1. PATIENT SAFETY through COMMUNICATION March 11, 2008

2. 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

3. MISSION To promote patient safety and quality health care for Manitobans

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

5. Objective 2 Identify emerging patient safety & quality care issues.

6. Objective 3 Promote “best practices” in patient safety.

7. Objective 4 Raise awareness of patient safety issues.

8. MIPS PATIENT ADVISORY COMMITTEE “ MPAC”

9. 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

10. 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   9000-24000 died. FACTS

11. 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

12. “Patient safety is everyone’s responsibility.”

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

14. 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?

15. ACTION CHECKLIST (Reality Check) Do I: 1. 1. Communicate in respectful open, honest manner daily? 2. 2. Communicate regularly with families & HC team? 3. 3. Provide families with timely health information? 4. 4. Use plain language and visual clues when discussing the patient with families? 5. 5. Regularly ask families to clarify what was discussed?

16. ACTION CHECKLIST DO I: 6. 6. Encourage families to ask questions? 7. 7. Discuss patient safety with families & HC team? 8. 8. Look for latent safety threats every day? 9. 9. Report/disclose any errors or potential errors that may impact on patients ? DO I PROMOTE PATIENT SAFETY??

17. BUILDING BLOCKS TO PATIENT SAFETY

18. Communication

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

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

22. 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

23. 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

24. BUILDING BLOCKS TO PATIENT SAFETY Communication Action

25. What can you-Health Care Provider- do?

26. ACTIONS OF HEALTH CARE PROVIDERS 1. 1. Open two-way communication 2. 2. Ongoing involvement 3. 3. Ongoing sharing 4. 4. Teamwork 5. 5. Advocate for Culture of Patient Safety

27. ACTION 1. 1. OPEN TWO-WAY COMMUNICATION: Talk with families/care givers. Listen to families/care givers. Talk with HC team. Listen to HC team.

28. ACTION 2. 2. ONGOING INVOLVEMENT: Families/care givers in health decisions Health care team Upper management

29. ACTION 3. 3. 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

30. ACTION 4. 4. TEAMWORK: Effectively collaborate with others Give and receive feedback on performance “No Blame” approach to incident reporting & analysis

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

32. BUILDING BLOCKS TO PATIENT SAFETY Communication Action Support

33. SUPPORT: 1. 1. 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?

34. SUPPORT: 2. 2. 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

35. SUPPORT: 3. 3. Are families/care givers involved in process of patient safety improvement? 4. 4. Is there a clear organizational policy? 5. 5. Are there adequate resources to respond to identified concerns?

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

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

38. 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

39. 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

40. It’s Safe to Ask 1. 1. What is my health problem? 2. 2. What do I need to do? 3. 3. Why do I need to do this?

43. What are the values behind in ISTA? 1. 1. 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) 2. 2. Ask questions.

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

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

46. PHASE 2, ISTA l Medication Card

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

48. Look for windows of opportunity Look for windows of opportunity

49. FAMILY STORIES

50. www.mbips.ca www.safetoask.ca

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