patient safety expo 2011

Celebrating Our Success in Quality and Patient Safety 2011 1
PATIENT SAFETY EXPO 2011 Celebrating Achievements! The Patient Safety Expo is a celebration of all the great work everyone at Halton Healthcare Services (HHS) does year round to make our organization the safest place it can be. This year marks our fifth Patient Safety Expo and there is so much to celebrate. Along with other healthcare colleagues across the country, we recognized Canadian Patient Safety Week (October 31 – November 4, 2011) by showcasing the quality improvement work across the organization with respect to patient safety. Everyone at HHS plays a role in ensuring that our organization is safe for patients, families, staff, physicians and volunteers. Patient safety is all about implementing best practices that are known to reduce morbidity and mortality and mitigate risk. This year we are again capturing all of the great work across the organization in a celebrations booklet which is being released at the Expo Awards evening. This booklet captures some of the excellent and creative initiatives at HHS that reflect considerable effort, ingenuity, team work and commitment – providing clear evidence that we are meeting our commitment ‐‐‘Together, Moving Quality and Safety Forward’. The purpose of ‘Expo 2011’ was to share and communicate patient safety initiatives with colleagues across the organization and to recognize our achievements. This year’s Expo activities included:  A full day of exhibits at each hospital which featured 56 exhibitors from many teams on November 1st in Georgetown; November 4th in Oakville; and November 10th in Milton.  An Evening Awards Gala on November 17th, at Rattlesnake Point Golf Club. Keynote Speaker: Katarina Busija, RN, on ‘Stop the Insanity! Innovation and Change in Healthcare.’ I hope you enjoy this booklet – the contents reflect a wide variety of people and departments who came together to help recognize and celebrate our achievements. Thanks to our storyboard authors for putting their abstracts in ‘SBAR’ format. I also want to recognize the sponsors who contributed so generously this year. Be sure to read about the ‘stories’ behind the exhibits, and the numerous award winners. Congratulations on all the work you do to promote a culture of quality improvement and patient safety! Lynn
Lynn Budgell Patient Safety Coordinator Chair – Expo 2011 Planning Committee 2
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2011 Safety Expo Planning Committee A very special thank you to all the members of the Expo 2011 Planning Committee, without whose vision and hard work, the outcome of the Expos would not have been so impressive. They worked tirelessly, had fun together, and are an amazing group of professionals. Anita Arnold Senior Technologist, Haematology, Laboratory Stephanie Black Occupational Therapist Assistant/ Physiotherapist Assistant, Rehabilitation Sheryl Brown Supervisor, Housekeeping / PAL Program Lynn Budgell Safety Expo Planning Chair, Patient Safety & Accreditation Coordinator Carole Dalton Patient Care Manager, Emergency Department Annette Down Director, Quality, Risk, Patient Safety and Ombud Jason Ford Physiotherapist Assistant Joanne Johnston Team Leader, Laboratory Dale Hamilton Supervisor, Housekeeping Deborah Hill Program Director, Emergency, Ambulatory Care and Cardio Respiratory Services Jennifer Luckanuck Physiotherapist, Minimal Lift Coordinator Cathleen MacIsaac Administrative Assistant Melanie Maddock Charge Technologist for General Imaging / X‐Ray Safety Officer Judy Maxwell Laboratory Quality Coordinator Rosemary McNeely Director of Volunteers, Oakville Hospital Volunteer Association Angie Molozzi Business Development, Marketing Specialist Elizabeth Pawlowski Patient Care Manager, Pre‐Admission Clinic, Surgical Day Care, PACU and Project Lead Surgical Services Lesley Patel Communications Specialist, Public Relations Kelly Roy Patient Care Manager, 2 Centre Karen Vokner Professional Practice Clinician, Med/Surg, Milton 4
Patient Safety Awards Reception Thursday, November 17, 2011 RattleSnake Point Golf Club A warm and gracious thank you to our Keynote Speaker: Katarina R. Busija Stop the Insanity! Innovation and Change in Healthcare Katarina is a well known and respected registered nurse and national patient safety advocate. Currently, she is Manager of Resident Care with Halton Region, Services for Seniors Division. She has previously worked as a Patient Safety Officer as well as having held various positions in medical oncology and hematology management and clinical trials coordination and management. Katarina has first hand experience dealing with a system breakdown. In 2004, her father was given a medication, which contributed to his death. This experience was personally and professionally devastating and motivated within Katarina a passion for partnership, improvement and change. Since then, Katarina became a member of Patients for Patient Safety Canada (PFPSC), a program of the Canadian Patient Safety Institute (CPSI) and WHO Patient Safety, and seeks to influence policy and practice, promote transparency on patient safety issues and provide opportunities for collaboration to make “Every Patient Safe.” 5
Awards Safety Champion Awards The Safety Champion Award is awarded to three ‘Safety Champions’ who have shown leadership and commitment to the development of the HHS Safety Program. They are respected by their colleagues, keen & positive, visible, innovative, approachable opinion leaders and change agents. shares in our commitment of recognizing deserving safety champions who show leadership and foresight to strive for change and improve practice where change is needed in the quest for the safest patient care possible. Baxter has generously contributed in the sponsorship of this award. Thank you Baxter! Congratulations to this year’s winners: Jean Gallen CRN for Obstetrics, Milton Jennifer Luckanuck Physiotherapist and Minimal Lift Coordinator, OTMH Anna‐Marie Merchant Manager of Obstetrics, Surgical Day Care, Ambulatory Care, GH In recognition of this award, our 2011 Safety Champion Award Winners will be attending the Institute for Healthcare Improvement’s 23rd Annual National Forum on Quality Improvement in Health Care, December 4‐7, 2011 in Orlando, Florida. This year’s theme for the IHI National Forum is “The Picture of Healthcare is Always Changing ‐ Join us and help Develop the Picture.” 6
Expo Safety Displays 5P Rounding
Indy Sahota, PPC Medicine Program; Carol Eaton, Patient Care Manager, 2E Medicine and NRT
Antimicrobial Stewardship – Who’s Job is That?
Jill White, Antimicrobial Stewardship Pharmacist, Pharmacy; Dr Tom Warren, Infectious Disease Physician; Helena Trabulsi, Director of Pharmacy; Grace White, Clinical Pharmacy Manager
Are you ready to get Strong and Steady?
Rehabilitation and Geriatric Program ‐ Cynthia Archibald, Physiotherapy Assistant; Lyndsay Beker, Nurse Practitioner; Cynthia Chiu, Physiotherapist; Shirley Coughlin, Occupational Therapist; Jacqueline Minezes, Manager
Bariatric Barriers – a Big Challenge
Sian Surridge, Occupational Therapist, Complex Continuing Care, Oakville
The Bugs Stop Here – Pump it Up!
Annette Down, Director of Quality, Risk, Safety and Ombud; Shirley Lanza, Manager, Infection Prevention and Control; Lynn Budgell, Patient Safety Coordinator
Bullet Rounds
Barb Deichert, RN; Jean Gravelle, OT; Darlene Lambe, DP, CCAC Coordinator; Jason Ford, OPTA; Jennifer Firth, PT; Laureen Taylor, RT; Nela Wilson, SLP
CAUTI – Let it Flow, Let it Flow, Let it Flow
Cathy Goacher, Coordinator, Professional Practice
Code Red: “The Heat is On”
Cheryl Gustafson, PCM Mental Health; Lisa‐
Marie Burka Daniels PPC Mental Health; Anthony Wright, CRN Mental Health
Coordinating Safe Care is Proactive – Not Reactive
Jacqueline Minezes, Manager Outpatient Rehab and Geriatrics; Kathy Theroux, COPD Coordinator, Rehab and Geriatrics
COPD Order Sets Are Like a Breath of Fresh Air
Hand Hygiene on 2C Inpatient Surgery: From Moment 1, We Will Save Lives
Carole Eaton, PCM 2E & NRT; Kathy Theroux, COPD Coordinator, Rehab & Geriatrics
Micky Brankovic 2C RN; Robert Renton, PPC 2C/2E/4W; Kelly Roy, PCM 2C Inpatient Surgery
Encouraging and Supporting Patients To Make Their Own Health Care Decisions
Jan Baker,RN, BN, CNeph(C); Vanessa Deck, RN, CNeph(C); M. Doyle, RN, CNeph(C) ‐ Kidney Function Clinic
To Err is Human: The Use of Safety Huddles to Enhance Perioperative Patient Care
Anne Marie Dutka RN, Interim PPC OR/MDR; Cindy MacFarlane, PCM OR/MDR; Liz Pawlowski, PCM PAC/SDU/PACU
Evidence‐Based Practice: Quality care via Quality Information @ the Library
Jeanna Hough, Manager Health Science Library
HHS Bedsores No More
Richard Bishop, RN, BScN, IIWCC, Skin and Wound Care Clinician HHS
Informed Consent‐The Multicultural Dimension
Jacqueline Goodban R.N.; Jennifer Cassista R.N.; Donna McPhail R.N; Milton Obstetrical Unit
It Takes a Village…
HHS Volunteer Services Team
Keeping our Seniors Safe with ConnectCARE
Angie Molezzi, Business Development ‐ Marketing Specialist
Falls
Georgetown Family Practice
Keeping the Stream Flowing
Flu Ends With You
Karina Prokopchuk, Manager, Occupational Health and Safety
Food Safety
Marianne Katusin, Manager, Food Service; Elma Hrapovich, Director, Food Services
The Foot is an Anatomical Marvel
Angie Molezzi, Business Development ‐ Marketing Specialist
For Safety Sake, Communicate
Stephanie Black OTA/PTA (c), 3C/W Rehab ; Natalie Neal OTA/PTA (c), 3C/W Rehab
Halton Healthcare Services Safer Elder Care Program ‐ Developing An Evidence Based Geriatric Model – Operationalizing NICHE – Early Implementer Site
Dr. Kirsten Lindner, Chair, Safer Eldercare Committee; Jennifer Luckanuck, Co‐Chair Safer Eldercare Committee; Delayne Haasz, Founder and Member of Safer Eldercare Committee
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Darlene Walsh, Patient Care Manager, MDH Emergency/Ambulatory Care
KID‐E.E.S.
Rebecca McAlpine, PPC, Maternal Child Program, Oakville
LEAN Architectural Basics **LAB**
Rosanne Janicki, MLT, ART, Milton Lab; Johanna Campbell, Manager, Milton and Georgetown Laboratory
Listening Circles… “We’re listening”
Deb Bond, Hospital Ombud, Annette Down, Director, Quality, Risk, Safety, Ombud, Kim Kohlberger, Director, Rehab and Geriatrics, Genny Cho, Manager, CCC, OTMH and MDH, Debbie Hansen, Manager, CCC, GH
Neonatal Mock Code Pink Drills
Anna‐Marie Merchant, Patient Care Manager, Obstetrics/Surgical Daycare/
Ambulatory Care Unit, Georgetown Hospital
Open the Door to Safety: Awareness is the Key!
Angie Molezzi, Business Development ‐ Marketing Specialist
Expo Safety Displays Patient Declaration of Values ‐ Let’s Work Together to Live the Shared Values
Deb Bond, Hospital Ombud; Annette Down, Director, Quality, Risk, Safety, Ombud
Pharmacy Innovations Improving Patient Safety
Angela Roode RN, BScN, CDE, PPC ‐ Safe Medication Practice; Veronica Breadner RN, Clinical Nurse Analyst ‐ Medication Management ; Boris Curcic, PharmD., RPh., Pharmacy Analyst
The Power of Patient Safety
Sonya Myles, RN, BScN, IBCLC, Breastfeeding Safety Huddles Advance the Game!
Judi Montgomery, PPC, Rehabilitation and Geriatrics Program
Safety Takes Time
Mary Miliucci, Supervisor, Medical Device Reprocessing, Georgetown Hospital
SBAR – A Sweet Way to Communicate!
Cathy Goacher, Coordinator, Professional Practice Office; Lynn Budgell, Coordinator, Patient Safety
Scanning Safely
Clinic ‐ Maternal Child Unit, Oakville
Deb Winger, Team Leader CT; Jacqui Munro, Senior Resource CT; Krista McIntosh, CEL Q‐Syte Needleless Connector
Skin Tears Professional Practice Clinicians, HHS
Regional Ethics Program
Richard Bishop, Wound Care Clinician and Hugo Fundanga Student Eoin Connolly, Ethicist
Ibrahim Merhi, PPC, ICU, Oakville Restraint Utilization: Safe vs. Unsafe Approaches
Erica Belluz, Rec. Therapist, CCC Milton; Janine Theben, Occupational Therapist, Milton CCC ; Tamara Crow, Occupational Therapy Assistant, CCC Milton
Roving Reporting at MDH
Jean Roy, CRN, Med/Surg; Norma Jones, CRN, Med/Surg; Karen Vokner, PPC, MDH; Janice Dziepak, Interim PCM, Med/Surg
Safety Crosses ‐ Cross your Fingers or Get Involved?
Lucia Yoon, RN, 2E; Judy Forward, Safety Champion 2E; Rob Renton, PPC for 2E, 4E and 2C
Soap Opera Someone Could Be Dying To Tell You Something
Speech Language Pathologists Alyssa Weinmaster, Alyssa Weinmaster, Ashley Tinkham, Bon‐Hi Moon, Melanie Ribeiro and Nela Wilson
The Sugar and Spice Story: New Point‐of
‐Care Glucose Meter Implementation
Jo Campbell, Manager, Milton/Georgetown Laboratory; Elaine Hooper, Manager, Information Systems; Cornelia Mascherin, Manager, Oakville Laboratory & POC Testing; Judy Maxwell, Laboratory Quality Coordinator; Angela Roode, PPC, Medication Practices and Diabetes Clinician
There’s No Reason to be Deathly Afraid of Coroner Cases
Deb Bond, Hospital Ombud; Lynn Budgell, Patient Safety Coordinator; Annette Down, Director, Quality, Risk, Safety, Ombud
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Two Heads Are Better Than One
Wilhelmine Jones RN, PACU Oakville
VAP Busters
Patti McLaren Manager, Cardio Respiratory Department, and Eileen Gagne, Milton Respiratory Therapy Department
What Happens When a Visitor Falls on Hospital Property?
Annette Down, Director of Quality, Risk, Safety and Ombud; Lynn Budgell, Patient Safety Coordinator; Cindy Svenkeson, Manager Parking and Security
Wheelchair Safety
Jason Ford, OTA/PTA; Jean Gravelle, OT; Jennifer Firth, PT
Within a Vein, Within a Minute, Best Practice is Assured: Daily Intravenous Site Management
Cheryl Berlettano RN 4E, Anna Casciol RN 4E, Amanda Kay RN 4E, Kate LawrenceRN 4E;
Rob Renton PPC 2C/2E/4E
WHO ARE YOU?? WHO, WHO, WHO, WHO? WE REALLY WANT TO KNOW….and Every Patient Has the Right to Know!
Sheryl Brown, EVS Supervisor; Cindy Svenkeson, Parking & Security Manager; JoAnn O’Hagan, Parking Supervisor; Sonya Martin, Call Center Operator
Your Body – Power Position for Work! Minimal Lift & Safe Client Handling Program
Jennifer Luckanuck, Minimal Lift Coordinator
Safety Display Awards The following awards were established to recognize the outstanding work done by our Expo participants. Hundreds cast their vote for the following categories: Most Creative Design Board (Display) Safety Takes Time
Mary Miliucci, Supervisor, Medical Device Reprocessing, Georgetown Hospital & WHO ARE YOU?? WHO, WHO, WHO, WHO? WE REALLY WANT TO KNOW…. and Every Patient Has the Right to Know!
Sheryl Brown, EVS Supervisor; Cindy Svenkeson, Parking & Security Manager; JoAnn O’Hagan, Parking Supervisor; Sonya Martin, Call Center Operator
Biggest Impact Open the Door to Safety: Awareness is the Key!
Angie Molezzi, Business Development ‐ Marketing Specialist
Most Original Initiative VAP Busters
Patti McLaren Manager, Cardio Respiratory Department, and Eileen Gagne, Milton Respiratory Therapy Department
Team Collaboration The Sugar and Spice Story: New Point‐of‐Care Glucose Meter Implementation
Jo Campbell, Manager, Milton/Georgetown Laboratory; Elaine Hooper, Manager, Information Systems; Cornelia Mascherin, Manager, Oakville Laboratory & POC Testing; Judy Maxwell, Laboratory Quality Coordinator; Angela Roode, PPC, Medication Practices and Diabetes Clinician
Best Initiative that Involved Patients and Families Listening Circles… “We’re listening”
Deb Bond, Hospital Ombud, Annette Down, Director, Quality, Risk, Safety, Ombud, Kim Kohlberger, Director, Rehab and Geriatrics, Genny Cho, Manager, CCC, OTMH and MDH, Debbie Hansen, Manager, CCC, GH & For Safety Sake, Communicate
Stephanie Black OTA/PTA (c), 3C/W Rehab ; Natalie Neal OTA/PTA (c), 3C/W Rehab
Honourable Mentions There’s No Reason to be Deathly Afraid of Coroner Cases
Deb Bond, Hospital Ombud; Lynn Budgell, Patient Safety Coordinator; Annette Down, Director, Quality, Risk, Safety, Ombud
Antimicrobial Stewardship – Who’s Job is That?
Jill White, Antimicrobial Stewardship Pharmacist, Pharmacy; Dr Tom Warren, Infectious Disease Physician; Helena Trabulsi, Director of Pharmacy; Grace White, Clinical Pharmacy Manager Restraint Utilization: Safe vs. Unsafe Approaches
Erica Belluz, Rec. Therapist, CCC Milton; Janine Theben, Occupational Therapist, Milton CCC; Tamara Crow, Occupational Therapy Assistant, CCC Milton
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COVIDIEN
Congratulates
Halton Healthcare
Services
on Celebrating
Patient Safety
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Quality Improvement/Safety Initiatives This section of the booklet provides a brief summary of the more than 50 quality improvement/safety initiatives showcased by our staff. In keeping with a corporate initiative to use a standardized approach to how we communicate across the organization, all of the storyboards descriptions have been structured using the S.B.A.R. format. Use of this structured approach can have a positive impact on our conversations, written or verbal. SBAR stands for: S: Situation: What is happening at the present time? B: Background: What are the circumstances leading up to this situation? A: Assessment: What do I think the problem is? R: Recommendation: What should we do to correct the problem? Each SBAR summary includes who to contact should you wish to connect – Safer together! 5P Rounding S: Patient satisfaction scores for responsiveness, communication and consideration are below <75% within the Medical Program. B: 5P rounding addresses five areas of patient concerns: pain, positioning, personal care, plan and patient safety. Evidence shows routine rounding results in; 50% fewer falls, 14% fewer pressure ulcers, 38% fewer call bells and increased patient satisfaction by 12 points. A: 5P rounding allows staff to address all areas of patient concerns with each encounter; improve communication, patient/healthcare relationships and patient satisfaction scores. R: Introduce 5Ps to the multidisciplinary team and start routine rounding throughout the program. Submitted by: Indy Sahota, PPC Medicine Program; Carol Eaton, Patient Care Manager, 2E Medicine and NRT Antimicrobial Stewardship – Who’s Job is That? S: The goal of an Antimicrobial Stewardship Program (ASP) is to promote safe use of antimicrobials. B: Antimicrobial drugs are the only class of therapeutic agents where use in one patient can lead to lack of benefit when the same drug is used subsequently in a different patient, as microbial resistance develops with use over time. A: Key strategies at HHS to promote safe use of antimicrobial drugs: HHS Automatic Stop Order Policy; Multidisciplinary Antimicrobial Stewardship Committee; Computer Generated Tools for Nurses, Pharmacists and Physicians; Antimicrobial Stewardship Team of Infectious Diseases (ID) Pharmacist and ID Physician; ID Physician Consults. R: Antimicrobial Stewardship is a team effort! Submitted By: Jill White, Antimicrobial Stewardship Pharmacist, Pharmacy; Dr Tom Warren, Infectious Disease Physician; Helena Trabulsi, Director of Pharmacy; Grace White, Pharmacy Clinical Pharmacy Manager 11
Are you Ready to get Strong and Steady? S: Seniors who fall are assessed by an interdisciplinary team in the Falls Clinic. Eligibility for the Strong and Steady Falls Prevention Program is determined and patients are enrolled. B: Falls account for 85% injury related hospitalizations in individuals 65 years and older. 60% of seniors who experience a fall do not return to their previous level of functioning. A: Performance indicators are submitted to the LHIN. R: Early identification of seniors at risk for falls and collaboration among stakeholders will facilitate access in care. Submitted by: Rehabilitation and Geriatric Program ‐ Cynthia Archibald, Physiotherapy Assistant; Lyndsay Beker, Nurse Practitioner; Cynthia Chiu, Physiotherapist; Shirley Coughlin, Occupational Therapist; Jacqueline Minezes, Manager Bariatric Barriers – a Big Challenge S: With obesity rates climbing, the race is on to get our larger patients up and moving safely. B: As obesity rates climb, so do the safety challenges of moving our larger patients. With 5 % of muscle strength lost per day of bed rest, it is particularly challenging to find effective solutions quickly enough. A: Staff are faced with many difficulties when our larger patients are being mobilized and the ideal/specialized equipment is not available. Several solutions were identified on CCC that have enabled us to maximize efficiencies in getting the right equipment to the right place at the right time and identifying the best methods to move the patient. R: The staff on CCC have found creative solutions to manage the ‘race against time’ in getting our larger patients up and moving safely. Submitted by: Sian Surridge, Occupational Therapist, Complex Continuing Care, Oakville The Bugs Stop Here – Pump it Up! S: Proper hand hygiene is a provincial and HHS priority. A renewed series of strategies is being launched corporate‐wide in November to coincide with Canadian Patient Safety Week. The goal is to saturate the organization with additional skills and tools to significantly improve compliance with hand hygiene practices – because it’s the right thing to do. 12
B: The Ministry Just Clean Your Hands program was created to help hospitals overcome the barriers to proper hand hygiene and improve compliance with hand hygiene best practices. Most healthcare settings report poor adherence to hand hygiene best practices. A program of regular auditing of hand hygiene practice and results reporting is mandated by the Ministry. A: HHS hand hygiene compliance rates are below the provincial average. Since it is such an important safety initiative, hand hygiene compliance is part of our corporate Quality Improvement Plan, with specific focus on Moment #1. R: The power to make a difference is in our hands ‐‐ everyone needs to be on board and “pump it up”! Submitted by: Annette Down, Director of Quality, Risk, Safety and Ombud; Shirley Lanza, Manager, Infection Prevention and Control; Lynn Budgell, Patient Safety Coordinator Bullet Rounds S: The Multidisciplinary team on the Acute Care unit holds daily morning Bullet Rounds at the start of day shift. B: The goal is for efficient, accurate reporting of patient medical and physical status amongst the team including doctors, early identification of potential discharge barriers and early intervention of appropriate Allied Health disciplines. A: A safety huddle is incorporated into rounds, communicating information and strategies that are in place to address issues such as patients at risk for falls. R: Through optimal team communication, this model has improved patient safety, facilitated timely therapeutic intervention, decreased length of stay and optimized patient flow to appropriate alternate services to meet their care needs. Submitted by: Barb Deichert, RN; Jean Gravelle, OT; Darlene Lambe, DP, CCAC Coordinator; Jason Ford, OPTA; Jennifer Firth, PT: Laureen Taylor, RT; Nela Wilson, SLP CAUTI – Let it Flow, Let it Flow, Let it Flow S: Catheter Associated Urinary Tract infections (CAUTI) are responsible for approximately 40% of hospital acquired infections. Up to 25% of hospitalized patients have a urinary catheter and approximately half of those are not clinically indicated. B: A working group began to focus on CAUTI 18 months ago with a webinar series offered through IHI. A survey of physicians/nurses was completed to determine our current state regarding appropriate use of urinary catheters. A tracking spreadsheet was developed to prompt discussion at 48 hours regarding the ongoing need for a catheter. A: It is important to reduce the number of patients being received on the inpatient units with a urinary catheter. R: The ER department is tracking patients with urinary catheters, assessing the appropriateness of the catheter and to removing any urinary catheters no longer indicated. Submitted by: Cathy Goacher, Coordinator, Professional Practice 13
Code Red: “The Heat is On” S: On Friday, April 22, 2011, a patient set a mattress on fire in a semi‐private room on the inpatient mental health unit. B: The inpatient mental health staff have participated in many mock Code Reds. A: Due to past participation in mock Code Reds, the staff were able to save lives and prevent injury by containing the fire, and removing patients and visitors in a timely manner. When reviewing the incident, one of the most important learnings was that “things are not always as they seem”. R: We need to always ensure we understand the big picture before jumping to conclusions or pointing fingers. This incident created opportunities for use of safety huddles and to review the process for quickly accessing fire fighting equipment on the unit. Submitted by: Cheryl Gustafson, PCM Mental Health; Lisa‐Marie Burka‐Daniels PPC Mental Health; Anthony Wright, CRN Mental Health Coordinating Safe Care is Proactive – Not Reactive S: A growing population diagnosed with COPD. B: At present 780,000 of the Ontarians that have COPD find it hard to breathe. The most common cause of COPD is smoking. A: People with COPD need support and education which leads to empowerment and lifestyle changes. Physicians and staff need someone who has a background education in COPD while promoting best practices. R: The COPD Coordinator works with the staff and physicians to ensure that safe quality care is achieved. Automatic referral on the COPD order set enables the Coordinator to meet with the patient and quickly establish a plan of care. Submitted by: Jacqueline Minezes, Manager Outpatient Rehab and Geriatrics; Kathy Theroux, COPD Coordinator, Rehab and Geriatrics COPD Order Sets Are Like a Breath of Fresh Air S: There was an opportunity to standardize the COPD order set across the organization. B: At HHS some sites were without a standardized order‐set and COPD pathways, others were inconsistent. Changes to the care giver and patient pathway have been created to reflect the standardized order set. A: From admission to discharge the order set is supported by the latest literature and best practice. COPD order sets move the patient along the health continuum from illness to wellness. R: We must support safety and deliver quality care through the use of the COPD order set. Easy access, team member support, and a clear format will ensure that the order set will be a success. Submitted by: Carole Eaton, PCM 2E & NRT; Kathy Theroux, COPD Coordinator, Rehab & Geriatrics 14
Encouraging and Supporting Patients To Make Their Own Healthcare Decisions S: The Kidney Function Clinic (KFC) staff saw an opportunity to embrace self management as a fundamental component of their patient care model for chronic kidney disease prevention and management. B: Self management is increasingly becoming a fundamental component of care for chronic disease prevention and treatment. The evidence points towards patients and their caregivers wanting to participate in their own decisions and when this happens, patients and families can experience a broad range of improved outcomes. A: In 2009 the KFC clinic embraced this concept of supporting patients to make their own decisions. At the time there were 1050 patients with Chronic Kidney Disease stages three to five in the program. The interdisciplinary team participated in a Stanford Self Management Program and incorporated the principles into practice. This involved developing a number of new initiatives, such as modifying the approach and language to use with patients. R: Evaluation of the new approach shows positive results – e.g. reported increased levels of patient satisfaction, increasing participation and independence in self monitoring. Submitted by: Jan Baker, RN, BN, CNeph(C); Vanessa Deck, RN, CNeph(C); Maria Doyle, RN, CNeph(C) ‐ Kidney Function Clinic To Err is Human: The Use of Safety Huddles to Enhance Perioperative Patient Care S: Expanding the culture of safety within the perioperative environment is vital to enhancing patient care outcomes. B: The use of safety huddles is an integral component in achieving this goal with the perioperative team at Halton Healthcare Services ‐ Oakville site. A: Safety huddles, held weekly within the perioperative program, allow for safety concerns to be quickly addressed and also provide a forum for proactive safety discussions. R: We experienced the benefits and challenges of implementing ‘safety huddles’ within our perioperative environment as well as understood staff perceptions of their effectiveness in enhancing a culture of safety within the operating room. Submitted by: Anne Marie Dutka RN, Interim PPC OR/MDR; Cindy MacFarlane, PCM OR/MDR; Liz Pawlowski, PCM PAC/SDU/PACU Evidence‐Based Practice: Quality Care Via Quality Information @ the Library S: A challenge in health care is connecting health care professionals to quality information resources to improve patient care. B: The role of professional information staff and the Library is proven to improve patient outcomes, shorten patient length‐of‐stay, help avoid adverse events and increase overall quality of care and patient safety. A: The Library works to instil an ethos of evidence‐based practice through a partnership with professional information staff to navigate and utilize the best of the vast amounts of available information. 15
R: The HHS Library can and should be readily accessed to help ensure quality care and improved patient outcomes. Submitted by: Jeanna Hough, Manager Health Science Library, HHS Falls S: Georgetown Family Practice is committed to identifying and working with patients who are identified as a falls risk. B: Georgetown Family Practice cares for many patients who are at risk for a fall. A: We have a process whereby patients who are assessed as a falls risk are highlighted to the whole team. R: This process stresses safety awareness and continuity as the patient moves through the Georgetown Hospital, whether the patient comes from ER to Med‐Surg, or moves to Complex Continuing Care and then CCAC or home. Submitted by: Staff of Georgetown Family Practice Flu Ends With You S: It’s November! Flu season is upon us and will last until April. B: Influenza is a contagious disease caused by a virus that affects the breathing passages. Every year in Canada, 5,000,000 people will be infected with influenza. A: Approximately 20,000 people will be hospitalized with the illness, which places a heavy burden on the healthcare system. R: Everyone needs to consider receiving a flu vaccine. Submitted by: Karina Prokopchuk, Manager, Occupational Health and Safety 16
Food Safety S: Everyone is at risk for foodbourne illness, however young children, the elderly, chronically ill people, and those whose immune system is compromised are at high risk = OUR PATIENTS! B: With increased surveillance and reporting in the marketplace of illnesses linked to foodbourne illness outbreaks, the ability to track our food sources has become increasingly important. A: We need to have the ability to provide assurance of the safety of our food at any moment. R: The Food Services Department has implemented a comprehensive quality assurance approach to procurement practices and is able to immediately respond and react to food recall notices. Submitted by: Marianne Katusin, Manager, Food Service;: Elma Hrapovich, Director, Food Services The Foot is an Anatomical Marvel S: The Oakville Hospital Footcare & Orthotic Centre has been providing relief to our patients suffering from various foot problems. Whether it is a Custom Orthotic, Compression Stockings, Routine Nailcare, or more advanced services like Diabetic & Arthritic Footcare, Plantar Fasciitis, and Corns/Calluses, we provide outstanding personalized care and education to help you maintain your healthy feet. B: The Oakville Hospital Footcare & Orthotic Centre is owned and operated by HHS, and has been providing a full spectrum of exceptional footcare services for over 20 years. A: Our team consists of Registered Chiropodists, Registered Practical Nurses, Professional Shoe Fitter, and Reflexologist. They work with children, adults and seniors, treating a wide variety of foot conditions. R: To learn more about The Oakville Hospital Footcare & Orthotic Centre or to book a biomechanical assessment with one of our highly trained professionals, please call 905‐338‐4669 or visit www.OakvilleHospitalFootcare.ca today. Submitted by: Angie Molezzi, Business Development ‐ Marketing Specialist For Safety Sake, Communicate S: Effective communication assists in collective goal setting, ensures a shared understanding of expectations and provides an opportunity for problem‐solving within the patient‐healthcare team. B: NRC Picker patient satisfaction results for 3C/W Rehab demonstrated that there were opportunities to improve communication between the healthcare team and patients. A: Staff on 3C/W Rehab were motivated to improve communication with their patients and families in their care plan. R: The Rehab Communication Folder was developed and it stores information patients collect during their stay as well as a “communication sheet” where questions and responses are recorded. This folder serves as a key source of communication between patients, families and staff. Submitted by: Stephanie Black OTA/PTA (c), 3C/W Rehab; Natalie Neal OTA/PTA (c), 3C/W Rehab 17
Halton Healthcare Services Safer Elder Care Program ‐ Developing An Evidence Based Geriatric Model – Operationalizing NICHE ‐ Early Implementer Site S: Older adults are the fastest growing sector of the population in Halton and in Canada, with those 85+ suffering most from chronic illness and frailty (StatsCan, 2007). B: This segment of the population has become the largest consumer of hospital‐based services and is most at risk for adverse health outcomes as a consequence of hospitalization. A: The key purpose of the “Safer Elder Care” (SEC) initiative is to decrease risk and improve the quality of care provided to geriatric patients at HHS. R: SEC hardwires ‘best practice’ concepts into core clinical processes targeting common geriatric issues (such as delirium, falls, mobility, continence/catheter use, pain, dementia, skin and wound care), through staff and patient education, policy and practice change. Submitted by: Dr. Kirsten Lindner, Chair, Safer Eldercare Committee; Jennifer Luckanuck, Co‐Chair Safer Eldercare Committee; Delayne Haasz, Founder and Member of Safer Eldercare Committee Hand Hygiene on 2C Inpatient Surgery: From Moment 1, We Will Save Lives S: HHS’ overall compliance with hand hygiene is 48%‐‐‐everyone in the corporation needs to improve hand hygiene compliance. B: 2 Center is using a multi‐modal approach to improve practice and change attitudes towards hand hygiene. Discussions at staff meetings, which began in May 2011, have revealed there is a knowledge gap on the 4 Moments of Hand Hygiene. As a result, there has been on‐going education on hand hygiene through safety huddles, staff meetings, auditing and the launch of our “Foam in, Foam Out” campaign. A: 2 Center’s compliance with Moment 1 has improved from 42% in Quarter 1, 2011 to 60% in Quarter 2, 2011. R: 2 Center’s goal is to achieve 80% compliance with Moment 1 by Quarter 4, 2012. Submitted by: Micky Brankovic 2C RN; Robert Renton, PPC 2C/2E/4W; Kelly Roy, PCM 2C Inpatient Surgery HHS Bedsores No More S: Pressure ulcers located on the heels are the second most common anatomical site behind the sacrum/coccyx. B: Our program, “Stomp Out Heel Ulcers” included an algorithm to assess patient risk, methods to remove heel pressure, documentation of new facility acquired pressure ulcers and educational material directed to inform and educate patients and their families. A: The results of our organization’s 2010 pressure ulcer prevalence survey revealed that pressure ulcers located on the heels were the most common site accounting for 35 ulcers or 42% of all pressure ulcers identified. 18
R: This program was launched in early January 2011 and most recent results demonstrated a 49% reduction in heel ulcers, 17 down from 35. Submitted by: Richard Bishop, RN, BScN, IIWCC, Skin and Wound Care Clinician HHS Informed Consent‐The Multicultural Dimension S: Informed consent is a legal procedure that ensures a patient knows and understands all of the risks involved in a specific treatment or procedure. B: In medical treatment requiring invasive (possibly life threatening) procedures, a doctor or healthcare provider must disclose sufficient information to the patient for him/ her (or substitute decision maker) to give informed consent. A: The elements of informed consent include informing the patient of the nature of the treatment, the potential risks and benefits and possible alternatives. In order for informed consent to be considered valid, the client must be competent and the consent should be given voluntarily. In a multi‐cultural environment, informed consent provides additional challenges due to cultural and language considerations. R: At HHS multi‐cultural challenges of informed consent are being addressed. Submitted by: Jacqueline Goodban R.N.; Jennifer Cassista R.N.; Donna McPhail R.N; Milton Obstetrical Unit It Takes a Village… S: Staff, physicians and volunteers are all responsible for patient safety. The average volunteer works two to four hours a week which equates to as little as 100 hours a year. Volunteers come to us with skills and experience, although it may not be from the healthcare field. B: The Department of Volunteer Services provides general orientation covering patient and volunteer safety, emergency codes and WHMIS but most of the learning occurs “on the job”. A: We need to consider the learning curve for volunteers, as they are in need of support to become comfortable in their new role. 19
R: “It takes a village” to ensure volunteers understand their role and provide services in a way that promotes patient safety at all times. Staff should recognize volunteers when they are doing things right and provide guidance when they notice a task can be done in a safer way. Together, we can provide the best and safest care to our patients. Submitted by: HHS Volunteer Services Team Keeping our Seniors Safe with ConnectCARE S: ConnectCARE Emergency Response Service allows seniors to live safely and independently in their own home for as long as possible with a simple press of a waterproof button, 24 hours a day, 7 days a week. ConnectCARE offers a complete range of sensors including: Fall Detector, CookStop Sensor , Wandering Client Sensor, Flood Detector, Bed Occupancy Sensor and so many more… B: ConnectCARE Emergency Response Service is owned and operated by HHS, and has been providing Emergency Response Service to Halton and surrounding areas for over 20 years A: Our state‐of‐the‐art technology allows a two‐way speaker to have live communication between the client and our monitoring centre to ensure appropriate action is taken. R: To learn more about ConnectCARE Emergency Response Services, please call 1‐800‐665‐7853 or visit www.ConnectCAREHalton.ca today. Submitted by: Angie Molezzi, Business Development ‐ Marketing Specialist Keeping the Stream Flowing S: Paediatric patients attending the Emergency Department (ED) for care who leave having not been seen or treated (LWBS) by an ED Physician represent a significant patient safety risk. B: Increasing volumes and changing have significantly strained existing resources. One key consequence is the number of patients leaving without being seen; paediatric patients are significantly over‐represented in this group. One key barrier was that MDH had no access to ‘Pay 4 Results’ funding until April 2011. 20
A: Implementation of RAFT was initiated in 2010/11 and improved (decreased) the percentage of patients leaving without treatment from our 2009/10 performance. However this continued to be substantially below the quality target of < 3%. Focused audits determined that paediatric patients were particularly susceptible to leaving without being seen during peak volume periods e.g. evenings. R: Flow process improvements and enhancements to nursing and physician resources (enabled through Pay 4 Results support) will positively impact our LWBS rate. Data analysis of pre and post P4R strategies will be reviewed to determine the impact. Submitted by: Darlene Walsh, Patient Care Manager, MDH Emergency/Ambulatory Care KID‐E.E.S. S: The KID‐E.S.S. program is a two year paediatrics learning and teaching strategy. KID‐E.E.S. stands for KIDS ‐Evidence based Education for Safety. B: This program specifically emphasizes Evidence based healthcare, Education and Safety by following pertinent paediatric nursing subjects each month in the first year and three in‐depth case studies the second year. A: Mission is “Growing Pediatric Nurses of Excellence”; Vision is “To be a community of nurse leaders in paediatric health by setting the standard for patient care through current research and evidence‐based practice guidelines. Promote optimal health for our clients and their families through practice, education and advocacy”. R: Through various learning and knowledge building techniques, paediatric nurses are challenged to increase their awareness of safe healthcare, apply research and best guidelines to the clinical arena, and remain committed to the global accountability we all share in the safe outcomes for our clients. Submitted by: Rebecca McAlpine, PPC, Maternal Child Program, Oakville LEAN Architectural Basics **LAB** S: Lean is derived from the Toyota Auto Production system which seeks to be more efficient. The lab’s objective is to set goals and priorities based on the needs of both staff and customers for optimal patient care delivery. B: During the off‐shift, a one‐man system is operating in the Milton Laboratory. A: We established a small team to map out some of our processes to improve the lab layout for quicker and more effective processing. R: By reallocating equipment, using faster centrifuges and having a convenient U‐shaped laboratory, we decreased steps and work flow obstructions. LEAN provides an effective and positive way for a safe and efficient contribution to optimal healthcare. Submitted by: Rosanne Janicki, MLT, ART, Milton Lab; Johanna Campbell, Manager, Milton and Georgetown Laboratory 21
Listening Circles… “We’re listening” S: The Ombud and the Rehab/Geriatrics program collaborated to offer Listening Circles to engage patients/families and to assess satisfaction with care and services. B: Through listening circles patients and their loved ones told us what we are doing well and what we can improve on. The patients felt valued and their families felt better connected. A: The program ran for five weeks at all three sites and covered a number of topics including toileting, call bell response, pain management, communication, comfort, food and activities. R: Share the benefit of listening circles and encourage their use as a tool. Submitted by: Deb Bond, Hospital Ombud; Annette Down, Director, Quality, Risk, Safety, Ombud; Kim Kohlberger, Director, Rehab and Geriatrics; Genny Cho, Manager, CCC, OTMH and MDH; Debbie Hansen, Manager, CCC, GH Neonatal Mock Code Pink Drills S: Whenever a baby is born, there must be at least one person skilled in Neonatal Resuscitation that is dedicated to the care of the newborn. In order to support Neonatal Resuscitation skills, members of the obstetrical team at Georgetown recently developed interdisciplinary Neonatal Mock Code Pink drills. B: It is estimated that 10 % of newborns will need extra help in transitioning to the extra uterine world and 1% of these newborns will need extensive resuscitation. A: It is difficult to develop and maintain Neonatal Resuscitation skills and so our team developed regularly scheduled, twice weekly drills. These have been successful and embraced by everyone ‐nurses, midwives, RT’s and physicians. Advantages are clear in providing us an opportunity to develop and maintain Neonatal Resuscitation skills, improve communication and promote effective team work. R: The Neonatal Mock Code Pink drills directly impact our patients’ safety. Others are encouraged to use the mock drill strategy as an effective means of enhancing patient safety. Submitted by: Anna‐Marie Merchant, Patient Care Manager, Obstetrics/Surgical Daycare/Ambulatory Care Unit, Georgetown Hospital Open the Door to Safety: Awareness is the Key! S: Work‐Fit Total Therapy Centre offers comprehensive rehabilitation services focusing on improving the safety and well being of our local Halton community members. We offer speciality programs including Hip and Knee Saver, Vestibular Rehab for Vertigo, Core Stability Training, Pre/Post Natal Physiotherapy and Corporate Return to Work Programs, FAE’s, Ergonomic Assessments, Educational Sessions and consultations. As a not‐for‐profit service, all net proceeds support hospital (HHS) programs. B: Work‐Fit Total Therapy is owned and operated by HHS, and has been providing a full spectrum of exceptional rehabilitation services for over 20 years. 22
A: The Work‐Fit Total Therapy Team works together in developing new and evidence based assessment and treatment programs that are customized to promote well being to our clients. R: To learn more about Work‐Fit or to book an assessment with one of our highly trained team members—
Physiotherapists, Registered Massage Therapists, Kinesiologist and Occupational Hand Therapist, please call (905) 845‐9540 or visit www.WorkfitPhysiotherapy.ca today. Submitted by: Angie Molezzi, Business Development ‐ Marketing Specialist Patient Declaration of Values ‐ Let’s Work Together to Live the Shared Values S: HHS has had a ‘Rights and Responsibilities’ statement in place for some time. It was recently replaced by the new Patient Declaration of Values or DOV. B: The DOV represents the voices of our patients, families and their caregivers. It identifies what they value the most when accessing care and services at any of our sites. A: The Ombud developed this document, following an analysis of feedback solicited over a five month period from patients, families and caregivers regarding their values. Data from patient satisfaction surveys was also analyzed and themes and trends were represented in the document. R: All staff, physicians and volunteers need to familiarize themselves with its content and be aware that in order to attain our goal of providing the best possible experience to our patients we must embrace the Patient Declaration of Values and live the components of the value statements every day. Submitted by: Deb Bond, Hospital Ombud; Annette Down, Director, Quality, Risk, Safety, Ombud
Pharmacy Innovations Improving Patient Safety S: The HHS Medication Management Plan features the use of Pharmacy systems automation to improve safety. It is important to keep nursing staff and physicians informed along the way of the project’s progress and benefits of automation. B: As part of Medication Management Plan, technology is key to safer medication distribution and delivery. Medications will be pre‐packaged, labelled and bar‐coded for use at patient bedside. 23
A: New Automated Pharmacy Systems will improve patient safety. The major components of the planned automation are: drug storage and retrieval unit, automated tablet and liquid packagers and automated dispensing units. R: Educating staff of future developments for Pharmacy and providing increased awareness and confidence in the Medication Management Plan. Submitted by: Angela Roode RN, BScN, CDE, PPC ‐ Safe Medication Practice; Veronica Breadner RN, Clinical Nurse Analyst ‐ Medication Management; Boris Curcic, PharmD., RPh., Pharmacy Analyst The Power of Patient Safety S: While we all recognise patient safety as important, do we understand the power that is at play behind it? B: The current processes surrounding the Internal Reporting System (IRS) may prevent staff from using it. A: Power plays an integral part in how we view patient safety and also how we use the incident reporting system. R: The ward and organizational culture plays a vital role in either encouraging or discouraging staff in reporting of incidents. Submitted by: Sonya Myles, RN, BScN, IBCLC, Breastfeeding Clinic ‐ Maternal Child Unit, Oakville Q‐Syte Needleless Connector S: The Flolink central line needleless connector, a positive pressure device, which is currently used at HHS, is no longer available. B: A review of the literature and a scan of the practices at surrounding hospitals has revealed that neutral devices are better than positive pressure devices. Positive pressure devices can lead to blood stream infections. Furthermore, HHS will continue the use of normal saline as the repeated use of heparin to flush lines can cause thrombocytopenia. A: As a result of the review, a decision has been made to transition to the BD Q‐Syte central line needleless connector. The Q‐Syte connector is a neutral device and can be flushed with saline. R: All HHS staff will be educated on the safety features and safe use of this device. Submitted by: Professional Practice Clinicians, HHS Regional Ethics Program S: HHS recently joined the Regional Ethics Program and hired Ethicist, Eoin Connolly. B: HHS has had a long history of providing ethics support to its patients and staff through its Ethics Committee and various ethics champions throughout the organization. 24
A: The ethical issues in healthcare have become more complex. Moreover, Accreditation Canada has increasingly focused on ethics as part of their accreditation process. R: Eoin Connolly and the Regional Ethics Program will facilitate and support ethical decision‐making processes from “bedside to boardroom” through: ethics consultation, education, policy development and review, as well as research ethics and ethics research. Submitted by: Eoin Connolly, Ethicist Restraint Utilization: Safe vs. Unsafe Approaches S: Use of safe restraints: Using technology to improve client safety. B: In the past, physical restraints such as wheelchair seat belts that clasped at the back, Posey lap belts, torso aprons and raised bed rails were used to deter patients from exiting their wheelchairs or beds. These types of restraints pose a danger to patient safety when used, especially when used improperly. Least restraint policies are driving change to electronic safety alarm systems, which can warn staff when patients are trying to exit their wheelchairs or beds. A: It is important to assess factors such as client ability to use the call bell, level of mobility and patterns of behaviour when utilizing restraint or alarm devices. R: By utilizing a checklist of factors to consider the appropriate type of electronic alarm device that will be utilized, HHS staff will be able to program devices correctly and ensure they are stored safely. Submitted by: Erica Belluz, Rec. Therapist, CCC Milton; Janine Theben, Occupational Therapist, Milton CCC; Tamara Crow, Occupational Therapy Assistant, CCC Milton Roving Reporting at Milton District Hospital S: The Med/Surg Unit at the Milton site has adopted a mobile bedside reporting structure for change of shift handoff to improve the effectiveness of patient related communication at high‐risk transition points. B: In early 2011, the Med/Surg Unit at Milton set out to improve patient safety and increase both patient and patient family involvement. Reporting at the bedside allowed the patient and their family to be involved as part of the care team; discussing the current treatment and their plan of care. Reporting at the bedside also allowed nurses to observe the patient an additional time in the day, and allow the in‐coming nurse to prioritize the shift based on patient need identified during the bedside report. A: A framework was created to ensure that the nurses covered pertinent care information while including additional information which could often be forgotten using traditional reporting methods, including armband review, risk concerns (i.e. falls, restraints, behaviours). No formal staff or patient feedback was conducted. Staff embraced the change as safety benefits were realized. R: Next steps are to integrate the SBAR tool into the bedside reporting framework. Room safety checks could also be incorporated into this reporting structure looking for functioning oxygen, suction and call‐bells, to name a few. Submitted by: Jean Roy, CRN, Med/Surg; Norma Jones, CRN, Med/Surg; Karen Vokner, PPC, MDH; Janice Dziepak, Interim PCM, Med/
Surg 25
Safety Crosses ‐ Cross your Fingers or get Involved? S: Patient Safety is a complex concept. Many of us assume that we are acting safely but are we actually providing safe ‘best practices’? The 2E Medicine team recognized the importance of using measurement to help evaluate use of ‘best practices’ and track safety‐related incidents. The ‘safety cross’ was recently chosen as a simple method to assist us. B: The Safety Cross is a piece of paper with days‐of‐the‐month where ‘safety incidents’ can be recorded (e.g. falls, medication errors, pressure ulcers). Monitoring and tracking incidents this way helps inform the team about our current state and improvement opportunities. A: Since recently implementing safety crosses, our entire team is engaged in patient safety best practice. Managing safety requires participation of the entire team at every moment and this is accomplished in safety huddles, staff meetings, bedside safety checks, 5P rounding, Geo Rounds, nursing and interdisciplinary care. R: Information about performance, so visible in the safety crosses, can be used by staff, educators and managers to monitor and promote involvement of everyone on the team – only then can we move forward with our goal of managing patient safety using best practice. Submitted by: Lucia Yoon, RN, 2E; Judy Forward, Safety Champion 2E; Rob Renton, PPC for 2E, 4E and 2C Safety Huddles Advance the Game! S: Inpatient Rehab is a leader in sustaining weekly ‘Safety Huddles’ for over two years. It has evolved into a valuable process demonstrated by our weekly commitment and the improvement strides made as a result. B: The Safety Huddle was implemented at HHS in 2008. It is a brief (5‐10 min.) action‐focused meeting of the inter‐
disciplinary team that promotes discussion and problem‐solving of patient/staff related safety issues. More than two years ago, Inpatient Rehab seized the opportunity to implement Safety Huddles in order to help advance their safety culture. A: The team now relies on regular weekly Huddles as an effective way to communicate safety‐related issues ‐ they are conducted weekly: at the same time and place; with a designated point‐person who rallies the team, documents the issues brought forward and coordinates the action plan. R: We recommend that all areas introduce Safety Huddles. Based on our experience, the benefits to staff and patients are undeniable. Submitted by: Judi Montgomery, PPC, Rehabilitation and Geriatrics Program Safety Takes Time S: The Medical Device Reprocessing Department must adhere to comprehensive sterilization standards in order to provide reusable items that are safe for patient care. 26
B: Following each step and adhering to each standard takes time. From beginning to end, the various stages in the sterilization process take about four hours – from inspecting, sorting and assembling instruments in readiness for sterilization, then cooling and distribution. A: We need to provide assurance of the safety of our reusable devices at all times. R: The Medical Device Reprocessing Department delivers high quality practises that meet rigorous standards so that these devices are ready for the delivery of safe patient care. Submitted by: Mary Miliucci, Supervisor, Medical Device Reprocessing, Georgetown Hospital SBAR – A Sweet Way to Communicate! S: HHS implemented use of SBAR (Situation‐Background‐Assessment‐Recommendations) on clinical units in 2007 and for administrative purposes (non‐clinical) in 2011. B: SBAR is an effective, structured format that is used to improve communication and patient safety. Its use adds predictability and consistency in what and how information is relayed. Situation = what is going on; Background = relevant history/context; Assessment = what we think; Recommendations = what is needed. Accreditation Canada has identified the need for us to have ‘effective communication at transition points’ (ROP); the literature on adverse events shows that 40% of critical patient incidents can be linked back to communication breakdown between clinicians. A: There is a need for renewed focus on SBAR – both evaluating use among clinicians and promoting it across HHS for many conversations, both written and verbal. R: SBAR has the potential to improve communication at HHS! It will be a continued focus through 2011‐12. Resources are available on Connections, the corporate intranet. Submitted by: Cathy Goacher, Coordinator, Professional Practice Office; Lynn Budgell, Coordinator, Patient Safety Scanning Safely S: HHS has an upgraded CT scanner, resulting in dose reduction. B: The ‘dose’ has been in the fore front of media attention. 27
A: HHS plans to set up a CT Dose Committee to disclose where the organization stands in this area. R: The CT Dose Committee will review current CT services to identify areas of potential vulnerability, review protocols to maximize dose‐reduction capabilities, ensure adequate staff training, confer with staff regarding unique operational areas of concern and review HHS’s current process for referrals. Submitted by: Deb Winger, Team Leader CT; Jacqui Munro, Senior Resource CT; Krista McIntosh, CEL Soap Opera S: ICU must improve hand washing during ‘Moment 1’. ICU hand hygiene rates for April‐June 2011 are 57.9% for Moment 1 & 70.2% for moment 4. B: Hand washing is the main method of preventing the spread of infection. In hospitals, emphasis is placed on decreasing the transmission of medication resistant organisms. A: “Soap Opera" posters were created to prompt questions and invite those interested in improving hand washing to participate on a team project. An electronic safety huddle was also used in the project. R: The first moment of hand hygiene must become a "habit" or an unconscious action every time a health professional enters the patient room. Submitted by: Ibrahim Merhi, PPC ICU Someone Could Be Dying To Tell You Something S: Often people with aphasia have much to say and their needs are not met and they become frustrated because they are not understood. B: Aphasia is a confusing word which is related to brain injury or stroke, and describes difficulties with reading, speaking, talking and writing for example. A: This poster board will consider ways to communicate with someone with aphasia. R: These communication tools may be used by patients, families and other caregivers. Submitted by: Speech Language Pathologists: Alyssa Weinmaster, Alyssa Weinmaster, Ashley Tinkham, Bon‐Hi Moon, Melanie Ribeiro and Nela Wilson The Sugar and Spice Story: New Point‐of‐Care Glucose Meter Implementation S: In September 2011, HHS implemented new NOVA Stat Strip Point‐of‐Care Glucose Meters. B: A Patient Safety concern was identified with the existing Glucose Meters producing potentially erroneous blood glucose results due to interfering substances. An RFP process was completed to purchase these for all three HHS sites. A multidisciplinary project team was formed to facilitate and complete implementation. 28
“The Sugar” “The Spice” A: Safer – eliminates interfering substances; more accurate  Mandatory patient wristband scanning results  New “patient override” Faster – test results in 6 seconds  Reviewed sampling technique Smaller – only 1.2ul capillary blood sample required  New lancet Easier – results transmit to patient’s electronic medical  Generic EMERGENCY barcode for patient without a record (EMR); device is straightforward with a colour wristband touch screen R: All 1260 nurses across HHS sites require training to be certified to use the new glucose meters. Certification and help with troubleshooting can be obtained through the Superuser on each unit. More information is available on Connections, the corporate intranet, under Tech Talk – New Glucose Meters. Submitted by: Jo Campbell, Manager, Milton/Georgetown Laboratory; Elaine Hooper, Manager, Information Systems; Cornelia Mascherin, Manager, Oakville Laboratory & POC Testing; Judy Maxwell, Laboratory Quality Coordinator; Angela Roode, PPC, Medication Practices and Diabetes Clinician There’s No Reason to be Deathly Afraid of Coroner Cases S: It is important that all staff and physicians understand the process, ensure information/documentation is released lawfully and assist the deceased’s loved ones in understanding the Coroner’s role following a death in hospital. B: Coroners are physicians with specialized training in conducting death investigations. They investigate reportable deaths as described in the Coroner’s Act of Ontario. A: They must answer five questions: who was the person?, when did they die?, where did they die?, how did they die?, by what means did they die? R: Healthcare providers must contact a coroner immediately about a reportable death as well as cooperating with the police who solicit information/documentation under the authority of a Coroner’s warrant or in cases where the coroner has delegated his power and authority to a medical practitioner or a police officer. Submitted by: Deb Bond, Hospital Ombud; Lynn Budgell, Patient Safety Coordinator; Annette Down, Director, Quality, Risk, Safety, Ombud Two Heads Are Better Than One S: The weekend staffing model in the Post Anaesthetic Care Unit (PACU) had nurses working 16 hour shifts, by themselves during the weekend. B: Fatigue and solo nursing are two areas that are well documented in the literature as contributing to adverse events. A: In response to this literature, the PACU has addressed fatigue and solo nursing by adding an additional nursing shift on the weekend. R: By adding an additional nurse, the numbers of hours of solo nursing has been decreased from 16 to 12, which includes night time on call hours. Furthermore, working in conjunction with nurses from ICU, OR, 2C and medical staff, we have 29
built support systems to assist the PACU nurses when they are working alone. Submitted by: Wilhelmine Jones RN, PACU Oakville VAP Busters S: Two new VAP‐Buster initiatives are being used by Respiratory Therapists in ICU. B: Taperguard Endotracheal Tubes, reduce micro‐aspiration by 90% and Anchorfast Endotracheal Tube Holders are an easy‐to‐use alternative for securing oral ETTs. A: The Taperguard endotracheal tube has replaced the EVAC tube and has been adopted by all hospitals in our LHIN; The Anchorfast ETT holder helps minimize possible ulcer formation on the lips and mucosal tissue and simplifies access for oral care. R: Both initiatives are currently being used in Oakville and Milton for select patients and have been adopted by all hospitals in our LHIN. Submitted by: Patti McLaren, Manager, Cardio Respiratory Department; and Eileen Gagne, Milton Respiratory Therapy Department What Happens When a Visitor Falls on Hospital Property? S: Visitor falls are the fifth highest ranked risk claim in terms of costs, according to the Healthcare Insurance Reciprocal of Canada (HIROC). B: A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, the ground or other surface. Significant harm and costs can be the result of injuries sustained by visitor slips, trips and falls. Everyone at HHS has a role to keep our premises free from hazards. A: There were 15 visitor falls reported in the incident reporting system in 2010/11. When a visitor falls at HHS there are a number of steps that are taken including ensuring that an incident report is completed, taking pictures of the area where the fall occurred, and possibly reporting the fall to our insurer (HIROC). R: All staff, physicians and volunteers have a role in making HHS a safe environment for visitors to reduce the risk of falls. Examples include ensuring that snow and ice are cleared in a timely way, conducting grounds inspections, reporting unsafe situations and implementing a standard spill response when a spill occurs. Submitted by: Annette Down, Director of Quality, Risk, Safety and Ombud; Lynn Budgell, Patient Safety Coordinator; Cindy Svenkeson, Manager Parking and Security Wheelchair Safety S: Staff on the inpatient rehab team of acute care in Georgetown Hospital felt there were safety concerns regarding wheelchairs being loaned to the inpatient population. B: Near‐miss situations involving wheelchair safety were evaluated to determine how to improve patient safety. 30
A: The Rehab team implemented a Wheelchair Safety Checklist for use at time of assembly and prior to delivery of chair to patient. R: Additional safety equipment was ordered and installed to address tipping risk and mechanical failure of wheelchairs. Improvement in patient safety related to wheelchair use has resulted. Submitted by: Jason Ford, OTA/PTA; Jean Gravelle, OT; Jennifer Firth, PT, Georgetown Hospital Within a Vein, Within a Minute, Best Practice is Assured: Daily Intravenous Site Management S: The routine use of intravenous therapy in hospital settings is estimated to affect as much as 90% of patients. This invasive therapy, although common place, is a regulated act that requires professional knowledge, judgement and skill. B: The infection rate for intravenous catheters is 0.5 per 1000 catheters days, and although the rate is low, when considered with the fact that 90% of patients receive intravenous therapy, the number becomes alarming. A: Audits and dialogue have taken place to establish what’s working well and what needs improvement. R: 4 East will establish leaders, reminders and protocols to ensure best practice for intravenous therapy. Submitted by: Cheryl Berlettano, RN 4E; Anna Casciol, RN 4E; Amanda Kay, RN 4E; Kate Lawrence, RN 4E; Rob Renton, PPC 2C/2E/4E WHO ARE YOU?? WHO, WHO, WHO, WHO? WE REALLY WANT TO KNOW….and Every Patient Has the Right to Know! S: The goal of the Environmental Services team is to ensure all staff and contract/visiting personnel are wearing HHS Photo ID badges to maintain safety and security for all. B: Historically, HHS staff have been required to wear Photo ID badges. With the reassurance of knowing their caregivers’ identity, patients will feel more at ease and able to focus on their comfort and well being. A: HHS staff, volunteers, and physician are responsible to be identified through their HHS Photo ID badges. Vendors and contractors will have HHS issued visitor badges supported by company ID. Supporting clinical students will have their institution issued ID badges. R: HHS believes that every patient has a right to know who is providing care and service. Submitted by; Sheryl Brown, EVS Supervisor; Cindy Svenkeson, Parking & Security Manager; JoAnn O’Hagan, Parking Supervisor; Sonya Martin, Call Center Operator Your Body – Power Position for Work! Minimal Lift & Safe Client Handling Program S: The importance of appropriate body mechanics for client handling in healthcare is paramount. B: Due to the work performed in the healthcare setting, such as client transfers, staff are at risk for client handling injuries. 31
A: HHS has a Minimal Lift and Safe Client Handling Policy on HOPP. Staff have choices around equipment to use for safe client handling at HHS. In addition, staff education is being implemented regarding keys hazards such as: force, fixed or awkward postures, and repetition. R: HHS has a new e‐learning module reviewing our Minimal Lift Policy Training and Safe Client Handling. All staff are encouraged/required to review this. Submitted by: Jennifer Luckanuck, Minimal Lift Coordinator HHS Receives Platinum Quality Healthcare Workplace Award The Ontario Hospital Association and the Ministry of Health and Long‐Term Care (MOHLTC) – HealthForceOntario presented HHS with the Quality Healthcare Workplace Award at the highest level available ‐Platinum‐ on Monday, November 7th at the annual OHA Health Achieve Conference. The award was developed to recognize organizational efforts to improve healthcare workplaces in ways that contribute to providers' quality of work‐life and the quality of the care and services they deliver. Awards are available at four levels ‐ Bronze, Silver, Gold and Platinum. This is the second year that the award has been available and in 2010, HHS achieved a Gold level Award. The award application for this year included a wide variety of quality of work‐life and patient safety initiatives at HHS including Kailo, Patient Safety Expos, Interdisciplinary Professional Practice Committee, department‐based suggestions systems, E‐schedule and our Preceptorship Program. 32
Many thanks are extended to our partners and colleagues who have provided draw prizes for our Expos and the Awards Celebration Reception. Gift Shop
HHS Library
Public Relations 33
A Special Thanks to our Sponsors… We would like to acknowledge the generosity and support of our partners and graciously extend our appreciation to each of them. 34