1. Ask. Listen. Talk. – Advancing the Patient Safety Agenda “Knowing is not enough; we must apply. Willing is not enough; we must do” Goethe February 9, 2012

2. A Transformation Autobiography in Five Chapters Chapter 1 I walk down the street There is a hole in the sidewalk I fall in I am lost..I am helpless. Its isn’t my fault. It takes forever to find a way out. Chapter 2 I walk down the same street There is a deep hole in the sidewalk. I pretend I don’t see it. I fall in again. I can’t believe I am in this same place. But it isn’t my fault. It still takes a long time to get out. Adapted from a Poem by P. Nelson Chapter 3 I walk down the same street. There is a deep hole in the sidewalk. I see it is there. I fall in, it’s a habit..but my Eyes are open. I know where I am. It is my fault. I get out immediately. Chapter 4 I walk down the same street. There is a deep hole in the sidewalk. I walk around it. Chapter 5 The hole is filled with the talents in this room, and your healthcare system 2

3. Why Are We Meeting – Its about Patients  More deaths after experiencing adverse events in hospital than deaths from breast cancer, motor vehicle and HIV combined 3  One in ten patients receive wrong medication or wrong dose  One in ten adults contract infection in hospital

4. Holes In The Sidewalk - Street  Thousands of Canadians die every year  Something goes wrong in 1 of 13 hospital stays  185,000 hospital errors annually  20-25% of hospital readmissions result from post discharge medication reconciliation issues  Health care work environments are unhealthy  Sick Leave, Long Term Disability and Workers Compensation claims are up  Anxiety and stress related claims on the rise  Presenteesim on the rise, the cognitively impaired who come to work  Every healthcare workers carry seeds of success: skills, talents, potentialities and enthusiasm. Unfortunately for many front line providers, the same seeds contain too many intellectual, emotional and systemic barriers. 4

5. Background  Canadian population Approx. 34.6 million  Canadian healthcare spending Approx. 180 billion  Public sector healthcare spending forecast projected to reach 70.6%  Private sector healthcare spending forecast projected to reach 29.4%  Provincial / territorial health planning 5

6. Milestones of the Modern Era  1991  1992  1996  1999  2000  2001  2001-3  2001  2002  2003  2011 Harvard Medical Practice Study Quality in Australian Health Care Study Annenberg conferences begin Colorado / Utah Study IOM Report: To Err is Human BMA/BMJ London Conference on Medical Error SAEM: San Francisco Conference on EM Error British study Halifax Symposia on Medical Error RCPSC National Steering Committee on Patient Safety RCPSC Report: Building a Safer System Canadian Patient Safety Institute & Baker Norton Study New CPSI Strategic Plan 6

7. Mission & Vision Mission  “To inspire extraordinary improvement in patient safety and quality” Vision  “Safe healthcare for all Canadians”  Our relationships are the core  We will align our priorities with provincial, territorial and national policy and operational direction 7

8. Our Main Roles Advocate Catalyst Integrator Broker Promoter  When our partners succeed, we succeed  Our drivers are – knowledge, evidence and analysis

9. My Patient Experience  Astonishing lack of privacy.  Difficult to distance my self from the agony, obstacles and progress of others.  I was there when there was no one else. I saw the blank stares of my roommates trying to make sense of their predicament.  On numerous occasion gloves were not changed between patient interventions. I began to wonder if protection was for the care giver, not the patient.  My vulnerability stripped me of my autonomy and power. I was scared on my back.  I saw and felt the impact of unruly, misplaced and aggressive patient expectations and behaviours.  I received great care, and I saw safety gaps in delivery of care.  I witnessed a “cultural shift” on a shift exchange.  Care is about perfect interactions between and among providers and patients. 9

10. The Challenge Priorities Middle Management Institutes Foundations Councils Others Institutes Foundations Councils Others Ministries Health Authorities Agencies Associations Public Ministries Health Authorities Agencies Associations Public Patient Client Resident Board/CEO Frontline

11. Strategic Directions 11

12. An Integrated Approach EDUCATION Effective Governance for Quality and Patient Safety [Clinical Leadership] [Executive Leadership] Patients For Patient Safety Canada Patient Safety Education Program Canadian Patient Safety Officer Course The Safety Competencies Framework Middle Management Board/CEO Frontline

13. An Integrated Approach DIRECTED RESEARCH Patient Safety in Home Care in Canada Economics of Patient Safety Patient Safety in Mental Health Patient Safety in Primary Care And EMS Patient Safety in Primary Care And EMS Patient Safety - Children Middle Management Board/CEO Frontline

14. An Integrated Approach TOOLS & RESOURCES Middle Management Board/CEO Frontline Canadian Disclosure Guidelines – Media Guidelines Canadian Framework for Managing Patient Safety Incidents Global Patient Safety Alerts Portal Improving Care Search Centre Simulation

15. Medication Reconciliation An Integrated Approach SAFER HEALTHCARE NOW! Acute Myocardial Infarction New Approach to Controlling Superbugs Central-Line Infection Veneous Thromboembolism Falls Prevention Surgical Site Infection Ventilator-Associated Pneumonia Safe Surgery Saves Lives Checklist Middle Management Board/CEO Frontline PATIENT SAFETY METRICS PATIENT SAFETY METRICS

16. Finding the Balance – Culture Eats Strategy for Lunch – Emotion Trumps Evidence A key consideration – success = soft  Ego  Integrity  Teamwork  Communications  Attitude  Commitment  Readiness for change Fundamentally health system organizations are a web of relationships, conversations and decisions among people.

17. ASK LISTEN TALK-New Adult Conversations  My professional and personal experience with patient safety:  Context is everything  Denial is our greatest threat  It is all about relationships  Patient voice must be listened to and acted on  To quote Don Berwick “Care is interaction among our assets and between assets and patients. To perfect care, we must have perfect interactions” 17

18. Video: Two Wolves

19. Thank You !  Hugh MacLeod: hmacleod@cpsi-icsp.ca  CPSI: www.patientsafetyinstitute.ca 19