PATIENT SAFETY through COMMUNICATION March 11, 2008

BACKGROUND on MIPS:  Independent, non-profit corporation  Created in May 2004  Governed by 12 member board:  Majority (7) elected by our membership and 5 appointed by Minister of Health  Board – citizens, providers, administrators

MISSION To promote patient safety and quality health care for Manitobans

Objective 1 Promote patient safety activities in Manitoba health care system.

Objective 2 Identify emerging patient safety & quality care issues.

Objective 3 Promote “best practices” in patient safety.

Objective 4 Raise awareness of patient safety issues.

MIPS PATIENT ADVISORY COMMITTEE “ MPAC”

MPAC l l Provide a voice for patients/families interested in patient safety & its promotion in healthcare settings l l Do activities to promote MIPS mission & objectives l l Create long-term strategies for patient & family involvement in MB Health care system

Canadian Adverse Events Study (2004): The results suggest that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about:   7. 5% (185,000) of adult hospital admissions (acute care) resulted in an adverse event   Of these, 37% (70,000) were considered preventable, and   died. FACTS

Safety in Long-Term Care Settings (2008) Wagner & Rust   Accidental injury - most common adverse event among nursing home residents with dementia & psychosis   Falls - most frequently reported adverse event in LTC settings   Medications- 42% of all adverse drug events preventable FACTS

“Patient safety is everyone’s responsibility.”

PATIENT SAFETY IS A COMMON GOAL l l Reduce preventable harm to patients l l Provide the safest quality care possible

DO I PROMOTE PATIENT SAFETY? Ask yourself: l l Do I value resident safety? l l Do I communicate effectively with residents & their families? l l Do I do all that I can to promote patient safety in my organization?

ACTION CHECKLIST (Reality Check) Do I: Communicate in respectful open, honest manner daily? Communicate regularly with families & HC team? Provide families with timely health information? Use plain language and visual clues when discussing the patient with families? Regularly ask families to clarify what was discussed?

ACTION CHECKLIST DO I: Encourage families to ask questions? Discuss patient safety with families & HC team? Look for latent safety threats every day? Report/disclose any errors or potential errors that may impact on patients ? DO I PROMOTE PATIENT SAFETY??

BUILDING BLOCKS TO PATIENT SAFETY

Communication

COMMUNICATION Why is it important? Bridge between HC providers, patients/ families & rest of HC team to achieve patient safety & quality care.

  Communication  Root cause of 70% of sentinel events reported to the Joint Commission, US.

WHAT TYPE OF COMMUNICATION IS NEEDED ? l l Verbal & Non-Verbal l l Respectful l l Honest l l Mutually trusting l l Accepting l l Empathetic

COMMUNICATION l l Interdisciplinary l l Engage family l l Care planning l l Reporting/disclosing incidents l l Medication safety l l Critical to culture of safety l l Timely shared

BUILDING BLOCKS TO PATIENT SAFETY Communication Action

What can you-Health Care Provider- do?

ACTIONS OF HEALTH CARE PROVIDERS Open two-way communication Ongoing involvement Ongoing sharing Teamwork Advocate for Culture of Patient Safety

ACTION OPEN TWO-WAY COMMUNICATION: Talk with families/care givers. Listen to families/care givers. Talk with HC team. Listen to HC team.

ACTION ONGOING INVOLVEMENT: Families/care givers in health decisions Health care team Upper management

ACTION ONGOING SHARING of: Patient information Importance of patient safety Latent threats to patient safety Reporting/disclosure of adverse events With: Families/care givers Rest of HC team

ACTION TEAMWORK: Effectively collaborate with others Give and receive feedback on performance “No Blame” approach to incident reporting & analysis

ACTION 5. ADVOCATE - CULTURE of PATIENT SAFETY Be a site “champion” Stay positive Involve families in important decisions Be persistent

BUILDING BLOCKS TO PATIENT SAFETY Communication Action Support

SUPPORT: Is there a patient safety culture?   Is patient safety:   A top priority in your organization & among leaders?   Viewed as a positive concept?   The focus of attention for all organizational activities?

SUPPORT: Is there a collaborative environment?   “Blame-free reporting system”   Proactive approach (errors/problems anticipated)   Share information (3 Cs)   Accountability - safety is everyone’s responsibility   Monitoring of situations & actions taken

SUPPORT: Are families/care givers involved in process of patient safety improvement? Is there a clear organizational policy? Are there adequate resources to respond to identified concerns?

SUPPORT: For residents, Balance Patient Safety Quality of Life/ Independence

TOOL for FAMILIES & HC PROVIDERS Is It … Safe to Ask? ISTA

It’s Safe to Ask Offers information and tips for providers and patients/families to :  Enhance clear communication  Make care a more positive experience  Increase health literacy  Help reduce adverse events

It’s Safe to Ask (ISTA) Target Groups: 1.Public Groups in Manitoba (such as elderly, low literacy, people with disabilities) 1.Health care providers

It’s Safe to Ask What is my health problem? What do I need to do? Why do I need to do this?

What are the values behind in ISTA? Know your rights as patients/families.   Personal Health Information Act (PHIA)   Right of patient to receive healthcare instructions and information in a way they/care givers can understand. ( Standards for PCH #1 Pte Bill of Rights) Ask questions.

What is MPAC telling families/care givers? Communicate with HC providers:   Ask questions   Learn some medical terminology   Seek credible resources   Gain support

Material translated into: Amharic English Arabic French Chinese Cree OjibwayOji-Cree Eritrean German Korean Punjabi Russian Spanish Tagalog 15 languages!

PHASE 2, ISTA l Medication Card

Patient Safety is achievable! Everyone must be willing to: Communicate Act Support

Look for windows of opportunity Look for windows of opportunity

FAMILY STORIES

COMING TOGETHER IS A BEGINNING. KEEPING TOGETHER IS PROGRESS. WORKING TOGETHER IS SUCCESS. Henry Ford