 Introduction and Approach Introduction A key theme in the National Patient Safety Consortium s Patient Safety Education Action Plan is Quality and Patient Safety Education for Leaders. A working group of partners, co led by the Canadian College of Health Leaders and HealthCareCAN were brought together to carry out an environmental to scan to advance work in this area. The group benefited from the timely release of the report Free from Harm (FFH) (2015). Focus on Patient Safety Patient safety is a public health problem in Canada; results in up to 1 death in 100 admissions (Baker, et al, 2004); significant harm in every 18 admissions (CIHI, CPSI, 2016); and costs of about $400 million per year (acute care) (CPSI, 2012). Patient safety needs a reset; it has been displaced from the centre of our efforts to improve quality. (Berwick, Feely, 2017). Patient Safety as a Component of Quality The Institute of Medicine (IOM), six aims for the healthcare system starts with (1) Safe (avoiding harm to patients from the care that is intended to help them); (2) Effective (services based on scientific knowledge to all who could benefit); (3) Patientcentered (respectful and responsive to patient needs and values); (4) Timely (reducing harmful delays); (5) Efficient (avoiding waste); (6) Equitable (care that does not vary due to gender, ethnicity, location, and socioeconomic status). Focus on Patient Safety Culture Improved culture is not just a means to an end but a key variable for improving patient safety in its own right (see diagram). Patient safety culture is a complex phenomenon that is not clearly understood by hospital leaders, thus making it difficult to operationalize. (Sammer, 2010). Focus on CEO/Senior Leaders/Boards Leaders have extraordinary power to influence behaviors, beliefs and practices within organizations. (Berwick, Feely, 2017). Patient Safety Culture/Climate Definitions Shared perceptions of existing safety policies, procedures, and practices; reflects the extent to which the organization values and rewards safety relative to other competing priorities as demonstrated through organizational polices and leader behavior. (Singer, 2013). An integrated pattern of individual and organizational behavior, based on shared beliefs and values that continuously seeks to minimize patient harm, which may result for the processes of care delivery. (Kizer, 1999). Plan 1. Describe the characteristics of a patient safety/quality culture. 2. Determine what senior leaders/boards need to KNOW to advance a patient safety/quality culture (e.g. key knowledge, curricula or learning objectives). 3. Develop a clear, concise, and evidence based checklist or bundle of key elements senior leaders need to DO (interventions) to operationalize a patient safety/quality culture. Approach The group built on the well researched work of highly credible organizations and thought leaders; over 50 resources were systematically reviewed to identify core areas of alignment. The Singer and Vogus (2013) 3 part model (see p. 3) provided the scaffold on which to present the 13 vital few/practical/tactical intervention areas which were identified. In patient safety, a bundle is a set of evidence based practices that must all be applied in order to reliably deliver good care. The culture bundle is arranged in three main parts with sub sections under each; as with other safety bundles, all components (vs. a piecemeal approach) are required to improve patient safety culture. The bundle was made inclusive of quality to facilitate/simplify dissemination and uptake. Initial validation of the bundle has occurred with Canadian academic, CEO, senior leader and board thought leaders.

Patient Safety & Quality Culture Bundle for CEOs/Senior Leaders Oct 2017 1. Enabling 2. Enacting 3. Learning Organizational priority setting; leadership practices that motivate the pursuit of safety Frontline actions that improve patient safety Learning practices that reinforce safe behaviours Organizational priority Board educated, engaged, accountable, prioritizes patient safety? Safety/quality vision, strategy, plan, goals (with patient, staff, physician input)? Safety/quality resources/infrastructure? CEO/Senior leadership behaviours Relentless communication about safety/quality vision, stories, results? Regular/daily interaction with units, staff, patients and families? Model key values (e.g. honesty, fairness, transparency, openness, learning, respect, humility, inclusiveness, person centredness)? Human resources Leaders/staff/physicians engaged; clear expectations/incentives for safety/quality? Just culture program/protocol? Disruptive behaviour protocol? Staff safety (physical/psychological/ burnout); safe environment program? Health information/technology/devices E health records support safety (e.g. decision support, alerts, monitoring)? Technology/devices support safety (e.g. human factors, standardized automated identification)? Health care system alignment Community/industry wide collaborations? Align with nat l/int l accreditation, regulatory, professional standards? Care units and managers Integrated, unit based safety practices (e.g. daily briefings, visual management, local problem solving)? Managers/physician leaders foster psychological safety (speaking up)? Care processes Standardized work/care processes where appropriate? Communication/patient hand off protocols (e.g. between shifts/units, across care continuum)? Patient and family engagement/coproduction of care Patients/families partners in all aspects of care (e.g. planning, decision making, rounds, access to health record/test results)? Patients/families involved in local safety/quality initiatives? Disclosure and apology protocols? Situational awareness/resilience Processes for real time/early detection of safety risks and patient deterioration (by staff/patients/families)? Protocols for escalation of care concerns (by staff/patients/families)? Education/capability building Leaders/staff/physicians trained in safety and improvement science, teamwork, communication? Team based training, drills? Safety reporting/management/analysis Effective risk/incident reporting system for events related to patients and staff incl. never events (incl. improvement focus, timely feedback, near misses)? Structured processes for responding to and learning from serious safety events/critical incidents (incl. systems analysis, patient/staff involvement and support)? Safety/quality measurement/reporting Regular measurement of safety culture (unit and organization)? Retrospective/prospective safety and quality process and outcome measures? Regular, transparent reporting of safety/quality plan results? Operational improvements Structured methods, infrastructure to improve reliability, streamline operations (e.g. PDSA, lean, human factors engineering, prospective risk analysis)? Adapted from: Singer & Vogus (2013). Reducing hospital errors: interventions that build safety culture. ARPH 34:373 96.

Key Resource Free from harm: fifteen years after To Err is Human, 2015 The Patient Safety Education for Leaders group greatly benefited from the release of this report; key excerpts include: Focus on Patient Safety There has been progress in the past 15 years, however patient safety remains an important public health issue. Preventable harm remains unacceptably frequent in all settings of care and among all patient populations. Although our understanding of the problem of patient harm has deepened and matured, this progress has been accompanied by a lessening intensity of focus on the issue. Patient safety must not be relegated to the backseat, proceeding haphazardly toward only those specific harms currently being measured and targeted for improvement by incentives. Today, we must not let the many competing priorities in healthcare divert our attention from the important goal of preventing harm to patients. On the contrary we need to keep our eyes on the road and step on the accelerator. All healthcare stakeholders should recommit to and prioritize patient safety in general and the goal of eliminating harm to patients in particular. Focus on Leadership and Culture It is no accident that we list leadership and culture first in our recommendations this was the overwhelming area of challenge and the most critical area to address according to our panelists. Advancement in patient safety requires an overarching shift from reactive, piecemeal interventions to a total systems approach to safety. Adopting such an approach would mean leadership consistently prioritizing safety culture and the well being and safety of the healthcare workforce. Need for Culture Bundle Leaders need practical, tactical strategies to actually change culture. Even though tools for developing a safety culture are available, a common set of best practices is needed. One can envision the development of a culture bundle, analogous to the bundle of interventions that drastically reduced ventilator associated pneumonia. Such a culture bundle would include evidence based strategies that leadership and teams across an organization could implement to drive meaningful culture change. Boards and leaders need sufficient education in the fundamentals of safety science to foster culture efforts. 4 Berwick, et al, 2015.

Other Key Resources IHI Whitepaper Patient Safety (2006) Singer and Vogus Interventions That Build Safety Culture (2013) Piecemeal initiatives to improve PS culture are inadequate; improving PS culture requires simultaneous interventions that: Enable: e.g. transformational leadership; leadership characteristics; human resources; IT; external regulators Enact: e.g. teamwork; communication; mindfulness; patient involvement; reporting; coordination between areas /at transitions Elaborate: e.g. learning (e.g. reports, complaints, M&Ms); education; monitoring (prospective, retrospective, concurrent); operational improvements (industrial techniques, infrastructure). Baker Beyond the Quick Fix (2015) Recommendations: PS /QI strategy; board monitoring of performance; measurement (organizational and microsystem levels); event reporting and analysis (focus on gaps and feasible recommendations); investments in work climate; patients and care givers included in PS and QI; investments in PS/QI infrastructure; leadership development; collaboration across organizations; pan Canadian information systems. CPSI Patient Safety Culture Website Dimensions: informed; reporting; learning; just; flexible. Contributors: leadership; patient/family engagement; teamwork and communication; openness to reporting; learning; resources; priority of safety versus production; education and training. BC Culture Change Toolbox: Components of PS Culture (2013) Teamwork and communication; safety climate; psychological safety; organizational fairness; just culture; stress recognition; working conditions; leadership; learning and improvement; patients as partners; transparency. ACHE/IHI/NPSF Leadership Blueprint for Culture of Safety (2017) Six leadership domains: vision; trust, respect and inclusion; board engagement; leadership development; just culture; behaviour expectations. PS strategy/aims; senior leader communication and awareness building (e.g. walkrounds); engage stakeholders (board, leaders, physicians, staff, patients/families) in PS; implement just culture; focus on process redesign/improved reliability (e.g. evidence based standardization, human factors); leader/ manager/staff accountability (e.g. for safety reporting, reliable processes/ daily work ) and aligned incentives for PS; PS infrastructure (staff and committees); assess PS culture; measure/track PS (e.g. mortality, trigger tool); support patients/families impacted by errors. IHI Whitepaper 7 Leadership Leverage Points (2008) System level aims; executable strategy; leadership attention; patients /families; CFO as quality champion; engage physicians; improvement capability. IHI Whitepaper High Impact Leadership (2013) Person centredness (e.g. patient involvement/stories); front line engagement (e.g. regular presence at front lines, visible champion, lead projects); relentless focus (e.g. talk about vision every day, align schedule with high priority initiatives; designate resources); transparency; build will to improve (e.g. communicate and model desired behaviors, openness, swift action against undesired behavior); boundarilessness (e.g. systems thinking, harvest ideas from and partner with other organizations). IHI Whitepaper Sustaining Improvement (2016) Quality control, improvement, culture; standardization; accountability (standard work); visual management; problem solving; escalation; integration; prioritization; daily work; policy; transparency; trust. IHI Whitepaper Safe, Reliable and Effective Care (2017) Leadership; psychological safety; accountability (act in safe and respectful manner); teamwork and communication; negotiation; continuous learning; improvement and measurement; reliability; transparency. 5

Key Concepts Safety science focusses on contributing factors and underlying causes of risk and harm, including errors and human factors. It includes many disciplines not typically considered part of healthcare. Recognizes the fundamental importance of system design in driving workforce behavior. In other industries, such as aviation, safety experts accept that human error must be expected, anticipated, and its effects mitigated. Safety science and human factors engineering is used to design systems to prevent errors, and to mitigate harm when errors occur. (Berwick et al., 2015). Implementation science supplements patient safety science; focusses on identifying and implementing valuable practices and lessons learned, and scaling up/translation across the organization and system. (Berwick et al., 2015). Just culture a culture that recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture recognizes many individual or active errors represent predictable interactions between humans and the systems in which they work. A just culture also does not tolerate conscious disregard of clear risks to patients or gross misconduct. (Berwick et al., 2015). Psychological safety an environment where: anyone can ask questions without looking stupid; anyone can ask for feedback without looking incompetent; anyone can be respectfully critical without appearing negative; anyone can suggest innovative ideas without being perceived as disruptive. (Frankel, 2017). Staff safety/health A precursor to providing high quality care are staff that are free from physical harm during daily work. (Perlo, 2017) Patient and family engagement recognized as a primary area of focus in PS/quality; includes engagement at three levels: direct care (diagnosis, treatment decisions, monitoring), organizational design and governance (planning, patient advisory counsels, QI projects), policy making (public health, research priorities, resource allocation). (Carman, 2013). High reliability/resilience reliable/mindful organizations are: preoccupied with failure (look for small signals of failure vs. preoccupation with success); reluctant to simplify interpretations (acknowledge complexity); sensitive to operations (aware of what is happening at front lines); committed to resilience (acting quickly when things go wrong, e.g. patient deterioration); and defer to experts (vs. authority). (Weick & Sutcliffe, 2015). Patient safety measurement five dimensions: past harm (incidents, mortality); reliability (compliance); sensitivity to operations (walk rounds, staffing levels, escalation); anticipation and preparedness (risk registers, safety culture scores, absenteeism); integration and learning (automated alerts, board dashboards). (Vincent, 2016). Frontline leadership/distributed leadership recognized as a key driver for change in healthcare; local leaders translate senior leader priorities/values into action at the microsystem level; they have great impact on unit cultures and learning processes. (IHI, 2016). Physician leadership recognized as a key driver for change in healthcare; six strategies for engaging physicians: discover common purpose; reframe values and beliefs; segment the engagement plan; use engaging improvement methods; show courage; adopt an engaging style. (Reinertsen, 2007). Staff engagement A joyful, engaged workforce will have: physical & psychological safety; meaning and purpose; choice and autonomy; recognition and rewards; participative management; camaraderie and teamwork; daily improvement; wellness and resilience; real time measurement. (Perlo, 2017) Teamwork/communication gaps in communication and/or poor teamwork are frequently noted as contributing factors to many patient safety events. Strong teams which train together and have established and reliable communication practices will have superior patient safety performance. (Baker, 2015). Industry wide standardization/alignment A key feature in other highrisk industries is alignment across the sector related to key priorities, national/international standards and regulation of safety critical practices and technologies. (Dixon Woods, 2016, Berwick et al., 2015). 6

7 References 1. ACHE, NPSF Lucian Leape Institute. (2017). Leading a culture of safety: a blueprint for success. 2. Baker R. (2010). Effective governance of quality and patient safety: a toolkit for healthcare board members and senior leaders. 3. Baker R. (2015). Beyond the quick fix strategies for improving patient safety. Institute of Health Policy, Management and Evaluation at the University of Toronto. 4. Baker R, Norton P, et al. (2004) The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 170(11):1678 86. 5. BC Patient Safety and Quality Council. (2013). Culture change toolbox. 6. Berwick D, Shojania K, et al. (2015). Free from harm: accelerating patient safety improvement fifteen years after To Err Is Human. National Patient Safety Foundation. 7. Berwick D, Feely D. (2017). WIHI: the next wave of patient safety. Institute for Healthcare Improvement (IHI) webinar. 8. Botwinick L, Bisognano M, Haraden C. (2006). Leadership guide to patient safety. IHI White Paper. 9. Canadian Institute for Health Information, Canadian Patient Safety Institute (2016). Measuring patient harm in Canadian hospitals. 10. Canadian Patient Safety Institute (CPSI). (Date unknown). Patient safety culture. 11. CPSI. (2012). The economics of patient safety in acute care: technical report. 12. Dixon Woods M, Pronovost P. (2016). Patient safety and the problem of many hands. BMJ Qual Saf. 25(7):485 488. 13. Frankel A, et al. (2017). A framework for safe, reliable, and effective care. IHI White Paper. 14. IHI. (Date unknown). What is a bundle? 15. IOM. (2001). Crossing the quality chasm: a new health system for the 21 st century. Washington, DC: National Academy Press. 16. The Joint Commission. (2017). The essential role of leadership in developing a safety culture. Sentinel event alert. 17. Kizer, K. (1999). Large system change and a culture of safety. In: Enhancing patient safety and reducing errors in health care. Chicago, IL: National Patient Safety Foundation. 18. Kristensen S, Christensen K, Jaquet A, Beck C, Sabroe S, Bartels P, Mainz, J. (2016). Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross sectional experimental study. BMJ Open. 1 10. 19. National Patient Safety Foundation. (2017). Call to action: preventable health care harm is a public health crisis and patient safety requires a coordianted public health response. 20. Perlo J, Balik B, Swensen S, et al. (2017). IHI framework for improving joy in work. IHI White Paper. 21. Reinertsen J, Bisognano M, Pugh M. (2008) Seven leadership leverage points for organization level improvement in health care (second edition). IHI White Paper. 22. Reinertsen J, Gosfield A, Rupp W, et al. (2007). Engaging physicians in a shared quality agenda. IHI White Paper. 23. Sammer C, et al. (2010). What is patient safety culture? A review of the literature. J Nur Schol. 42:2;156 165. 24. Scoville R, Little K, Rakover J, Luther K, Mate K. (2016). Sustaining improvement. IHI White Paper. 25. Singer S, Vogus T. (2013). Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 34:373 396. 26. Swensen S, et al. (2013). High impact leadership: improve care, improve the health of populations, and reduce costs. IHI White Paper. 27. Vincent C, et al. (2016). A framework for measuring and monitoring safety: a practical guide to using a new framework for measuring and monitoring safety in the NHS. The Health Foundation Quick Guide. 28. Weick, K, Sutcliffe, K. (2015). Managing the unexpected: sustained performance in a complex world. Hoboken, NJ: John Wiley & Sons.