emergency Health Services

www.qmentumquarterly.com
Publications Mail Agreement
No. 40045878
JuLY 2010 volume 2, number 3
Emergency Health
Services
Contents Emergency Health Services Volume 2, Number 3
l
5.
Introduction
l
Taking the Vitals of Emergency
Health Services
in Temporary Locations:
26. Nursing
Listening to Ontario’s Nurses
The Future of Emergency Medical
Services in Canada
30.
Erin E. Tilley & Lori Adler
Wendy Nicklin
6.
Louis Hugo Francescutti
Safety in Emergency Medical
10. Patient
Services
William Hill
14.
Respecting Patients’ Wishes
With No CPR
Ron Yee & Charles Sun
Organizational Performance
18. Enhancing
Through Process Improvement
David M. Williams
in the Emergency:
22. Urgency
In Support of National Standards
of Emergency Care
Alan Drummond
Emergency Departments in Canada:
What We Learned From Recent
Accreditation Findings
Stéphane Cardinal & Tracy Murphy
34.
Hospital Disaster Readiness:
Why Are We Unprepared?
Daniel Kollek
38.
Manitoba Health’s Emergency Response
Management System: Development,
Implementation, and Improvement
John Lindsay & Gerry Delorme
42.
46.
CSA and Emergency Management
Ron Meyers
In Closing
Committed and Involved
Gilles Lanteigne
Qmentum Quarterly: Quality in Health Care is the product of a partnership between Accreditation Canada and Les éditions du Point.
Accreditation Canada is a not-for-profit, independent organization that has been fostering quality in health services across Canada and
internationally for over 50 years. Accreditation Canada provides health and social service organizations with an external peer review to
assess the quality of their services based on standards of excellence. Accreditation Canada is accredited by the International Society for
Quality in Health Care.
Les éditions du Point is a specialized publisher. One of its journals, Le Point en administration de la santé et des services sociaux, is intended for
health professionals and administrators and has been published for six years. Les éditions du Point’s publications target administrators,
managers, and professionals in health care. The publications are intended as tools for information, support, professional development, and
continuing education, as well as for reflection, analysis, and expression. While remaining very close to the concerns of the targeted
readership, the publications are also guided by national and international thinking.
3
Emergency Health Services Volume 2, Number 3
l
Qmentum Quarterly: Quality in Health Care is an avenue for sharing expertise, innovation,
and leading practices across Canada. The publication provides a forum for health and social services
organizations that are committed to learning about and improving quality and patient safety.
Publisher
Normand Bouchard
Managing Editors
Erin McLaughlin-Guthrie
and Suzanne Perron
Produced in partnership with
Accreditation Canada
Wendy Nicklin
President and Chief Executive Officer
Gilles Lanteigne
Executive Vice-President
Donna Anderson
Vice-President, Corporate Affairs
Liane Craig
Director, Strategic Communications
Contributors to this edition
Lori Adler, Stéphane Cardinal,
Gerry Delorme, Alan Drummond,
Louis Hugo Francescutti, William Hill,
Daniel Kollek, Gilles Lanteigne,
John Lindsay, Ron Meyers,
Tracy Murphy, Wendy Nicklin,
Charles Sun, Erin E. Tilley,
David M. Williams, and Ron Yee
4
Production Director
Michel Gagnon
514 277-4544, Ext. 229
Sales and Marketing
André Falardeau
514 277-4544, Ext. 239
Toll-free: 1 888 832-3031, Ext. 239
Special Projects Development
Christian Grenier
514 277-4544, Ext. 233
Subscriptions and Customer Service
Sylvie Anne Turgeon
514 277-4544, Ext. 241
Toll-free: 1 888 832-3031, Ext. 241
Copy Editor
Erin McLaughlin-Guthrie
Concept and Layout
PDG Média
www.pdg-media.com
Printing
J.B. Deschamps
Cover Photo
Marc Boucher, Digiphoto,
Edmundston, New Brunswick
Legal deposit
Qmentum Quarterly
Library and Archives Canada
ISSN 1918-039X
Publications Mail Agreement No. 40045878
Please return undeliverable Canadian
addresses to:
7855 Louis-H.-Lafontaine Blvd., Suite 202
Montreal, Quebec, Canada H1K 4E4
514 277-4544, Ext. 228
Fax: 514 277-4970
[email protected]
www.leseditionsdupoint.com
All rights reserved.
Qmentum Quarterly’s content cannot
be reproduced, in whole or in part,
without the written permission of
the publisher.
Printed on Chorus Art, a chlorine-free
paper containing 50% recycled content,
25% of which is post-consumer waste,
FSC certified.
WENDY NICKLIN
President and Chief Executive Officer
Accreditation Canada
Introduction
Taking the Vitals of Emergency
Health Services
P
ick up any Canadian newspaper and chances are you’ll
stumble upon an article on some aspect of emergency
health services. We’ve all heard the horror stories,
either from the media, a family member, or a friend.
But rather than get discouraged about the problems that do
exist, those of us with an interest in health care are in a unique
position to do something about it.
Here’s what we’re doing. A few years ago, due to increasing
interest from stakeholders and escalating pressures within
the health care environment, Accreditation Canada began
work on an emergency health services initiative that led to
the creation of Emergency Medical Services Standards and
Emergency Department Services Standards. Organizations
that assess themselves against these national standards rec‑
ognize that embarking upon the road of quality improvement
and safety will in turn help improve client outcomes and
contribute to the effectiveness of the health care system.
When EMS and other health care providers collaborate
towards quality improvement, better patient care is achieved.
This issue of Qmentum Quarterly begins outside of the hospital
in the vital field of emergency medical services. Louis
Francescutti of the University of Alberta shares his thoughts
on re-energizing emergency medical services, which includes
providing paramedics with the opportunity to work within
their full scope of practice. William Hill of Medavie EMS
describes his organization’s journey to develop and implement
a patient safety plan, and the progress they are making in the
area of patient safety. Ron Yee, recently retired from the BC
Ambulance Service, and Charles Sun with the Vancouver
Island Health Authority summarize the British Columbia
No CPR Program, which helps paramedics and other
frontline health care providers identify and respect a patient’s
wish regarding death.
Emergency health services represents a continuum, and David
Williams of truesimple consulting takes us from emergency
medical services to inside the doors of the emergency depart‑
ment with a look at how process improvement can improve
patient care. Alan Drummond of Perth and Smith Falls District
Hospital reflects on the need for national standards for
emergency care and reviews early attempts at defining these
standards. Erin Tilley and Lori Adler of the College of
Nurses of Ontario examine the effects of overcrowding from
the perspective of emergency room nurses, and share the
results of recent research on this subject. From Accreditation
Canada, Stéphane Cardinal and Tracy Murphy summarize
findings from recent accreditation surveys that used the
Emergency Department Services Standards, noting strengths
as well as opportunities for improvement.
It wouldn’t be an Emergency Health Services issue without
taking a look at the important aspect of emergency man‑
agement and disaster preparedness. Daniel Kollek of the
Centre for Excellence in Emergency Preparedness discusses
the reasons behind the lack of disaster readiness in Canadian
hospitals and shares how being prepared for disasters can
improve quality of care. John Lindsay of Brandon University
and Gerry Delorme of Manitoba Health provide a brief
history of incident management systems and tell us about
Manitoba’s Emergency Response Management System. Finally,
Ron Meyers of the Canadian Standards Association explains
the importance of having an emergency management program
and gives us an overview of their Emergency Management and
Business Continuity Programs standard.
When perusing the articles in this issue, you will notice how
emergency situations are repeatedly shown to be key health
care access points for Canadians. For Accreditation Canada’s
Qmentum accreditation program to truly represent the
health care continuum, it was essential to include emergency
health services. We are pleased to provide accreditation to
emergency medical services and emergency departments, and
we will continue our work to contribute to improving quality
throughout the health care continuum with the emergency
health services initiative. On behalf of everyone at
Accreditation Canada, I wish you a good summer with some
time for rest and relaxation with family and friends.
Until next time…
5
Louis Hugo Francescutti
The Future of Emergency Medical
Services in Canada
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
6
6
O
ur current Emergency Medical Services (EMS)
model in Canada is not meeting the needs of
the community and is unlikely to do so unless
it undergoes a radical rethink, reorganizing,
and re-energizing.
The best approach that I could find that moves our think‑
ing in this direction was a 2005 National Health Service
(NHS) report entitled Taking Healthcare to the Patient:
Transforming NHS Ambulance Services. Two interesting terms
are coined: Hear and Treat, which calls for improved quality in taking calls and providing advice to patients requiring
urgent care, and See and Treat, an approach that expands
the range of health care services provided in the community
(Department of Health [U.K.], 2005).
Pre-Vietnam era EMS in North America and around the world
had very little to offer the patient other than a “scoop and run
approach.” As a matter of fact, many of these services were run
out of the back of hearses. In the immediate
post-Vietnam era, we saw the EMS
community advance with a whole new
set of skills developed and honed on the
We can no longer
battlefield. EMS was coming of age with better
afford to do things
trained personnel and better equipped
ambulances and dispatch systems. Emergency
the old-fashioned
medical technicians and paramedics were
way. We need
suddenly thrust into the limelight with
to be far more
popular television shows such as Emergency!
(and later Rescue 911). EMS had suddenly
innovative.
acquired a different attitude and approach to
pre-hospital care.
Now, almost 40 years later, we are in need of a similar
re-energizing of the EMS community in Canada. We need to
be able to bring health care out of health care facilities and
directly into the communities and homes of Canadians. We
need to empower EMS practitioners with a new set of skills
to allow them to safely assess, treat, and refer patients as they
see fit according to well-researched, proven, and reproducible
guide­lines or care paths similar to the Canadian Prehospital
Evidence Based Protocols (2010).
We can no longer afford to do things the old-fashioned way.
We need to be far more innovative.
Imagine a scenario where a call to 9-1-1 may or may not give
you an immediate response. Let me be clear: we want to make
sure that for true emergencies that are life-and-death, the
call is answered within five seconds, the acuity of the situation
is immediately determined, and the appropriate resources are
dispatched.
But for all other calls, we need to rethink what we are doing.
Just because you call 9-1-1 should not mean that you get a
full and predictable costly response. Not everyone who calls
9-1-1 needs an ambulance, not everyone who calls 9-1-1
has an emergency, and not everyone who calls 9-1-1 should
be guaranteed an immediate response. The only way we can
move in this new direction is if we capture data from calls
and mine them for patterns and outcomes. Then we
can start designing new approaches to dealing with old
problems.
A similar call to action in the 2006
Emergency Medical Services Chiefs
of Canada (EMSCC) white paper on
the future of EMS called for a stronger
integration of EMS into existing health
care models. They go on to make the
case for more stable sources of funding; a
totally new approach to systematic
improvement; a greater emphasis on EMS
personnel development; a bolstering of
EMS leadership capacity; and newer, more
responsive community-based initiatives
(EMSCC, 2006).
So where should we go from here? The answer is simple: base
the delivery of EMS on the needs of the community. It really is
that simple. Start by looking at the data: What are the practice
patterns that currently exist? That is where you will see your
first indication of just how little information is readily avail‑
able upon which to base good future decisions. We need to
develop, implement, and evaluate modern surveillance and
data capture systems. Electronic medical records must be
instituted across the country that capture similar fields so
comparisons can be made later. We need more rigorously
trained and dedicated EMS personnel that are given the
mandate and resources to analyze data collected and make
appropriate recommendations for improvements.
These actions will provide the foundation for continuous
quality improvement and the development of robust
emergency care protocols that will allow for comprehensive
performance and outcome measures to be assessed. These
systems will need to meet Accreditation Canada’s newly
developed national Emergency Medical Services accreditation standards.
The current emphasis on trauma and acute cardiac care
needs to shift to a more holistic, preventive approach. Injury
prevention needs to become a higher priority for the EMS
community. If you consider that over 50% to 60% of all trauma
deaths occur at the scene of the injury event, prevention is the
only cure for these deaths.
7
KATIE LAFERTY
There should be one national standard of EMS training, a
simplified nomenclature of positions, and a common, easily
accessible examination process. The certifications achieved
should be recognized and transferrable across Canada. We
may also need an appropriate period in which to grandfather
existing personnel through an alternate route of certification. Special emphasis needs to be focused on developing and
training EMS leadership skills as well.
Paramedics need to be given the training and authority to
practice within their full scope of training. For example, they
need to be able to assess wounds and determine if they are
capable of managing that wound in the field. They need to be
able to determine which patient with a psychiatric presentation
needs transport to an acute care facility versus referral to an out‑
patient mental health clinic. They need to be able to refuse to
provide immediate care if a more suitable level of care can be
arranged with other providers. Not every intoxicated patient
needs to go to the ER. EMS “frequent flyers” need to stop flying
and be given a more suitable means of transport such as a bus
ticket or a taxi chit if appropriate.
8
Paramedics need to be able to safely offer that alternative level
of care or transportation and then be able to follow up and see
if they were correct. These decisions, difficult initially, need
to be based on evidence. EMS personnel need to be given
immediate feedback on their decisions. Will they make errors?
Most likely, just like other health care providers do. But the
ultimate goal should be to minimize repetitive errors.
Greater emphasis on the training of EMS personnel
directed at understanding their role in relation to other
primary care providers, social service support groups, and
other public safety organizations will allow greater options
for their patients. EMS paramedics need to be able to work
side by side with other health care providers: they need to
be at the triage desks in the ER, on home care visits, in the
plaster clinics, in the wound clinics, in the mental health
intake facilities, and in primary care offices. The skills and
relationships they will develop while on these rotations will
cement their roles as true partners in health care delivery.
They will need the support of the entire community as they
take on an expanding scope of practice.
The focus on patient outcomes cannot be lost in this
realignment of delivery of care; it must always remain at the
forefront of the evolution of EMS delivery. A great example
of what can be done to improve patient outcomes is the use
of thrombolytic drugs in acute myocardial infarctions by EMS
personnel in the pre-hospital environment.
EMS providers will truly become the ambassadors of
health care. If we are successful, then we will have reduced
unnecessary transports to acute care facilities; we will have
improved patients’ outcomes by better connecting them with
the appropriate resources; we will have reduced costs by
preventing the majority of injuries within our society; and we
will have lengthened the careers of EMS providers through
empowerment and greater satisfaction in what they are doing
on a day-to-day basis.
EMS organizations across North America are changing
(Manitoba Health, n.d.; National Highway Traffic Safety
Administration, n.d.). The previous restricting and artificial boundaries of health care have disappeared. EMS has the
untapped potential to extend health care’s reach deep within
our communities and homes for the betterment of our patients.
In closing, one needs to look no further than the
Long and Brier Initiative in Nova Scotia to see how
innovation in EMS can transform our thinking. Paramedics
were shown to be able to meet the needs of two isolated island
communities that had previously been without a primary care
physician (Health Council of Canada, 2009). Building on this
exciting new approach, a call has been made for an Urban
Community Paramedic Model where paramedics would
incorporate their full set of skills for appropriately triaged
patients (Bardua, 2009).
We owe it to Canadians to do much better than we have
been doing. There will never be enough physicians to meet
the needs of the ever growing and aging population across this
vast country. A revitalized, properly reorganized, and newly
empowered Emergency Medical Services approach can
solve some of health care’s access and timeliness issues
immediately. Q
Louis Hugo Francescutti, MD, PhD, MPH, FRCPC, FACPM,
CCFP, is a Montrealer who fell in love with Alberta’s open space
and blue skies. He has a combined MD/PhD from the University
of Alberta and an MPH from Johns Hopkins University. Louis has
spearheaded a number of public safety awareness initiatives and is
the Founder of the Coalition for Cellphone-Free Driving. He is a
Professor at the University of Alberta and a frequent national health
columnist for television and radio. He is one of Alberta’s Hundred
Physicians of the Century. In 2009, Louis was chosen as PresidentElect for the Royal College of Physicians and Surgeons of Canada.
references
Bardua, D. (2009) The urban community paramedic: A concept
model. Canadian Emergency News, 32(3), 9. Retrieved April 22, 2010,
from http://www.emsnews.com/News.aspx?id=18
Canadian Prehospital Evidence Based Protocols. (2010.) Retrieved April
22, 2010, from Dalhousie University’s Department of Emergency
Medicine
website:
http://emergency.medicine.dal.ca/ehsprotocols/
protocols/toc.cfm
Department of Health [U.K.]. (2005). Taking Healthcare to the Patient:
Transforming NHS Ambulance Services. Retrieved April 22, 2010, from
the International Roundtable on Community Paramedicine website:
http://ircp.info/LinkClick.aspx?fileticket=CDMEr2ukLxo%3d&tabid=2
59&mid=743
Emergency Medical Services Chiefs of Canada. (2006). The Future
of EMS in Canada: Defining the New Road Ahead. Retrieved April 22,
2010, from the Saskatchewan Emergency Medical Services Association
website: www.semsa.org/Downloadables/EMSCC-Primary%20Health%20
Care.pdf
Health Council of Canada. (2009). Primary health care teams –
A Nova Scotia perspective. Retrieved April 22, 2010, from http://www.
healthcouncilcanada.ca/docs/rpts/2009/TeamsInAction_NovaScotia_
Summary.pdf
Manitoba Health. (n.d.). Emergency Medical Services in Manitoba:
Planning for Tomorrow – Making a Difference Today. Retrieved April 22,
2010, from www.gov.mb.ca/health/ems/planning.html?print
National Highway Traffic Safety Administration [U.S.]. (n.d.).Executive
Summary. EMS Agenda for the Future: Implementation Guide. Available
from http://www.nhtsa.dot.gov/people/injury/ems/agenda/
9
William
Hill
KATIE LAFERTY
Patient Safety in Emergency
Medical Services
Ambulance New Brunswick (ANB) land unit has transferred care of a patient to ANB Air Care crew departing to a distant health care facility.
T
he safe delivery of health care in today’s landscape
poses formidable challenges in terms of an aging
population, increasing acuity and comorbidities,
limited health care resources, changing treatment
innovations, and technology. Additionally, there is the
realization that patients who enter the health care
system may suffer untoward injury or further illness as a
result of their care. Such events have caused temporary and
permanent disability, extended hospital stays, and, in rare
cases, death. Many of these events are preventable. The
patients treated and transported by Emergency Medical
10
Services (EMS) are not exempt from such events, and,
one may argue, are faced with further perils as a result
of care provided within an unpredictable and often uncontrollable environment. While adverse events have been
occurring for centuries, patient safety as a formal concept
and discipline has only recently evolved nationally in
the health care system, and has yet to formally emerge in
the EMS industry. This article describes the activities of
Medavie EMS, a Canadian EMS agency, and our efforts
in establishing a patient safety program.
Developing a Patient
Safety Plan
EMS services are provided by qualified
and experienced paramedics, registered
nurses, management teams, human resources
professionals, fleet maintenance specialists,
communications officers, and educators.
Establishing the role and responsibilities
for each of these professionals and their
contributions to safe patient care is essential
if we are to achieve any significant impact
system-wide.
Medavie EMS has developed and
implemented a Corporate Patient Safety
Many staff
Plan to guide our efforts over the next 18
commented that they
months. Our intention is that this
plan will improve consistency through‑
were interested
out our operating companies when
in participating in
reporting adverse events and near
safety-related training
misses, using common language and
standards, delivering key messages and
and improvement
education, and sustaining a culture of
initiatives.
safety. The plan also includes the
development of a governance model
required to maintain our momentum in
ensuring the delivery of safe patient care.
The first critical step, however, is a documented commitment
for patient safety at the senior management level by way of
the organization’s strategic plan. Patient safety must take
its place as a strategic goal as the organization moves
forward. Our organization has realized that we must define
and develop a culture of safety for our company and begin
building a framework that will nurture such a culture.
Our earliest efforts in the area of patient safety began with
the formation of a Patient Safety Working Group that
was given the task of identifying the high-risk activities in
our current practices. Once the high-risk practices were
identified, this collaborative working group compared
each of them with the published practices within our
organization. Gaps were identified, and the group went to
An Island EMS ambulance posted at the approach of the Confederation Bridge in Prince Edward Island.
11
Corporate Patient Safety Plan. About half of the activities
identified in this plan originated from staff feedback. Some of
the broad areas identified by our staff for improvement included
the following:
n n n n
n
communication with our staff
leadership/engagement of staff
comfort and willingness to report adverse events and near
misses
education on safety
operational issues (such as hours of work or low priority
patient transports during inclement weather)
The risks inherent within the EMS industry that affect patient
safety can be found in any ambulance service regardless of geography. Although some of these risks are unique to our industry, our patients share many of the same risks faced in health
care facilities.
A Communications Officer at the EHS Medical Communications
Centre in Nova Scotia conducts emergency dispatch services.
work and developed patient and workplace safety–related
policies and procedures. For instance, one policy required
much tighter criteria on how emergency vehicles are operated
while travelling in emergency mode.
Some of the broadly defined high-risk areas identified by the
group were in the following areas:
medical procedures and interventions (especially those
that are high risk with low volume)
n medication management and administration
n transport/patient handling
n protection on scene
n patient care (protocol compliance)
n infection control
n transfer of patient care
n vehicle and medical equipment maintenance
n vehicle design
n
The group developed and distributed an organization-wide
survey that was designed to measure the attitudes and level
of awareness of our staff on patient and workplace safety.
The survey, which had 25 questions, was sent to almost 1,800
employees and had a 36% response rate. The survey resulted
in a report that included 20 recommendations designed to
improve patient and workplace safety organization-wide. Much
of the feedback encouraged more discussion on safety during
staff meetings. Many staff commented that they were interest‑
ed in participating in safety-related training and improvement initiatives. Several of these recommendations have been
satisfied to date, and the remainder are contained in our
12
Accrediting Emergency Medical Services
Medavie EMS has had experience with accreditation. One of
our operating companies, contracted to operate Emergency
Health Services (EHS) in Nova Scotia, was the first EMS organization in Canada to receive accreditation from the Commission on Accreditation of Ambulance Services (CAAS). Our
EHS Life Flight program has been accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS)
and our EHS Medical Communications Centre has been accredited by the National Academies of Emergency Dispatch
(NAED).
The recently released Emergency Medical Services Standards
from Accreditation Canada represent an important step
towards promoting quality in EMS throughout Canada. Island
EMS in Prince Edward Island, one of our operating companies,
was one of the four Canadian services that participated as a
pilot site for the EMS Standards. These standards link EMS
with the health care continuum from point of entry, through‑
out the course of patient care, to discharge. These standards
will prove invaluable in driving quality and safety activities
regardless of the type of service provider (public or private) or
the size of the service area (district, municipal, or provincial).
Applying the Required Organizational
Practices in EMS
The Medavie EMS Patient Safety Working Group has reviewed
the current 31 Required Organizational Practices (ROPs) and
has selected 25 that were thought to be applicable to our organization. By adopting and implementing the ROPs early, we
hope to align with Accreditation Canada’s practices on patient
safety. Our review resulted in the following outcomes for each
patient safety area:
Safety Culture: All the ROPs under this area are applicable
to our organization.
Communication: The ROPs on two client identifiers, verification processes for high-risk activities, and information transfer
are applicable.
Medication Use: The ROP for infusion pumps training is
applicable for land and air practices in our organization, as
are the ROPs addressing concentrated electrolytes and drug
concentrations.
Worklife/Workforce: All of these ROPs are applicable and
practiced in our organization.
Infection Control: This is a critical area for EMS and, for the
most part, is applicable and present in our practices. There is
work to be done on identifying useful measurements for infection rates in EMS.
Risk Assessment: The falls prevention strategy ROP as it
exists does not apply to EMS because it focuses on the health
care facility environment. However, we are currently developing a falls prevention strategy that is specific to EMS. The
ROP for pressure ulcer prevention would apply (with modifications) to a portion of our patient population undergoing longer
transports. We believe EMS has some specific and unique practices and that risk assessment as it pertains to EMS requires
further thought and future discussion.
Our next steps include conducting an internal audit of the
use of the selected ROPs in our organization and identifying
gaps in compliance across all operating companies. When
these gaps have been identified, we will work collaboratively
in developing the solutions and processes required to
demonstrate compliance.
n
Each of our companies has begun including and quoting
the Safety Competencies in our clinical quality activities
and will be reinforcing them for specific case reviews and
during morbidity and mortality rounds. These reviews are
designed to evaluate protocol compliance and competency
issues.
We have oriented our senior and operations management
teams to the Safety Competencies.
n
We are developing strategies to integrate the Safety
Competencies into our staff performance appraisal process
and to include them within our new employee orientation
process.
n
The EMS industry must be mindful that the risk of harm is
ever present. We strongly believe that we must take a prospective approach and become our own worst critics. In our efforts
to date, Medavie EMS has committed to the task of identifying risk and key measures for patient safety while fostering a
culture of patient safety. Q
William (Bill) Hill, CCP, MBA, CHE, is employed by
Medavie EMS as Principal, Clinical Quality & Patient Safety.
Medavie EMS provides ambulance services (land, air, communications, paramedic education) for the respective provincial and
municipal governments through its operating companies: Emergency Medical Care Inc. in Nova Scotia; Island EMS Inc. in Prince
Edward Island; New Brunswick EMS Inc.; Medavie EMS Ontario
in Muskoka, Ontario; Medacom Atlantic (emergency communications centre) in Prince Edward Island; and the Atlantic Paramedic
Academy in Moncton, New Brunswick. Bill is also a surveyor for
Accreditation Canada.
Integrating Safety Competencies in EMS
The Safety Competencies published by the Canadian Patient
Safety Institute (CPSI) have provided Medavie EMS with a
great opportunity to enhance our current patient safety practices. The Safety Competencies represent another facet of our
efforts to build a framework and encourage a culture of safety.
Our activities include the following:
Our training institution, the Atlantic Paramedic Academy,
has adopted the Safety Competencies and has integrated
them within the Primary Care Paramedic/Advanced Care
Paramedic curricula.
n
A Muskoka EMS crew provides mobile community coverage in the
District of Muskoka in Ontario.
13
Ron Yee
Charles Sun
Respecting Patients’ Wishes
With No CPR
14
B
ritish Columbia has an exemplary
paramedic service that is focused
on preserving life until an
emergency department is reached.
Unless there is clear information to the
contrary, resuscitation is universally attempt‑
ed if indicated when 9-1-1 is called.
A simple, easily
accessible method was
needed to ensure that
No CPR wishes would
be made known to and
be respected by health
care providers.
In the early 1990s, it became evident that
some individuals in specific demographic
groups, namely those at the natural end
of their life or those suffering from a
terminal illness, do not wish to be
resuscitated. Unfortunately, this information
was not consistently available to attending paramedics
when faced with a lifeless patient. It became impera‑
tive to have a defined method to identify the patient’s
wishes regarding death. Thus the British Columbia No
CPR Program became a major project for the Medical
Advisory Committee of the BC Ambulance Service.
Illustrating the complexity of this issue, a Vancouver survey by
the BC Ambulance Service discovered over 70 different forms
attempting to address the issue of death wishes. These living
wills were found to be lengthy documents that were generally
not available at the scene during the last moments of life. A
simple, easily accessible method was needed to ensure that No
CPR wishes would be made known to and
be respected by health care providers.
The BC Ambulance Service Medical
Advisory Committee, the BC Ministry
of Health Services, BC Medical Asso‑
ciation executives, and practicing para‑
medics formed a dedicated cooperative
partnership (the first of its kind in
Canada) and persevered to provide a
solution to this distressing and confusing
issue. Although the process was lengthy
and at times tedious, by June 2001 the
universal BC No CPR form, identifica‑
tion bracelet, and application process was established. The
BC No CPR partnership focuses on educating and respecting
the wishes of individuals who suffer from a terminal illness or
who are approaching the end of their natural life.
The BC No CPR form, bracelet, and related process are
beneficial to both the patient and their family, and to frontline
health care providers and the health care system:
n
Important decision-making guidance that encompasses a
wide range of end-of-life issues is provided to patients
and their families. To ensure that the patient and their
family have the same understanding of the situation and
intend to respect the patient’s wishes, this process clarifies
their understanding of the illness, the prognosis, their
plans, and their care goals.
n
n
n
By signing a standardized form, adults or authorized
substitute decision makers may legally express their wish
for the patient to not be given CPR. In the application
process, a physician monitors safety concerns; however,
the decision to invoke No CPR is made by the patient
or the appointed substitute decision maker.
A signed BC No CPR form prevents unnecessary ambulance
calls, emergency resuscitation, and hospital emergency
treatment, thereby helping to provide a peaceful death
scene and potentially reducing medically related costs.
The paramedic’s obligation to provide CPR is eliminated.
A legally binding MedicAlert No CPR bracelet or necklet
allows all those attending a death to immediately recognize
and respect the wishes of the individual at any location
where the death may occur.
Accurate identification of No CPR patients is enhanced by
a key safeguard: MedicAlert mails the bracelet or necklet
to the patient’s physician who places it on the patient.
n
15
MedicAlert provides identification bracelets and necklets
free of charge for the No CPR Program.
n
n
Use of a MedicAlert bracelet or necklet offers the
individual secure electronic storage of pertinent medical
information including chronic conditions, medications,
allergies, and implants. With patient consent, this
updatable information can be made available to health care
providers in situations where the individual is unable to
communicate.
Public accountability is demonstrated by respecting the
treatment wishes of BC residents.
n
The No CPR form can be obtained in hard copy from the BC
Ministry of Health Services or online at the BC Ministry of
Health Services, BC Medical Association, or MedicAlert
websites. It is hoped that one day the No CPR concept will
be implemented beyond British Columbia.
The policies and procedures related to No CPR within the
hospital environment are well established. The BC No CPR
Program has successfully achieved clarity of No CPR wishes in
the complex community setting. Q
A special thank you is extended to Lynn Klein and Peter deGroot
of BC Ambulance Service for their dedicated efforts on the creation
and maintenance of the BC No CPR Program. Gratitude is also
expressed to Linda Sun for her information gathering and editing of
this summation article.
Ron Yee has recently retired from the British Columbia
Ambulance Service, where he was responsible for medical programs
policy development and related provincial policy integration. He
developed innovative program improvements including a
province-wide initiative where seniors who have fallen in their
homes and have refused transport to hospital are referred by
paramedics to community health services in order to prevent future
falls. Through his career in health care, Ron has worked in
institutional and community mental health, long term care, and
quality improvement.
Charles Sun, MD, MCFP(EM), FRCPC, is an Emergency
Physician for Vancouver Island Health Authority. He is an
Associate Professor with the University of British Columbia
and is involved in the teaching of medical students and physician
assistants at the hospitals. Charles was the VP Medical Programs
for the British Columbia Ambulance Service for 20 years. The
need for the No CPR Program came directly as a result of real
incidents involving 9-1-1 calls in B.C.
David
M. Williams
KATIE LAFERTY
Enhancing Organizational
Performance Through Process
Improvement
18
9
“
-1-1, what’s your emergency?” A man has collapsed in
a coffee shop. As the emergency call taker asks key
questions, firefighters are already responding from
nearby and an ambulance is on its way. When emergency personnel arrive, they check vital signs, initiate treatment,
and capture a 12-lead ECG. The strip reads “STEMI Suspected.”
The lead paramedic notifies the hospital they are en route with
a ST segment elevation myocardial infarction (STEMI) patient.
The crew is directed to bypass the emergency department and
head straight to the catheterization (cath) lab. The time from
first contact of 9-1-1 to intervention is 43 minutes; two min‑
utes less than the system’s mean and just under half the industry
goal of 90 minutes from first contact to percutaneous coronary
intervention (PCI) (Antman et al., 2008). How can this level
of performance be achieved?
The science of improvement starts with
the four key components that Deming
(1994) described as the “system of profound
knowledge.” These components set the
foundation for improvement work:
Each element is measured on a 1–4 scale with the lower score
being best. The scoring is placed into an equation:
[D + (2 x I) + (2 x C1) + C2 + E]
The formula generates scores that range from 7 to 28. The final
result provides an indication of whether the project
is a winner (7–14), needs work (14–17), or is not worth
embarking on (over 17).
By conducting small
scale, low-risk tests of
change, improvement
teams can learn
quickly, modify often,
and achieve results
faster.
Systems: appreciating that people and
processes are integrated into larger
systems
n Variation: recognizing that every process
has variation, variation can be reduced,
and special causes of variation should be
eliminated
n Learning in Action: appreciating how we learn and
the power of learning in action for improvement
n Psychology: understanding the impact of engagement,
change, and incentives on people
n
1. Duration of time until the project is completed
2. Integrity of the team and its ability to complete
the task on time
3. Commitment to change of top management (C1) and
employees (C2) affected by the change
4. Effort over and above the usual work required to
complete the task
The system of profound knowledge provides a theoretical
framework from which to approach process improvement.
Selecting a good project is important for successful process
improvement. A good project may include modifying an exist‑
ing process that works well but results in some errors, or com‑
pletely redeveloping a new process that replaces a failure-ridden
existing process. Bad projects are ones that look at building in
extra inspection or audits or that create a workaround (e.g. extra
approvals) for the problem. It is important to choose a project
that focuses on improving the process, not on reacting to its
performance.
Selecting a good project can be a challenge. One tool to
aid in assessing a project’s potential is called the DICE
assessment (Sirkin, Keenan, & Jackson, 2005). Developed by
the Boston Consulting Group, the DICE assessment includes
four elements:
Choosing project sponsors will aid success
for improvement projects. Sponsors
help improvement teams stay focused
on the aim and aligned with an organization’s strategic goals. They can both
champion the project work and aid in reducing or eliminating bottlenecks. A good
sponsor is a both a coach and an advocate.
Forming a good team involves including
people closest to the process being improved who can work together to test changes
and work with stakeholders. Team members should be enabled
to spend a dedicated portion of their time on the improvement
effort and not be expected to do this work in addition to
their full regular duties.
Developing an aim statement is essential to clearly define
the target of your work. An aim statement should answer
the question, What am I trying to accomplish? (Langley et
al., 2009), and define what you are doing, to whom, and by
when. For example, for STEMI patients identified out-ofhospital, reduce the time from 9-1-1 call to PCI by 50% by
September 1, 2010.
Defining measures helps teams know when changes they are
testing result in improvement. There are three types of measures
(Langley et al., 2009):
1.
2.
3.
Outcome measures are the results and tell us how the
overall system is performing
Process measures look at specific parts or steps in the
process
Balancing measures assess related data to make sure
changes in the process do not create unintended
changes elsewhere
19
Learning in action by conducting small tests of change is
the “secret sauce” of improvement. By conducting small
scale, low-risk tests of change, improvement teams can learn
quickly, modify often, and achieve results faster. Armed with clear
aims and measures, teams can use PDSA (Plan, Do, Study, Act)
cycles to develop a single test, try it on one patient, study what
happens, and then modify based on what they learn.
For example, a hospital might test what happens if a suspected
STEMI patient was allowed to bypass the emergency department and go straight to the cath lab based on the field paramed‑
ic’s assessment. One case, one patient, and relatively low risk to
all involved, but the knowledge gained from this test about the
process and future improvements can be immense.
Spreading changes is an important final step in the improvement
process once the team feels they have measurably improved the
process and that performance is sustained. Rogers (2003) identified that people adopt innovations and change at different times
and in different ways. Appreciating this diffuse conversion and
working with the improvement team and key stakeholders to
facilitate implementation can be essential for widespread implementation and sustainable results.
The man in the earlier example survived because of a system of
defined processes that worked in unison to address his condition
in a reliable and reproducible manner. Process improvement
enables the best clinical care possible to be delivered and more
people to be served. It is hard work, but successful outcomes are
well documented and well worth it. Q
20
David M. Williams, PhD, is an Improvement Advisor with
truesimple consulting (www.truesimple.com) in Austin, Texas.
He works with organizations to help them set clear aims, develop measures, and test small, rapid-cycle changes that result in
improvement. He also serves as an improvement advisor and faculty member for the Institute for Healthcare Improvement (IHI)
and frequently works with ambulance services in conjunction with Fitch & Associates, LLC. David can be reached at
[email protected].
references
Antman, E. M., Hand, M., Armstrong, P. W., Bates, E. R., Green,
L. A., Halasyamani, L. K., ... Yancy, C. W. (2008). 2007 Focused
update of the ACC/AHA 2004 guidelines for the management of
patients with ST-Elevation Myocardial Infarction: A report of the
American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation, 117, 296–329. doi: 10.1161/
CIRCULATIONAHA.107.188209
Deming, W. E. (1994). The new economics for industry, government, education (2nd ed.). Cambridge, MA: Massachusetts Institute of Technology,
Center for Advanced Engineering Study.
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W, Norman, C.
L., & Provost, L. P. (2009). The improvement guide: A practical approach
to enhancing organizational performance (2nd ed.). San Francisco, CA:
Jossey-Bass.
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Sirkin, H. L., Keenan, P., & Jackson, A. (2005, October). The hard side
of change management. Harvard Business Review, 83, 108–118.
Alan Drummond
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
22
22
T
he emergency department is a major point of to call attention to the perennial problem of emergency
access to health care for all Canadians. Four‑ department overcrowding.
teen million Canadians visit the emergency
department (ED) on an annual basis (Cana‑ In rural Canada, a shortage of physicians and nurses who are
dian Institute for Health Information, 2005) but for many, willing and able to staff the emergency department is lead‑
regrettably, their visit to the emergency department is an ing to service disruptions and community anxiety. In Nova
unsatisfactory experience. Being the proverbial “canary in Scotia the service disruptions became an election issue. In
the coal mine,” the problems and pressures that beset the Ontario, disruptions have led to controversial attempts at
emergency department are a reflection of a health care sys‑ regionalization of emergency services by regional health
tem in trouble. The patient who waits for eight hours in a authorities. Defining once and for all a standard for the train‑
crowded emergency waiting room, the family members who ing requirements and staffing levels for specific categories
watch their elderly loved ones “warehoused” in a brightly of emergency facilities would oblige governments to facili‑
lit and noisy ED corridor while waiting for a hospital bed to tate adequate training opportunities for their own province’s
become available, or patients who arrive at their com‑ emergency departments. It would also force hospital boards
munity emergency department to find
and regional health authorities to review
it closed because of a lack of sufficient
their unique circumstances with a view to
physicians or nurses to properly staff the
regional co-operation, which would guaran‑
Emergency department
department know only too well that some‑
tee regional access to emergency services.
overcrowding is widely
thing terribly wrong has happened to
regarded by Canadian
our national belief of universal access to
Improved system issues would not be
emergency physicians
timely and quality care.
the only benefit of defined and enforce‑
able minimum operational performance
and nurses as the
Underlying all of these difficulties, I believe,
standards. Direct patient care at the
number one
is a lack of clearly defined minimum
bedside would also be subject to scrutiny
impediment to
operational performance standards for
and improvement.
quality care.
Canadian emergency departments. This
article will examine that need, review
In 1991, the Ontario government
some early attempts at defining standards
surveyed the 199 emergency departments
for emergency care, and discuss the important work in the province and found that more than 50% of the
currently being undertaken by Accreditation Canada in departments surveyed were lacking in essential life
this area.
saving equipment (Sublett, 1991). The issue was not one
of access to CT scanners and angiography but rather to
laryngoscopes and resuscitative drugs. Surprisingly,
The Need for Standards for Emergency
nothing tangible has been done to address the identified
Care
issues of the lack of standardized equipment and diagnostic
Emergency department overcrowding is widely regarded by capabilities for the province’s emergency departments.
Canadian emergency physicians and nurses as the number
one impediment to quality care. More than a matter of mere A 2000 study of Canadian emergency departments demons‑
patient inconvenience, ED overcrowding is clearly associa‑ trated that essential pediatric resuscitation equipment was
ted with increased patient morbidity and mortality, system “unavailable in a disturbingly high number of EDs across
gridlock, and increased costs to the system. It would sim‑ Canada.” For example, 15% of Canadian emergency depart‑
ply not be allowed to exist if there were mandated standards ments did not have access to intraosseous needles, 18% did
with respect to occupancy, timely patient assessment, and not have pediatric oximeters available, and 60% did not
appropriate access to hospital ward beds.
have infant warming devices (McGillivray, Nijssen-Jordan,
Kramer, Yang, & Platt, 2001).
Indeed, in February 2008, the fire department in New
Westminster, British Columbia, was able to articulate, in com‑ A 2001 study of 179 hospitals in Ontario revealed that only
mon sense terms, what those of us who work in the emergency 0.6% were adequately stocked with antidotes for poisonings.
department understand is nonsensical and unacceptable. The The authors concluded that “most acute care hospitals in
fire marshals declared the congested and dysfunctional ER Ontario do not stock even minimally adequate amounts of
at the Royal Columbian Hospital an unsafe fire hazard and several emergency antidotes, possibly jeopardizing the sur‑
ordered it cleared (Hunter, 2008). Some Canadian emer‑ vival of an acutely poisoned patient” (Juurlink, McGuigan,
gency physicians called for a national Fire Marshal’s Day Paton, & Redelmeier, 2001).
23
KATIE LAFERTY
The findings with respect to processes of care and
the adoption of evidence-based medicine are equally
discouraging.
A 2004 study of the compliance of teaching centres with
guidelines for the emergency management of asthma
revealed that overall compliance with guidelines was
only 70%. Compliance with management guidelines for
severe asthma was only 41% (Krym, Crawford, &
MacDonald, 2004).
A 1999 study of compliance with the internationally ac‑
knowledged Ottawa Ankle Rules showed a disturbing lack
of impact from an active process of dissemination of the
guidelines developed to reduce the use of unnecessary radiog‑
raphy of sprained ankles. Following an intensive educational
program, the number of X-rays taken for obviously sprained
ankles remained the same (Cameron & Naylor, 1999).
Initial Attempts
Clearly, for both the patient on the emergency stretcher
and the emergency system as a whole, much more needs
to be done to define minimum performance expectations.
Regrettably, precious little time or energy has been devoted
to articulating a national vision for minimum standards of
emergency care.
The first attempt at defining a standard was with the release
of the federal Ministry of National Health and Welfare’s
Emergency Units in Hospitals document in 1981 (and again in
1988). Hospitals were subdivided into four broad categories
(A, B, C, D) that defined departments from the academic
tertiary care centre to the small, rural community emergency
department. Recommendations were made on space require‑
ments, staffing, credentialing, equipment, diagnostics,
inter- and intra-hospital relationships, and quality assurance
mechanisms. Unfortunately, none of these articulated ex‑
pectations had the power of enforcement and were largely
ignored at the provincial level.
In 1989, the Ontario government was the first provincial
government to introduce minimum emergency department
standards with the release by the Ministry of Health and
Long-Term Care (MOHLTC) of Guidelines for Emergency
Units. This was a comprehensive document that reviewed
all aspects of emergency service delivery and made hard,
tangible recommendations to guarantee an acceptable level
of care for all Ontarians.
As noted previously, two years later a survey of the 199
hospitals in Ontario with emergency departments revealed
that only 50% of Ontario ERs met a disturbingly minimum
standard (Sublett, 1991). Curiously, nothing was done at the
time to rectify these apparent deficiencies and the report was
lost in a bureaucratic maze. In the late 1990s, a physician
advisor to the MOHLTC attempted to revise and restore the
concept, but after ten drafts the guidelines remained as only
a draft discussion document.
In 1997, the Rural Section of the Canadian Association of
Emergency Physicians (CAEP) called for minimum stan‑
dards of care for all rural emergency care facilities, from the
basic industrial aid station to the northern nursing station
to the rural community hospital. Experts in rural medicine
and emergency medicine developed tangible recommenda‑
tions on staffing, education and credentialing, departmental
equipment and supplies, necessary pharmacological agents,
diagnostic imperatives, quality assurance, and inter-hospital
transfers for all levels of rural health care facilities (CAEP,
1997). The document, unfortunately, gained no traction
with the nation’s health ministries.
The issue, however, refuses to die.
In Ontario, the report of the Hospital Emergency Department
and Ambulance Effectiveness Working Group (the Schwartz
report) highlighted “the differing practices and expectations
for hospital EDs across Ontario” (MOHLTC, 2005). The
report called for “a consistent standard which can be
monitored and enforced.” Similarly, in 2006, a tripar‑
tite committee of the Ontario Hospital Association, the
Ontario Medical Association, and the MOHLTC that
reviewed access to emergency services called for the
24
“immediate development of standards for emergency
departments setting out best practices and establishing
minimum operational performance standards for every
classification of emergency department in Ontario”
(Physician Hospital Care Committee, 2006).
for all Canadian emergency health care facilities.
Thanks to Accreditation Canada’s vision, commitment
to direct accountability, and hard work, all Canadians
will be the ultimate beneficiaries. Q
Four years later, still nothing has been done to fulfill
these recommendations in the only province that has
acknowledged the need.
Alan Drummond is the Medical Director of the emergency
department at the Perth and Smiths Falls District Hospital. He
is a Past Chair of the Ontario Medical Association’s Section
on Emergency Medicine and a Past President of the Canadian
Association of Emergency Physicians. He currently serves as
the Chair of Public Affairs for the Canadian Association of
Emergency Physicians.
Accreditation Canada’s Role
It was, therefore, with a great deal of satisfaction that the
Canadian Association of Emergency Physicians learned that
Accreditation Canada was willing to take a leadership role
in the development and promotion of national standards for
emergency care.
Over a number of subsequent years, with funding from
Health Canada and with broad national representation
from emergency medicine and nursing, emergency medical
services, and hospital administration, defined standards were
developed for emergency departments on a national basis.
The standards document is admittedly a modest, early attempt
at capturing processes of quality care in the highly complex
world of the modern Canadian emergency department. Much
more needs to be done to refine the necessary parameters of
care to guarantee that Canadians’ expectations are met when
they present to their local emergency department. It is, how‑
ever, a welcome start and the leadership of Accreditation
Canada is to be applauded.
The Emergency Department Services Standards were first
used in 2008/2009, and 125 client organizations had on-site
surveys using these new standards. In reviewing the
accreditation findings of this initial use, of the 125
organizations surveyed there were close to 1,500 unmet
criteria with an average of 12 unmet criteria per surveyed
facility. Among the top 20 unmet criteria, medication
reconciliation ranked the highest. Also high on the list
of unmet criteria were identifying and monitoring
process and outcome indicators, and participating in regular
safety briefings. These are important findings; with further
and more in-depth analysis, other equally important issues
with respect to the processes of care will be highlighted and
dutifully corrected.
While these initial findings are important, what is even
more important is that Accreditation Canada has done
what all other health care jurisdictions have failed to do:
they have started an irrevocable process towards the
development of a minimum operational performance standard
references
Cameron, C., & Naylor, C. D. (1999). No impact from active dissemi‑
nation of the Ottawa Ankle Rules: Further evidence of the need for
local implementation of practice guidelines. Canadian Medical
Association Journal, 160(8), 1165–1168.
Canadian Association of Emergency Physicians. (1997). Recommen‑
dations for the management of rural, remote and isolated health care
facilities in Canada. Available from http://www.caep.ca/template.asp?id
=E7A52001BF0943D99813500B034B25DC
Canadian Institute for Health Information. (2005). Understanding emergency department wait times: Who is using emergency departments and how
long are they waiting? Ottawa: Author.
Hunter, J. (2008, February 14). Fire inspectors shut down crowded wait‑
ing room. The Globe and Mail. Available from
http://www.theglobeandmail.com/subscribe.jsp?art=21753
Juurlink, D. N., McGuigan, M. A., Paton, T. W., & Redelmeier, D. A.
(2001). Availability of antidotes at acute care hospitals in Ontario.
Canadian Medical Association Journal, 165(1), 27–30.
Krym, V. F., Crawford, B., & MacDonald, R. (2004). Compliance with
guidelines for emergency management of asthma in adults: Experience at
a tertiary care teaching hospital. Canadian Journal of Emergency Medicine,
6(5), 321–326.
McGillivray, D., Nijssen-Jordan, C., Kramer, M. S., Yang, H., & Platt, R.
(2001). Critical pediatric equipment availability in Canadian hospital
emergency departments. Annals of Emergency Medicine, 37, 371–376.
Ministry of Health and Long-Term Care. (2005). Improving access to
emergency services: A System Commitment. The report of the Hospital Emergency Department and Ambulance Effectiveness Working Group. Retrieved
from http://www.health.gov.on.ca/english/public/pub/ministry_reports/
emerg_dept_05/emerg_dept_05.pdf
Physician Hospital Care Committee (OHA, OMA, & MOHLTC).
(2006). Improving access to emergency care: Addressing system issues. Re‑
trieved from http://www.health.gov.on.ca/english/public/pub/ministry_
reports/improving_access/improving_access.pdf
Sublett, S. (1991). Is it time to close your hospital’s ER? Canadian
Medical Association Journal, 145, 1489–1492.
25
Erin E. Tilley
Lori Adler
Nursing in Temporary Locations:
Listening to Ontario’s Nurses
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
26
26
Introduction
T
he emergency department is a complex and multifaceted care setting. Emergency department
overcrowding has become a widespread phenomenon that is associated with many untoward
consequences for clients and health care providers. Of
particular concern in the last several years are longer
emergency department wait times and lengths of stay,
and decreased availability of in-patient beds resulting in
nursing of clients in temporary locations. Often referred to as
“hallway nursing,” temporary locations include the use of hall‑
ways, tub rooms, and utility rooms.
The third area that emerges from the literature concerns
the need for standardized definitions and measures of
overcrowding. For example, Korn and Mansfield (2008)
offer a tool that uses readily available data to predict staffing.
Fourth, several studies examine client, staff, and administrative outcomes in relation to emergency department overcrowding. For example, Bond and colleagues (2007) found that
perceived overcrowding had a major impact on increasing
stress among nurses. Nurses also report experiencing moral
distress in situations where they believe that basic human
needs are unmet and clients are not treated with respect and
dignity (Kilcoyne & Dowling, 2007).
Reviewing the Literature
There is a large body of literature focused
on emergency department performance
addressing issues such as time waiting
for treatment, overcrowding, cost, human
resources, and the use of best practices.
Five areas are particularly relevant to
the examination of hallway nursing:
(1) nursing roles, (2) local improvement, (3) performance measurement, (4)
outcomes, and (5) policy statements.
Stakeholders should
support the
development of
innovative strategies
to promote the
delivery of safe and
effective care in
conditions of
emergency department
overcrowding, which
would encourage
solutions that consider
the local context.
First, two issues emerge related to nurs‑
ing roles. One article found that nurses
may experience increased pressure in
the context of emergency room overcrowding, which may contribute to
incomplete client assessments (“ED
nurses,” 2006). The availability of appropriately trained staff is another issue
(Walker-Cillo, Jones, & McCoy, 2008)
including the use of nurse practitioners to improve emergency department client flow and throughput (Carter &
Chochinov, 2007).
Second, the literature is rich with descriptions of local
improvement activities that have addressed issues of
emergency department overcrowding, such as a reengineered process of client triage (DeRuggerio, 2008),
implementation of a physician triage liaison (Holroyd et al.,
2007), and the implementation of best practices (Sedlak
& Roberts, 2004). While improvements reported in the
literature are most often implemented in single sites and
organizations and cannot be generalized, they offer
important lessons for individuals and teams interested
in local improvement.
The last area that emerges in the literature
pertains to several organizations and
governments releasing policies related to
emergency department overcrowding. For
instance, the Canadian Nurses Association (2009) released a policy statement
calling for an interprofessional, intersectoral, and multi-faceted approach to address
emergency department overcrowding.
Listening to Ontario’s
Nurses
The College of Nurses of Ontario (CNO)
is the regulatory body for nursing in
Ontario and regulates nursing to protect
the public interest by setting registration
requirements, establishing and enforcing
standards of nursing practice, and assuring
the continued competence of nurses. The
issue of hallway nursing was raised by CNO
members in 2007 when they identified
barriers to applying CNO’s standards of practice in their
practice settings. In response, CNO initiated a series of
teleconferences in 2008 to better understand the experiences
of nurses and other stakeholders, to assist nurses in applying
CNO’s standards of practice, and to provide opportunities to
share in collective problem solving. Four teleconferences were
held over four months and opportunities for discussion were
provided. The sessions were audiotaped and transcribed. The
transcriptions were used to conduct a qualitative analysis
of the data to identify underlying themes and to catalogue
locally developed interventions.
Three themes emerged from the data: (1) escalating
pressure, (2) practice standards, and (3) diminishing
resilience. First, participants expressed a general sense that
27
KATIE LAFERTY
emergency departments and in-patient units are under
enormous pressure and that emergency department
nurses are feeling the effects of this pressure from many
fronts. One nurse talked about her experience when ten
ambulances were lined up to transfer clients but were
unable to do so because there were insufficient beds,
staff, and resources available. Second, participants were
unanimous in expressing concerns about the difficulties
experienced in meeting CNO’s standards of practice. One
participant explained that the equipment is not suitable:
“There are no call bells, there are no bathrooms, there
are no screens, often [clients] are attached to oxygen on
wheels, often [clients] need portable suctioning...It’s an
obstruction in the hallway.” Third, participants noted that
the resilience so often demonstrated by nurses as they
make the best of a suboptimal situation is diminishing.
Participants told CNO that nurses are experiencing fatigue and that they are concerned that hallway nursing will
become the “new normal.”
During the teleconferences, participants identified several
strategies that their organizations have implemented to
reduce emergency department overcrowding. Most of the
strategies involved enhanced collaboration with internal and
external partners. Several strategies focused on enhancing
client flow and improving bed utilization. For example,
one facility focused on better relationships with client
transportation services to address lower acuity transfers.
Another facility put support workers in the emergency
department 24 hours a day to assist with non-nursing
duties. Several participants referred to strategies that
focused on high-risk client populations and the need for
early identification and specialized interventions. For
example, one participant noted that an admission nurse
was put in place at the organization who is able to prioritize
clients that are high risk, and anyone with issues such as skin
breakdown, nutritional needs, or falls are given priority to
receive an inpatient bed.
Implementing Change
Our findings derived from the teleconferences and the
literature review point to five areas in which emergency
department administrators and care providers can improve
emergency department processes:
1. support the use of standards of practice
2. develop and support the use of evidence-informed
protocols and policies
3. maximize the use of existing human resources
4. support the use of emergency department performance
measures, and encourage the collection and reporting
of additional performance data
5. encourage local innovation
First, emergency departments need to facilitate the application of regulatory standards of practice by nurses. For example,
support nurses to meet CNO’s Infection Prevention and Control
practice standard by ensuring appropriate resources are in
28
place. Second, it is recommended that emergency departments
develop and support the use of evidence-informed protocols and
policies, which includes defining the roles and responsibilities
of health care providers in overcrowding situations. When
nurses and other health care providers are knowledgeable
about and engaged in protocols and policies, they are well
positioned to identify and act on potential threats to client
safety. Third, stakeholders should maximize the use of
existing human resources, including nurse practitioners
whose expertise can help relieve emergency department
overcrowding. Fourth, it is recommended that stakehold‑
ers support the use of emergency department performance
measures (e.g. time to admission, time to discharge, and
client satisfaction) by nurses and other care providers, which
would encourage the implementation, communication, and
evaluation of measures associated with emergency department overcrowding and the nursing of clients in temporary
locations. Last, stakeholders should support the development of
innovative strategies to promote the delivery of safe and
effective care in conditions of emergency department
overcrowding, which would encourage solutions that consider
the local context.
Conclusion
The issues associated with emergency department overcrowding and nursing in temporary locations are complex.
CNO initiated the teleconference series to better understand
the experiences of nurses and other stakeholders working
under conditions of emergency department overcrowding,
and to provide an opportunity to discuss the issue and share
in collective problem solving. The views expressed in the
teleconferences provide a powerful narrative of the challenges faced by nurses when caring for clients in temporary
locations.
It is widely recognized that improvements associated with
emergency department overcrowding and nursing in temporary locations are highly dependent on factors outside the
emergency department; therefore, multi-faceted strategies
need to be implemented to have an impact. Our findings can
help emergency department administrators and care providers implement change when they are used as part of a larger
strategy to improve emergency department processes. Q
This article is a summary of the College of Nurses of Ontario’s
report, Nursing in Temporary Locations: Listening to Ontario’s Nurses. The CNO gratefully acknowledges the contribution of Deborah Tregunno, RN, PhD, Assistant Professor of the
School of Nursing at York University in Toronto, in the consultation and development of this report. The complete report can
be found at http://www.cno.org/docs/prac/NursingInTheHalls
August2009.pdf
Erin E. Tilley, RN, BHSc, BScN, MN, is a Policy Analyst
with the College of Nurses of Ontario. She is responsible for analyzing and developing policies related to regulatory issues, providing advice and support to committees and Council, and scanning
the environment to identify issues and trends that impact CNO.
Prior to joining CNO, Erin worked in a variety of settings including as a staff nurse and research officer.
Lori Adler, RN, BScN, MHSc, is the Manager, Practice
Standards, with the College of Nurses of Ontario. She leads
the development, revision, evaluation, and application of CNO
practice documents. She was the moderator for the Nursing in
the Halls teleconference series held in 2008. Prior to joining
CNO, Lori provided leadership as a director, clinical nurse
specialist, educator, clinician, manager, and staff nurse in a
variety of settings.
references
Bond, K., Ospina, M. B., Blitz, S., Afilalo, M., Campbell, S. G.,
Bullard, M., ... Rowe, B. H. (2007). Frequency, determinants and impact of overcrowding in emergency departments in Canada: A national
survey. Healthcare Quarterly, 10(4), 32–40.
Canadian Nurses Association (2009). Overcapacity protocols and capacity in Canada’s health system: Position statement. Retrieved February 10,
2009, from http://www.cna-nurses.ca/CNA/documents/pdf/publications/
PS101_Overcapacity_e.pdf
Carter, A., & Chochinov, A. (2007). A systematic review of the impact
of nurse practitioners on cost, quality of care, satisfaction and wait times
in the emergency department. Canadian Journal of Emergency Medicine,
9(4), 286–295.
DeRuggerio, K. (2008). ED nurses revamp triage because of
overcrowding. ED Nursing, 11(3), 29.
ED nurses must stop these triage mistakes that could get them sued. ED
Nursing, 9(9), 97–100.
Holroyd, B. R., Bullard, M. J., Latoszek, K., Gordon, D., Allen, S., Tam,
S., ... Rowe, B. H. (2007). Impact of a triage liaison physician on emergency department overcrowding and throughput: A randomized controlled trial. Academic Emergency Medicine, 14(8), 702–708.
Kilcoyne, M., & Dowling, M. (2007). Working in an overcrowded accident and emergency department: Nurses’ narratives. Australian Journal of
Advanced Nursing, 25(2), 21–27.
Korn, R., & Mansfield, M. (2008). ED overcrowding: An assessment
tool to monitor ED registered nurse workload that accounts for admitted patients residing in the emergency department. Journal of Emergency
Nursing, 34(5), 441–446. doi:10.1016/j.jen.2007.06.025
Sedlak, S. K., & Roberts, A. (2004). Implementation of best practices to
reduce overall emergency department length of stay. Topics in Emergency
Medicine, 26(4), 312–321.
Walker-Cillo, G., Jones, C., & McCoy, E. (2008). Psychiatric nurse: A
role in overcrowding. Journal of Emergency Nursing, 34(5), 455–457.
doi:10.1016/j.jen.2008.05.007
29
Stéphane Cardinal
Tracy Murphy
Emergency Departments in
Canada: What We Learned From
Recent Accreditation Findings
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
Introduction
A
ccreditation Canada has been leading the health
service accreditation process in Canada for over
50 years. Our Qmentum accreditation program
evaluates the quality of care and service
delivered by health organizations against national standards of
excellence. Given the importance of quality and safety in
30
emergency health services, Health Canada provided funding
in 2007 for the development of Emergency Department (ED)
Services Standards for our accreditation program. These standards were developed as part of the emergency health services
initiative, which also included the development of Emergency
Medical Services (pre-hospital) Standards in 2009. Both sets of
standards were developed to enhance the performance review
of emergency health services across the continuum of care.
30
The development of the Emergency
Department Services Standards was guided
by the Emergency Health Services
advisory committee, which was made up
of surveyors, stakeholders, and leading
experts in the field. The advisory
committee oversaw the work of the
Emergency Department Services Stan‑
dards working group. After their development, the Emergency Department Services
Standards underwent national consulta‑
tion and pilot testing at five sites across
Canada. In 2008, these comprehensive,
evidence-based standards were released
as part of the Qmentum accreditation
program for acute care organizations
with an emergency department.
Methodology
A significant benefit of
having both Emergency
Department Services
Standards and
Emergency Medical
Services Standards is the
increased quality
improvement
opportunities that are
created through the
accreditation process as
hospital staff and EMS
providers work
collaboratively to
achieve better patient
care and outcomes.
This article presents the accreditation
findings for organizations that used
the Emergency Department Services
Standards between mid-2008 and mid-2009. The data was
analyzed and compiled at an aggregate level. For 2009,
modifications to the previous year’s standards included
wording changes, the expansion of guidelines, and the
addition or deletion of standards and criteria. Consequently,
the 2008 and 2009 standards were mapped to each other
for this analysis to allow for comparisons between the two
survey years.
Results
Accreditation Activity at a Glance
In 2008 and 2009, 125 organizations had on-site surveys that
included the Emergency Department Services Standards. Of
these organizations, 78% were in Ontario and Quebec.
Reviewing the results for the 125 surveys, a number of
strengths can be found in terms of compliance with the
Emergency Department Services Standards. Strengths
refer to a very low number of or no unmet criteria for this
sample of 2008/2009 surveys. Among the positives, we
found that most emergency department teams collaborated
with their partners to inform community, clients, referring
organizations, and providers about how to access emergency
health services, including the emergency department. Most
of the surveyed emergency departments had strategies in
place to effectively manage overcrowding, including plans
to manage clients when in-patient beds were unavailable.
Most emergency department teams were able to recognize
overcrowding and followed their policies
to reduce it before diverting ambulances
or requesting aid from alternative health
care sites. Of course, the availability of
plans and an adherence to strategies
does not necessarily mean that there
was no overcrowding in the surveyed
emergency departments during that
period. Two other areas of strength
for the 125 surveys were that most
emergency departments had emergency
preparedness plans in place and staff
had been trained on the plans, and that
client information in the emergency
department was available to the ap‑
propriate staff, service providers, and
volunteers in a timely manner.
Unmet Criteria
Each standard consists of criteria, which
provide greater specificity as to the
elements that enable the standard to
be met. The distribution of unmet criteria is used when
analyzing accreditation findings. Results show there were
1,489 unmet criteria out of a total of 12,573 criteria
in the 125 Qmentum surveys conducted in 2008/2009
that used the Emergency Department Services Standards.
There was an average of 12 unmet criteria per survey,
with a range of 1 to 35 unmet criteria. There were 99
criteria to be met in the 2008 Emergency Department
Services Standards and 105 criteria in 2009; therefore, an
average of 11.8% of ED criteria per survey were not met.
The Emergency Department Services Standards are
organized by subsection. Our analysis showed that the
greatest challenges pertained to the Monitoring Quality and
Achieving Positive Outcomes subsection. In 2008, for example,
the standard related to using evidence-based guidelines and
best practice information to improve quality of services, as
well as the standard related to promoting safety and making
ongoing improvements, had 12 criteria among the top 20
unmet criteria; these represent 28% of total unmet criteria.
Table 1 shows the Top 20 unmet criteria in the Emergency
Department Services Standards. Analysis of the findings
revealed that 57% of all unmet criteria were in the Top 20.
Each criterion is assigned a quality dimension, and the majority of unmet criteria pertained to two quality dimensions:
Safety and Effectiveness. Criteria related to medication
reconciliation were the most common unmet criteria in the
Emergency Department Services Standards. Moreover, the
top three unmet criteria were an indicator and two Required
31
KATIE LAFERTY
Organizational Practices (ROPs): the indicator on medication
reconciliation was unmet in 73% of surveys, the ROP on
medication reconciliation following triage was unmet
in 72%, and the ROP on medication reconciliation at
referral or transfer was unmet in 70%. ROPs are essential
practices that a client organization must have in place to
enhance client safety and minimize risk. These results
suggest that emergency departments are challenged by
medication reconciliation, which has implications for
the emergency department’s leadership, quality of care
provided, resource allocation, and staff education.
Rounding out the top five unmet criteria were evaluating
and documenting each team member’s performance (42%
Table 1. Top 20 Unmet Criteria in the Emergency Department Services Standards in 2008/2009
Rank
Percentage of surveys
where criterion was unmet
Quality
Dimension
Criterion
1
73%
Safety
INDICATOR: Medication reconciliation following triage.
2
72%
Safety
ROP: The team reconciles the client’s medications following triage, with the involvement of
the client.
3
70%
Safety
ROP: The team reconciles medications with the client at referral or transfer and communicates information about the client’s medications to the next provider of service at referral
or transfer to another setting, service, service provider, or level of care within or outside the
organization.
4
42%
Effectiveness
Team leaders regularly evaluate and document each team member’s performance in an objective, interactive, and positive way.
5
40%
Effectiveness
The team has the workspace needed to deliver effective services in the Emergency Department.
6
38%
Effectiveness
The team compares its results with other similar interventions, programs, or organizations.
7
33%
Effectiveness
The team identifies and monitors process and outcome measures for its Emergency Department services.
7
33%
Safety
Staff and service providers participate in regular safety briefings to share information about
potential safety problems, reduce the risk of error, and improve the quality of service.
7
33%
Client-centred
services
The team monitors clients’ perspectives on the quality of Emergency Department services.
7
33%
Effectiveness
The interdisciplinary team follows a formal process to regularly evaluate its functioning,
identify priorities for action, and make improvements.
11
30%
Effectiveness
The team works together to develop goals and objectives.
12
28%
Client-centred
services
The team communicates the evidence-based guidelines, research, and best practice information to clients receiving services.*
13
27%
Effectiveness
The team monitors the achievement of its goals and objectives.*
13
27%
Effectiveness
The team reviews its [evidence-based] guidelines to make sure they are up-to-date and reflect
current research and best practice information.
13
27%
Effectiveness
The team uses the information it collects about the quality of its services to identify successes
and opportunities for improvement, and makes improvements in a timely way.
16
24%
Effectiveness
The team reviews and selects which evidence-based guidelines it will use.**
17
22%
Population Focus
The team links with its partners and other organizations to share and use research and best
practice information.*
18
20%
Effectiveness
The team collects and uses other research and best practice information.*
18
20%
Worklife
The team has a fair and objective process to recognize team members for their contributions.**
20
18%
Safety
The team identifies, reports, records, and monitors in a timely way sentinel events, near
misses, and adverse events.
* These criteria were removed from the Emergency Department Services Standards in 2009. (While the criteria were still relevant, the subsection was reworked and
emphasis placed on other areas.)
** These criteria were significantly reworded between 2008 and 2009.
32
of surveys) and having the workspace to deliver effective
services (40% of surveys). For the Safety quality dimension,
two other unmet criteria were in the Top 20: participating in
regular safety briefings to share information about potential
safety problems, reduce the risk of error, and improve the
quality of service; and identifying, reporting, recording, and
monitoring sentinel events, near misses, and adverse events
in a timely way.
ROP Compliance
Table 2 provides a summary of compliance for the five
ROPs in the Emergency Department Services Standards.
Overall, there is good compliance for three of the ROPs,
while compliance is low for medication reconciliation
following triage and at referral/transfer.
Table 2. Compliance Rate for the Required
Organizational Practices in the Emergency
Department Services Standards in 2008/2009
ROP
Compliance Rate
Staff and service providers receive ongoing, effective training on infusion pumps.*
86%
The team uses at least two client identifiers before
providing any services or procedures.
86%
The team transfers information effectively among
service providers at transition points.
86%
The team reconciles medications with the client at
referral or transfer and communicates information
about the client’s medications to the next provider
of service at referral or transfer to another setting,
service, service provider, or level of care within or
outside the organization.
30%
The team reconciles the client’s medications following triage, with the involvement of the client.
28%
* New ROP in the 2009 Emergency Department Services Standards.
Conclusion
Specific accreditation standards were developed for emer‑
gency departments to improve system performance review
across the continuum of care. Enhancements to the
Emergency Department Services Standards are expected in
the coming year and will build on accreditation results and
client feedback. These changes include the development of
specific criteria to address the needs of children and youth in
emergency departments.
While attending the annual Association of Municipal
Emergency Medical Services of Ontario conference in 2009,
we had the opportunity to speak with several Emergency
Medical Services (EMS) providers. They indicated that a
significant benefit of having both Emergency Department
Services Standards and Emergency Medical Services
Standards is the increased quality improvement opportunities
that are created through the accreditation process as hospital
staff and EMS providers work collaboratively to achieve
better patient care and outcomes. One EMS provider
particularly appreciated the opportunity to be invited by the
hospital as a community partner to discuss the EMS provider
perspective on quality improvement processes.
Emergency departments play an essential role in health
services. The Emergency Department Services Standards
provide a specific avenue to address quality and safety in this
fast-paced environment. Emergency departments across
the country are encouraged to use Accreditation Canada’s
Emergency Department Services Standards to review and
improve the quality and safety of their services, and to ensure
the effective integration of the standards with their ongoing
quality improvement program. Thank you to everyone who
participated in the national consultation, pilot testing, and
on the advisory committee. Congratulations to the staff,
physicians, and volunteers within the emergency departments
that have already used these new standards. Your contribution
does make a difference. Q
For more information on Accreditation Canada’s Emergency
Department Services Standards and Emergency Medical Services
Standards, please contact [email protected].
Stéphane Cardinal, MSc, is the Director of Partnerships and
Project Management at Accreditation Canada. She is involved
in partnerships development, proposals development and contract
negotiation, and cross-unit planning and implementation. She
managed programs targeting aboriginal communities, Canadian
Forces Health Services, and Correctional Service of Canada.
Stéphane has over 20 years of experience in business development
and project management in both the private and public sectors.
Before joining Accreditation Canada, she worked in international
development, and lived and worked in Bangladesh, Zimbabwe,
and the United States.
Tracy Murphy is a Health Services Consultant who has
worked with Accreditation Canada for over 10 years. Tracy has a
master’s degree in Health Administration and is a Certified Health
Executive. Tracy is also an Educational Consultant with the
Canadian Healthcare Association and is a CHE Program
Consultant with the Canadian College of Health Service
Executives.
33
Daniel Kollek
Hospital Disaster Readiness:
Why Are We Unprepared?
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
34
34
I
t is a recurrent theme that the further away one is from
the actual delivery of disaster care, the better prepared
one perceives the system to be. At the extreme, recent
correspondence from the Canadian Association of Emergency Physicians to the provincial health ministers across
Canada voiced concern about the health care system’s ability
to respond to disaster. Uniformly, all health ministers in the
provinces that responded (8 of 10) stated that their provinces
were prepared.
lack of formal, replicable, and evidence-based disaster preparedness assessment underpins all other problems in that
if we do not measure our inabilities, we will not be able to
remedy them.
Why Is Hospital Readiness Not Assessed?
One of the oft-quoted reasons for not having a disaster assessment tool is that disasters are so variable that it is impossible
to design a uniform assessment tool for readiness. While it is
Unfortunately, the reality at the front lines is not so rosy. Front- true that disasters may be variable, the response to disasters
line providers have repeatedly expressed serious concerns about is far more uniform. Israeli hospitals, likely the world leaders
the ability of health care systems, and spein preparedness for dealing with disasters,
cifically health care facilities, to respond in
have developed standard operating proProcesses that are
a disaster (Kanter & Moran, 2007; Kollek,
cedures that facilitate the management of
2003; Kollek & Cwinn, 2009; Tachibanai,
mass casualty incidents. Not only do these
discovered to be useful
Takemura, Sone, Segami, & Kato, 2005).
procedures allow for an organized response
in expediting care in a
Staff is inadequately trained despite the
to a disaster, they also allow for an ongoing
disaster situation can
existence of competency lists and curriprocess of quality improvement since there
easily find their way
cula (Hsu et al., 2006; Tachibanai et al.,
are standards against which to measure
2005). U.S. data shows that there is a
performance (Adini, Goldberg, Laor, Cohen,
into the day-to-day
large amount of variability between
& Bar-Dayan, 2007).
function of the
regions and facilities (Higgins, Wainright,
organization.
Lu, & Carrico, 2004). Canadian data,
Incidentally, the statement that there is a
while limited for reasons that will be
large variability in potential disasters leads
expanded on further, also shows that
one to ask why hospitals do not routinely
there are areas of strength and weakness and that there is both perform risk assessment to determine which disasters may
regional variability and variability in preparedness for specific befall them. Currently in Canada, there is no evidence that
any formal risk assessment tool has been deployed across
types of events.
hospitals, despite the fact that such tools, specifically
This discrepancy between high- and middle-level adminis- Canadian tools, do exist.
tration’s perception of readiness and frontline caregivers’ perception of a lack thereof stems from three key reasons. The Another reason for the lack of formal assessment is the lack
first and simplest of these is the distance, both geographic and of a standard of care. This was alluded to earlier and stems
in terms of training and expertise, between the administrator from the misperception that each type of disaster requires its
and the individuals actually delivering the care in a disaster own unique plan and that a standard of care must be derived
for each. Recent thinking in the disaster world has for years
setting.
focused on an “all hazards” approach as opposed to individual
Second is the fact that, particularly in health care, disaster plans. The “all hazards approach” requires a basic plan that is
preparedness is an “orphan” entity. Health care professionals then adapted for specific events. This basic plan is the backhave extremely limited training in disaster preparedness bone of the hospital disaster response and can and should be
(Bagatell & Wiese, 2008; Hsu et al., 2006), disaster management measured against a standard of care.
experts have almost no expertise in health care, and there is no
overarching authority that is able to bridge the gap between The third reason for not performing formal readiness assessthese two groups. This diffusion of responsibility exists at all ments is that, while the literature is replete with calls for the
levels, but reaches an extreme at the federal level. The development of such a tool (Barbera, Yeatts, & Macintyre,
Minister of Public Safety has the expertise and the tools for 2009; Lazar, Cagliuso Sr., & Gebbie, 2009; McCarthy, Brewsdisaster response and the Minister of Health has at her disposal ter, Hsu, Macintyre, & Kelen, 2009), the perception is that
significant expertise in health care issues, yet both of them are nothing is available or what is available is not validated (Jenkins, Kelen, Sauer, Fredericksen, & McCarthy, 2009; Kaji,
lacking in the expertise of the other.
Langford, & Lewis, 2008; Kaji & Lewis, 2008). This percepThe third reason is the absence of any formal assessment of tion is incorrect because tools, specifically Canadian tools, do
health care facility disaster preparedness in Canada. This exist for both risk and readiness assessment. With support from
35
KATIE LAFERTY
management, potential problems such as disasters are seen as
deferrable concerns. This opinion exists despite the ability of
disaster preparedness to help with overall efficiency. The irony
is that, with our alternate level of care (ALC) statistics, our
blocked emergency departments, and our overwhelmed prehospital services, the disaster is upon us already. We are blinded to it because it arrived with a whimper, not a bang.
Disaster Preparedness Improves Overall
Quality of Care
While the likelihood of a disaster occurring is small, the impact of a disaster can be extremely significant. First and foremost, there is a direct health care impact on the population,
be it from mass trauma, an infectious agent, a chemical release,
weather patterns, or other causes. Disasters can also have
an impact on the ability of the hospital to function. As the
workload increases, the staff themselves may become ill and
fear within the health care community may grow. Last, the reputation of an organization that responds poorly to disasters
is tarnished for an extremely long period of time. Tragedies
such as the 2004 Indian Ocean tsunami or Hurricane Katrina
in 2005, shown on 24/7 news channels, provide an eyewitness
account of disaster management or lack thereof in our global
village world (Jenkins et al., 2009). Any mention of the Federal [U.S.] Emergency Management Agency (FEMA) today
immediately brings to mind the response to Hurricane Katrina
while all good works that FEMA had performed in the past are
forgotten. Thus, beyond the immediate impact on the population, the hospital staff, and the hospital’s ability to function,
the impact of a disaster on the public relations image of the
hospital can be in and of itself disastrous and sustained for a
very long term.
the Public Health Agency of Canada (PHAC), the Centre
for Excellence in Emergency Preparedness (CEEP) has developed such tools and has presented them in multiple forums
since 2003. Two proposals to put these interactive tools online
to have them available to hospitals have been made to the
Chemical, Biological, Radiological-Nuclear, and Explosives
Research and Technology Initiative (CRTI), but these were
not approved.
The final reason that hospitals have not assessed their
readiness is the most understandable. Faced with pressing and
immediate issues such as hospital overcrowding and budget
36
Standardizing approaches to surge management during disasters is the first step in quality improvement. Because disaster
response is an organization-wide process, this improvement
has an impact on the entire hospital. Processes that are discovered to be useful in expediting care in a disaster situation
can easily find their way into the day-to-day function of the
organization. If disaster is defined as an event that outstrips
the organization’s ability to deliver health care, preparedness
is a method of “vaccination,” raising the threshold not only in
disaster periods but also in normal day-to-day function. Hospitals that function well prior to an event may have less need to
invoke their disaster plan to begin with.
Areas for Review and Training
Since 2001, the Centre for Excellence in Emergency
Preparedness has been called upon to provide both research
and education on a variety of disaster topics. Over time, recur-
rent themes emerge and their importance is supported by what
little research exists in the Canadian context. The recurrent
education and assessment needs are
n
n
n
n
n
n
n
n
n
n
n
n
risk and hazard vulnerability analysis
general readiness assessment and mitigation
Chemical, Biological, Radiological-Nuclear, and Explosives
(CBRNE) readiness and mitigation
incident management systems and communication
triage
hospital emergency surge capacity
integration of volunteers into the disaster response
populations at risk: pediatrics, geriatrics, mental health
emerging infections: SARS, bioterrorism, pandemic influenza
integrating hospital response with external support such as
disaster medical assistance teams
preparing for mass gatherings
medico-legal issues
While this list may seem overwhelming, it is reassuring that
much of this material exists in the literature and that there are
Canadian experts who can deliver the education and assessment
to hospitals.
The Way Forward
Preparing for disasters is a daunting task, not so much because of
the depth of the issue but because of its breadth. It has been said
that the way to eat an elephant is one bite at a time. The first
two “bites” of this particular elephant are for hospitals to perform
risk assessments and readiness assessments. Once these are done,
it will be a far more manageable task to remedy the identified
gaps. Until such time as these assessments are done, we are all
at risk of being found unprepared when the disaster – whatever
it may be – strikes. More so, it is incumbent on hospitals to take
the initiative on this issue since it falls between the cracks of the
health care and public safety systems, lacks clear ownership, and
is often forgotten or deferred in the presence of more pressing
issues such as hospital overcrowding and budget crunches. Q
Further information on the Centre for Excellence in Emergency
Preparedness can be obtained at www.ceep.ca or by contacting
[email protected].
Daniel Kollek is an award-winning Emergency Physician; an Assistant Clinical Professor in the Section of Emergency Medicine at
McMaster University in Hamilton, Ontario; Chair of the Canadian
Association of Emergency Physicians Disaster Committee; and the
Executive Director of the Centre for Excellence in Emergency Preparedness. His research papers and presentations have spanned many
disaster-related topics such as terrorism and CBRNE readiness. Prior
to his career in medicine, he was a combat officer in the Israeli Defence Forces.
references
Adini, B., Goldberg, A., Laor, D., Cohen, R., & Bar-Dayan, Y. (2007).
Factors that may influence the preparation of standards of procedures for
dealing with mass-casualty incidents. Prehospital and Disaster Medicine,
22(3), 175–180.
Bagatell, S., & Wiese, J. (2008) The elite code grey team: A new model
for residency preparedness and training in advance of a disaster. The American Journal of the Medical Sciences, 336(2), 174–178.
Barbera, J. A., Yeatts, D. J., & Macintyre, A. G. (2009). Challenge of hospital emergency preparedness: Analysis and recommendations. Disaster
Medicine and Public Health Preparedness, 3(Suppl 1), S74–S82.
Higgins, W., Wainright, C., Lu, N., & Carrico, R. (2004). Assessing hospital preparedness using an instrument based on the Mass Casualty Disaster Plan Checklist: Results of a statewide survey. American Journal of
Infection Control, 32(6), 327–332.
Hsu, E.B., Thomas, T. L., Bass, E. B., Whyne, D., Kelen, G. D., & Green,
G. B. (2006). Healthcare worker competencies for disaster training. BMC
Medical Education, 6(19). doi:10.1186/1472-6920-6-19
Jenkins, J. L., Kelen, G. D., Sauer, L. M., Fredericksen, K. A., & McCarthy, M. L. (2009). Review of hospital preparedness instruments for National Incident Management System compliance. Disaster Medicine and
Public Health Preparedness, 3(Suppl 1), S83–S89.
Kaji, A. H., Langford, V., & Lewis, R. J. (2008). Assessing hospital disaster
preparedness: A comparison of an on-site survey, directly observed drill performance, and video analysis of teamwork. Annals of Emergency Medicine,
52(3), 195–201, 201.e1-e12. doi:10.1016/j.annemergmed.2007.10.026
Kaji, A. H., & Lewis, R. J. (2008). Assessment of the reliability of the
Johns Hopkins/Agency for Healthcare Research and Quality hospital disaster drill evaluation tool. Annals of Emergency Medicine, 52(3), 204–10,
210.e1-8. doi:10.1016/j.annemergmed.2007.07.025
Kanter R. K., & Moran J. R. (2007). Hospital emergency surge capacity:
An empiric New York statewide study. Annals of Emergency Medicine.
50(3), 314–319. doi:10.1016/j.annemergmed.2006.10.019
Kollek, D. (2003). Canadian ED preparedness for a nuclear, biological or
chemical event. Canadian Journal of Emergency Medicine, 5(1), 18–26.
Kollek D., & Cwinn A. A. (2009). Hospital Emergency Readiness
Overview (HERO) Study [Abstract]. Prehospital and Disaster Medicine,
24(2), s50.
Lazar, E. J., Cagliuso, N. V., Sr., & Gebbie, K. M. (2009). Are we
ready and how do we know? The urgent need for performance metrics
in hospital emergency management. Disaster Medicine and Public Health
Preparedness, 3(1), 57–60.
McCarthy, M. L., Brewster, P., Hsu, E. B., Macintyre, A. G., & Kelen, G.
D. (2009). Consensus and tools needed to measure health care emergency
management capabilities. Disaster Medicine and Public Health Preparedness,
3(Suppl 1), S45–S51.
Tachibanai, T., Takemura, S., Sone, T., Segami, K., & Kato, N. (2005).
Competence necessary for Japanese public health center directors in responding to public health emergencies. Nippon Koshu Eisei Zasshi, 52(11),
943–956.
37
John Lindsay
Gerry Delorme
Manitoba Health’s Emergency Response
Management System: Development,
Implementation, and Improvement
M
anitoba Health’s Office of Disaster Management
(ODM) has a mandate to ensure “the health care
system is capable of providing a coordinated and
effective response to the health needs of Mani‑
tobans during a disaster” (Manitoba Finance, 2009). In 2004,
ODM undertook to develop and implement a policy regarding
the use of incident management systems in the Manitoba health
sector and specifically to create the Manitoba Health Emer‑
gency Response Management System (ERMS). Subsequently,
ERMS has been activated for several major incidents and the
lessons from these experiences has led to improvements in the
system. This article reviews this process and provides insight
into incident management systems and the challenges of their
implementation.
38
History of IMS
The health sector has experience in making critical decisions
in rapidly and dynamically evolving situations, usually in the
context of a health practitioner making decisions regarding
the care of an individual patient. At the same time, when the
health sector faces broader policy and public health decisions,
the tendency is to favour an evidence-driven and consensusbased approach. Unfortunately, disasters present the health
sector with pressure to make rapid decisions in a setting that
demands inter- and intra-departmental coordination. This can
cause conflict if either the decisions are made too rapidly and
in isolation or if reaching consensus delays the decision too
long for effective action.
38
Incident management systems (IMS) are designed to provide
a temporary decision making and communication process with
an associated organizational structure. The intention is to ad‑
dress the time and information constraints that occur in emer‑
gencies, especially when numerous and often diverse agencies
need to coordinate their actions. Historically, “the critical
innovation of the ICS [Incident Command Systems] was to
temporarily centralize response authority to direct multiple
organizations” (Moynihan, 2009).
The critical point in understanding an incident management
system is that it is a decision-making system with an integra‑
ted planning cycle and associated communication process
designed to address situations with time and information
constraints. The organizational structure, the most obvious
aspect of IMS and often the focus of the most debate, is meant
to support the decision making. The failure of IMS in specific
incidents has more to do with a failure to train staff on these
processes rather than an inability to apply the structure (Buck,
Trainor, & Aguirre, 2006).
The first variations, called Incident
Command Systems (ICS), were developed
IMS in Manitoba
The Emergency
in the United States and included
Response Management
California’s FIRESCOPE, the Phoenix Fire
In December 2005, Manitoba Health
Department’s Fire Ground Command
(the provincial health department now
System in Manitoba
System, and the National Wildfire
known as Manitoba Health and Healthy
Health has been
Coordinating Group’s National Interagency
Living) adopted an IMS policy. The policy
activated a number of
Incident Management System (Jamieson,
statement was “Manitoba Health and the
times in recent years to
2005). These systems were driven by the
Regional Health Authorities will use in‑
need to allow different responding agencies
cident management systems to provide a
respond to a variety of
to work together more efficiently, more
management and accountability structure,
emergencies and disasters.
effectively, and most importantly, more sa‑
combined with appropriate planning and
fely during large emergencies. They were
communication procedures, to respond
focused on the actions occurring at the site
effectively to emergencies and disasters”
of the emergency and were used during the response phase of (Manitoba Health, 2005b). This decision was driven by several
the emergency.
factors. The National Framework for Health Emergency Management (Federal/Provincial/Territorial Network for Emergency
Subsequent refinement and standardization occurred with the Preparedness and Response, 2004) was promoting incident
National Fire Protection Association (NFPA) releasing various management systems, while at the provincial level, the Fires
editions of its Standard on Emergency Services Incident Manage- Prevention and Emergency Response Act was the incident ma‑
ment. The NFPA defines an incident management system as “a nagement system to be used at the site of an emergency. The
system that defines the roles and responsibilities to be assumed potential for conflict in the event of an incident at a health
by the responders and the standard operating procedures to be care facility underscored the need for an integrated approach.
used in the management and direction of emergency incidents
and other functions” (NFPA, 2008). The shift in terminology Effective incident management systems share a number of
from “command” to “management” was in part in recognition common characteristics (Federal Emergency Management
of a broader set of responsibilities beyond the emergency site Agency, 2007). These were incorporated in Manitoba Health’s
IMS policy to acknowledge that the regional health autho‑
(Lindell, Perry, & Prater, 2005).
rities may already have had response plans and organizational
The other change that has transformed the use of incident procedures that met the definition of IMS without being
management systems has been its adoption by agencies that par‑ specifically referred to as such. Manitoba Health was seeking a
ticipate in emergency response away from the actual incident supportive and transitional approach rather than a prescriptive
site. The most cohesive example of this has been the Hospital one. As such, the policy states the following:
Emergency Incident Command System (HEICS) that applied
the principles of IMS to the hospital setting in the late 1980s Each Regional Health Authority and Manitoba Health
(Zane & Prestipino, 2004). Since then, the concept has been shall have incident management systems to manage their
extended to see a series of IMS layers linked together, such as response to an emergency or disaster that will
the Medical Surge Capacity and Capability (MSCC) Mana‑
n
ensure an effective emergency response and help to gement System developed for the U.S. Department of Health
ensure continuity of care
and Human Services (CNA Corporation, 2007). In both
n be based on the incident management system
cases, the IMS structure and principles have been upheld
structure and functions under the sectional headings
while still tailoring the system to suit the organizational
of Command; Planning; Operations; Logistics; and
needs.
Finance and Administration
39
KATIE LAFERTY
use consistent, common terminology
be modular and adaptable to any situation regardless
of size or type
n be adapted to meet the needs of the jurisdiction using
it by involving stakeholders in its development
n be integrated with other agencies (vertical and
horizontal integration)
n be suitable for use by all components of the health
sector
n allow for unified command/management
n be defined and documented in writing
n have clearly defined functions and responsibilities
which are consistent with normal roles
n
have clearly defined implementation, escalation,
de-escalation, and termination procedures (Manitoba
Health, 2005b)
n
n
The policy goes on to outline expectations for activa‑
tion procedures, communications, planning, and quality
improvement.
To fulfill the incident management system policy, Manitoba
Health developed and adopted its own IMS, the Emergency
Response Management System (ERMS). This system outlined
the roles and responsibilities for staff from across the depart‑
ment (Manitoba Health, 2005a). This was critical as emer‑
40
gencies often brought together parts of the organization that
may not have worked with each other on a regular basis. The
purpose of the ERMS was to ensure clear lines of authority
and to simplify the organization’s decision-making process,
including the sharing and implementation of those decisions,
given the time and information constraints of the emergency.
Previous experience during the SARS outbreak had highlight‑
ed the importance of this purpose in an organization as large
and diverse as a health ministry.
The Emergency Response Management System in Manitoba
Health has been activated a number of times in recent years
to respond to a variety of emergencies and disasters. The scal‑
ability of ERMS has allowed it to be used during emergencies
that require the coordination of a small number of Manitoba
Health’s business units such as disease outbreaks (e.g. 2005
tuberculosis outbreak, 2006 invasive pneumococcal disease
outbreak, 2009 mumps outbreak), natural hazards (e.g. 2007
Elie tornado, 2009 Manitoba ice storm, 2009 Red River flood),
as well as complex health-system-wide responses (e.g. 2007
Manitoba Nurses Union potential labour action, 2009
pandemic H1N1 influenza).
Implementing the Emergency Response Management System
involves the need to adjust the system to suit operational
needs while retaining the core structure and processes and
fulfilling the characteristics of an effective incident manage‑
ment system. This combination of preparedness and flexibility
demonstrates the value of such systems in providing
effective emergency management in a complex operational
and political environment. As Kendra and Wachtendorf
(2003) conclude in their study of the New York City
response to the attack on the World Trade Center, “training and
preparation remain fundamental, but creative thinking,
flexibility, and the ability to improvise in newly emergent
situations are vital.”
The experiences within Manitoba Health also highlight
the need for ongoing program review and improvement.
The health sector has long recognized the importance of
evidence-based decision making and integrated quality
improvement systems; adopting an incident management
system to suit a large health organization required the latter
to ensure the former. The initial need for an IMS was identified
out of internal reviews of the SARS response in 2003 and each
time it is activated, new information is added to the process of
improving the system.
references
Buck, D. A., Trainor, J. E., & Aguirre, B. E. (2006). A critical evaluation
of the incident command system and NIMS. Journal of Homeland Security
and Emergency Management 3(3). doi:10.2202/1547-7355.1252
Canadian Standards Association. (2008). Z1600: Emergency Management
and Business Continuity Programs. Available from the CSA For Occupa‑
tional Health & Safety website: http://ohs.csa.ca/standards/emergency/
Emergency_Management/dsp_Emergency-Management.asp
CNA Corporation. (2007). Medical surge capacity and capability:
A management system for integrating medical and health resources during
large-scale emergencies (2nd ed.). (Prepared for the U.S. Department of
Health and Human Services). Available from http://www.hhs.gov/disasters/
discussion/planners/mscc/index.html
Federal Emergency Management Agency. (2007). National Incident Management System: National standard curriculum training development guidance–FY07. Retrieved March 29, 2010, from http://www.fema.gov/pdf/
emergency/nims/nims_tsctdg_0307v2.pdf
Federal/Provincial/Territorial Network for Emergency Prepared‑
ness and Response. (2004). National framework for health emergency
management: Guideline for program development. Prepared for the
Conference of Federal/Provincial/Territorial Ministers of Health.
Unpublished internal policy document.
Jamieson, G. (2005, February). NIMS and the incident command
system. The Police Chief, 72(2).
Available from http://www.policechiefmagazine.org/
Kendra, J. M., & Wachtendorf, T. (2003). Elements of resilience after the
World Trade Center disaster: Reconstituting New York City’s Emergency
Operations Centre. Disasters, 27(1), 37–53.
Incident management systems are just one component of the
comprehensive approach to emergency management now
gaining widespread acceptance (Public Safety Canada, n.d.).
The future of emergency management in the health sector
and beyond will see greater standardization (cf. Canadian
Standards Association, 2008) and professionalization. Part of
this evolution must involve an integrated quality improvement
cycle to meet the overarching goal of safer communities. Q
John Lindsay is an Assistant Professor in the Applied Disaster and
Emergency Studies department at Brandon University in Manitoba
where he combines research with his experiences as an emergency
manager in Canada and New Zealand. John received a Master
of City Planning degree from the University of Manitoba in
1993 with a research focus on urban planning and emergency
management. He continues to be interested in the connections
between disaster vulnerability, population health, and sustainable
urban development practices.
Gerry Delorme is Director of the Office of Disaster Management
at Manitoba Health.
Lindell, M. K., Perry, R.W., & Prater, C. S. (2005). Organizing response
to disasters with the Incident Command System/Incident Management
System (ICS/IMS). Paper presented at the International Workshop on
Emergency Response and Rescue, October 31–November 1, 2005. Re‑
trieved March 29, 2010, from the National Science and Technology
Center for Disaster Reduction website: http://ncdr.nat.gov.tw/iwerr/doc/
pdf/S10%20PDF/s10-1%20Lindell.pdf
Manitoba Finance. (2009). 2009 Manitoba Estimates of Expenditure and Revenue. Retrieved March 29, 2010, from the Government
of Manitoba website: http://www.gov.mb.ca/finance/budget09/papers/
r_and_e.pdf
Manitoba Health. (2005a). Emergency Response Management System
(ERMS) guideline. Unpublished internal policy document.
Manitoba Health. (2005b). Incident management system policy. Unpu‑
blished internal policy document.
Moynihan, D. P. (2009). The network governance of crisis response: Case
studies of incident command systems. Journal of Public Administration Research and Theory, 19(4), 895–915. doi:10.1093/jopart/mun033
National Fire Protection Association. (2008). NFPA 1561: Standard
on Emergency Services Incident Management System. Available from
http://www.nfpa.org/AboutTheCodes/AboutTheCodes.asp?Doc
Num=1561
Public Safety Canada. (n.d.). An emergency management framework
for Canada. Available from http://www.publicsafety.gc.ca/prg/em/
emfrmwrk-eng.aspx
Zane, R., & Prestipino, A. L. (2004). Implementing the hospital
emergency incident command system: An integrated delivery system’s
experience. Prehospital and Disaster Medicine, 19(4), 311–317.
41
Ron Meyers
CSA and Emergency Management
Urgency in the Emergency:
In Support of National Standards
of Emergency Care
42
42
E
mergencies have become more complex, severe, and
widespread. A natural or human-induced disaster
can happen anytime, anywhere. We have seen many
examples such as pandemics and epidemics (H1N1
and SARS), power outages (2003 Northeast Blackout), acts
of terrorism (9/11), IT and communication system failures,
and natural disasters that can suddenly and severely
impact Canadian health care operations, large or small. The
economic consequences can be severe. Recent research
suggests a disaster like an influenza pandemic could cost the
Canadian economy $9 billion due to absenteeism among
critical industry workers such as those working in the health
care industry. All organizations face a certain amount of
uncertainty and risk; in order to assure sustainability of
operations and maintain resilience and performance, health
care organizations must have an effective system to manage
their own hazards and threats.
Emergency Management
Programs
of a major emergency. An effective emergency management
program can prevent an emerging crisis from becoming an
organizational disaster.
Working with Accreditation Canada
Accreditation Canada and the Canadian Standards
Association (CSA) have teamed up to look at how emergency
management in the accreditation standards can be
enhanced to support health care organizations in
working towards a more comprehensive approach, such as
the one outlined in the new CSA Standard on Emergency
Management and Business Continuity Programs, Z1600.
Accreditation Canada and CSA will also work to identify what training and implementation resources are needed
to improve the capability of health care organizations to
respond to emergencies and disasters, which will minimize
adverse events and enhance public safety.
An effective
emergency
management
program can prevent
an emerging crisis
from becoming an
organizational disaster.
The emergency environment has changed
in a dynamic way. Successful emergency
management must not only include the
traditional focus on preparedness and
response, but must also put more emphasis on prevention, mitigation, and business continuity and recovery activities.
A fundamental shift in thinking and a
comprehensive approach to managing
emergencies is essential. A compre‑
hensive emergency management program means a
complete process aimed at the reduction of loss and
the protection of assets from all types of hazards
through a risk-based program of prevention, mitigation,
preparedness, response, and recovery activities. Some
factors that have changed the way emergency management
programs are designed include climate change, urbanization,
critical infrastructure dependencies and interdependencies,
terrorism, and the increased mobility of people.
The purpose of an emergency management program is
to protect people, property, the environment, and the
economic viability of the organization. Of paramount
importance is the protection of life. The development
and implementation of a comprehensive emergency
management program will provide health care organizations
with a structured capability to continue to operate in
the face of a major emergency or business disruption. It
provides a road map for the health care organization to
sustain good corporate governance, retain the confidence
of its stakeholders, and manage its reputation in the face
CSA Z1600 Standard
CSA has been working with leading
Canadian emergency management stakeholders over the past decade to develop and
maintain national standards for emergency
preparedness and response, risk management, and personal protective equipment
used by first responders.
CSA has continued to expand its work in
this area to address the full spectrum of
emergency management. One such initiative involved working with Public Safety Canada and other
stakeholders to create the new voluntary Canadian standard
on Emergency Management and Business Continuity Programs,
Z1600, published in August 2008. The standard outlines the
requirements for a comprehensive emergency management
program that incorporates a risk-based, all-hazards methodol‑
ogy and integrates emergency management and business continuity programs for a total program approach.
The goal of this standard is to help Canadian organizations of
all sizes take a more proactive approach to managing their risks
and hazards, both internal and external hazards and threats.
The standard guides them in developing strategies and plans
that may (a) prevent some emergencies before they occur, (b)
lessen the frequency and impact of emergencies that do occur,
(c) help organizations to be prepared to respond in a timely
and effective manner to the worst emergencies, and (d) speed
the recovery process following an event. The CSA Z1600
standard also serves as a benchmark that allows organizations to evaluate or initiate an emergency management and
business continuity program that will work for them.
43
KATIE LAFERTY
The CSA Z1600 Standard was developed by a team of experts including first responders, the private sector, nongovernmental organizations, emergency management and
business continuity specialists, and all levels of government.
A key objective for CSA’s Z1600 Technical Committee
was to ensure close alignment with government/regulatory
initiatives and policy direction, such as alignment with the
Government of Canada’s new Emergency Management Act.
The standard reflects the convergence of public and private
sector planning efforts over the past 10 years.
CSA Z1600-08 Program Assessment Tool
The CSA Z1600-08 Emergency Management and Business
Continuity Programs Assessment Tool is a practical,
intuitive, and affordable software application that provides a
road map to successfully develop and implement a comprehensive CSA Z1600–compliant emergency preparedness and
business continuity program. The application guides users
through a process that includes verification through documentation, observations, and interviews. It contains conven‑
ient hyperlinks allowing users to quickly view informative
material with just a click of the mouse. CSA Z1600-08 helps
to identify gaps in an existing program and create an action
plan to close gaps, including task-assignment features.
CSA Training for Z1600
Compliance with CSA standards can be a pathway to greater
efficiencies, a road map for best practice, and proof of due diligence in the event of emergency. However, it is essential that
any information tool, whether it is a standard, guideline, or
checklist, be understood, accepted, and used in order to be
relevant and effective. The often complex and highly technical content of standards must be demystified and made easy
to understand so the standard can be implemented properly
at a practical, day-to-day level.
CSA offers training on the Z1600 Emergency Management
and Business Continuity Programs standard and on auditing
for the CSA Z1600 standard. The auditing training focuses
on effective auditing techniques using supporting guidelines
from ISO 19011 for auditing management systems, and demonstrates how to direct a systematic, independent, and objective assessment of emergency management and business
continuity programs.
International Collaborations
Because emergencies know no borders, CSA is fully en‑
gaged with leading standards development organizations in
the United States including the National Fire Protection
Association and the American National Standards Institute
44
(ANSI), and serves as a member of ANSI’s Homeland Security Standards Panel. CSA is an active member of the joint
Strategic Advisory Group on Security of the International
Organization for Standardization (ISO), International Electrotechnical Commission, and International Telecommunication Union. On behalf of the Standards Council of Canada,
CSA also participates on the ISO Technical Committee on
Societal Security, which is aimed at increasing emergency man‑
agement and business continuity capabilities, and manages the
Canadian Advisory Committee to ensure Canadian interests
are appropriately represented at the international level.
Conclusion
A key objective of the Accreditation Canada and CSA collaboration is to solicit feedback from health care organizations
to better understand their emergency management chal‑
lenges. To that end, Accreditation Canada and CSA held
a focus group in March 2010 with health care stakeholders
from across Canada. Participants provided valuable feedback on the issues and challenges they face. Moving forward,
Accreditation Canada and CSA will continue to work together
in determining how best to assist health care organizations to
improve their emergency management capability. Q
Ron Meyers is a Project Manager for the Canadian Standards
Association. He works in the areas of emergency, security and
risk management, and protective equipment and systems, which
included the development of the Canadian National Standard on
Emergency Management and Business Continuity Programs,
CSA Z1600. He is a Canadian Registered Safety Professional
(CRSP) with over 15 years of experience in Occupational and
Public Health and Safety. Ron can be contacted at ron.meyers@
csa.ca.
GILLES LANTEIGNE
Executive Vice-President
Accreditation Canada
In Closing
Committed and Involved
F
rom emergency medical services to emergency
departments to emergency management, it is my hope
that this issue of Qmentum Quarterly has given you
some new insights into the multi-faceted world of emergency health services. Given the ever-changing health care environment, it is important for Accreditation Canada to make
continual improvements to keep our program and standards
up to date. Work on the emergency health services initiative
continues, with upcoming refinements that will address
pediatric clientele and the trauma component of emergency
health services.
The Emergency Medical Services (EMS) Standards were
added to Qmentum for 2010. To help EMS organizations take the
first steps in their accreditation journey, Accreditation Canada
will be hosting a conference on Improving Emergency Medical
Services Through Accreditation. This day-long conference,
which will take place on September 16, 2010, in Mississauga,
Ontario, will be of interest to EMS professionals from organizations that provide ambulance services, medical transport
services, and communication and dispatch services. For more
information, please visit our website at www.accreditation.ca.
If you have EMS experience, consider becoming a surveyor for
Accreditation Canada. Surveyors are dedicated professionals
who provide their expertise to guide organizations in quality
improvement. If you are interested in this opportunity to give
back to the health care community, we invite you to contact
[email protected].
we are tasked with caring for the health of our clients, but we
must not forget to look after the health of our organizations. We
have a broad range of articles lined up to help in this endeavour,
including articles on employee engagement, restructuring,
leadership, workplace health and safety, risk assessment,
and training.
When we began producing Qmentum Quarterly nearly two years
ago, we were pleased to provide a forum for sharing knowledge.
But you should also know that Accreditation Canada has an
additional avenue: the Knowledge Exchange section of our
website. It currently houses leading practices, patient safety
resources, and a link to the International Society for Quality
in Health Care (ISQua) Research website, but there is room
for much more. We are committed to supporting knowledge
exchange in Canada. With your help, we would like to see this
section grow to become the place to go for sharing information.
You can find it at www.accreditation.ca/knowledge-exchange/
Many thanks go out to all of our contributors for this issue—
we appreciate that you have taken time to share your
valuable experience and support quality improvement. To our
readers, thanks once again for your interest in Qmentum
Quarterly. We enjoy receiving your thoughts on Qmentum
Quarterly and encourage you to continue to share your feedback
with us.
Together we are making great strides!
Looking ahead, the theme of the next edition of Qmentum
Quarterly is Organizational Health. Working in health care,
If you would like to make changes to your subscription information, please contact:
Sylvie Anne Turgeon Subscriptions and Customer Service - Les éditions du Point
Tel: 514 277-4544, ext. 241 Toll-free: 1 888 832-3031, ext. 241 E-mail: [email protected]
46
SUBSCRIBE
TODAY!
Qmentum Quarterly: Quality in Health Care is
an avenue for sharing expertise, innovation, and
leading practices across Canada. The publication
provides a forum for health and social services
organizations that are commited to learning about
and improving quality and patient safety.
4 issues (1 year) $39.95
($45.10 incl.taxes)
8 issues (2 years) $64.95
($73.31 incl.taxes)
Gift/group subscription
Save when ordering 5 or
more subscriptions (1 year)
$29.95 each ($33.81 incl.taxes)
Qmentum Quarterly offers you
3 FAST AND EASY WAYS to subscribe:
• By visiting our website at
www.qmentumquarterly.com and registering online
• By filling out the subscription card
inside the publication
Don’t miss the next issue of Qmemtum Quarterly:
Quality in Health Care. Subscription rates are
affordable and worth the investment.
• By calling our office at 1 888 832 -3031 ext. 241