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  1. 1. Looking East: How CanAlbertas Blueprint Guide Us?Margot Harvie RN BN MEdQuality & Safety Education Lead February 27, 2013
  2. 2. Blueprint Project Vision All those involved inproviding healthcare have acommon understanding ofkey components of patientsafety and quality and usethis to continually invest inmaking patient care safer2
  3. 3. Blueprint Project Mission Work collaboratively to develop a detailedframework of learning outcomes andobjectives and some priority supportingcurriculum resources incorporating keymessages about patient safetyconcepts/topics that can be used in educatingall who work in the healthcare system aboutthe principles and processes of patient safety 3
  4. 4. Blueprint Project Project Partners HQCA, Alberta Health Services, University ofAlberta, University of Calgary, University ofLethbridge, Mount Royal University, NorthernAlberta Institute of Technology, NorquestCollege, Canadian Patient Safety Institute, BCPatient Safety and Quality Council, ManitobaInstitute for Patient Safety 4
  5. 5. Genesis of the Blueprint Project Blueprint Project Multi-year collaborative sponsored byPatient Safety the HQCACurriculum ProjectWorking GroupCalgary Health Region -development of model200720082009 2010 20112012 2013 Patient Safety Curriculum: Gaining Consensus workshop 200 individuals providing feedback on initial model and framework5
  6. 6. Healthcare System Safety Model 6
  7. 7. Early lessons..... Curriculum Framework not the rightterminology to use Simple is better! 7
  8. 8. Evolution of the Model PersonnelEnvironment /Equipment Organization RegulatoryPatients Agency8
  9. 9. UNSAFE ACTS UNSAFE ACTSCrewLOCAL WORKPLACE FACTORSLOCAL WORKPLACE FACTORS PHYSICAL ENVIRONMENTORGANIZATIONAL FACTORSORGANIZATIONAL ENVIRONMENTORGANIZATIONAL FACTORS REGULATORY ENVIRONMENT 9
  10. 10. Patient CrewPERSONNELCrew PHYSICAL ENVIRONMENT ENVIRONMENT / EQUIPMENT PHYSICAL ENVIRONMENTORGANIZATIONAL ENVIRONMENT ORGANIZATIONAL ENVIRONMENTTHE ORGANIZATION REGULATORY ENVIRONMENT REGULATORY ENVIRONMENTREGULATORY AGENCIES10
  11. 11. The Healthcare Encounter Safety and Quality ModelHealth CareProvidingReceiving 11
  12. 12. The Healthcare Encounter Safetyand Quality Model The functions players12
  13. 13. The Healthcare Encounter Safetyand Quality Model
  14. 14. The Patient Safety Puzzle
  15. 15. The Patient Safety Puzzle
  16. 16. The Patient Safety Puzzle
  17. 17. May - First Steering Committee meeting2007 2008 20092010 2011 2012 2013September PrinciplesThink Tank Meeting17
  18. 18. Blueprint Project Structure18
  19. 19. A few things we learned... Individuals interested, but really needed coreworking group Collaboration takes time! Group writing is painful and time consuming,but very rich 19
  20. 20. Spring - Environmental ScanSeptember - Patient SafetyFramework for AlbertansCertificate in Patent Safety &Quality Course2007 2008 2009 20102011 2012 2013 June - Patient Safety Principles Document First Event Analysis Think- tank20
  21. 21. Environmental Scan Purpose Determine extent to which systems approachto patient safety integrated into healthcareprovider education programs Determine what kinds of resources would behelpful in supporting integration of systemsapproach to patient safety Gather feedback about utility and content ofPatient Safety Education Self-Assessment tool21
  22. 22. Environmental Scan Method Based on literature review, a draft PatientSafety Education Self-Assessment Tool(PSESAT) was developed to assist post-secondary healthcare provider educationprograms in determining to what extent asystems approach to patient safety has beenintegrated into their curriculum Tool developed in collaboration witheducators across Alberta22
  23. 23. Environmental Scan Tool Three themes explored through tool items1. Patient safety-related concepts taught in theprogram with a focus on a systems orientationto patient safety2. Leadership and organizational factors thatsupport a systems approach to patient safetywithin an education program3. Responding to close calls and adverse eventsinvolving students 23
  24. 24. PSESAT 24
  25. 25. Environmental Scan Key Findings Patient safety scale ratings were highsuggesting that patient safety is well-integrated into most programs, however it isnot clear to what extent this reflects a systemsoriented view of safety Respondents often stated that they did notcompletely understand the terms or conceptsrelated to a systems approach that wereembedded in the tool items 25
  26. 26. Environmental Scan Key Findings A disconnect between educational programsand clinical settings was evident which mayhinder student practice of newly learnedpatient safety concepts Programs expressed interest in user-friendlyresources to help them learn about theconcepts of a systems approach to patientsafety - case studies, interactive technology-based resources and networking opportunities 26
  27. 27. Environmental Scan Key Findings Respondents recognized that the process ofcompleting the self-assessment tool may be itsmost important function Critically reflecting on the tool items as agroup raises awareness of a systems orientedapproach Suggestions to improve tool mainly centeredon improving clarity of wording anddeveloping a consistent rating scale 27
  28. 28. Patient Safety FrameworkBased on an understanding of what is required to make healthcare safer 28
  29. 29. Certificate in Patient Safety & Quality Partnership with Office of Continuing MedicalEducation & Professional Practice, W21CUniversity of Calgary & HQCA Third year of course - now using blended on-line and face to face format29
  30. 30. May - FacultyDevelopmentWorkshops Completion of Patient Safety Principles Outcomes Matrix2007 2008 2009 2010 2011 20122013 Patient Safety Conundrum DocumentSecond EventAnalysis Think-tank30
  31. 31. Faculty Development Workshops Opportunity identified in environmental scan Help make the shift from individual providerresponsibility for safe patient care to anintegrated systems view of patient safety Important step in addressing Strategy 5 in thePatient Safety Framework for Albertans about 30 participants - positive feedback 31
  32. 32. Outcomes Matrix32
  33. 33. More learning HUGE project Difficult to juggle big picture and deep dives Cant be done off the side of anyones desk Lots of great ideas... 33
  34. 34. Full time Quality & Safety Education Lead hired2007 2008 2009 2010 2011 2012 2013SSA:PSRJune - AdvisoryNov - Workshop34
  35. 35. SSA:PSR Theory-based, developedspecifically for healthcarereviews Draws from aviation andhuman factors investigationtechniques35
  36. 36. Yes - more lessons! Project needs more of a stakeholder groupthan a steering committee Still tons more work to do Struggling with engagement vs getting thework done New process for completing learning outcomes 36
  37. 37. Whats next?SSA:PSRFebruary - pilotcertificate course Map learning objectives to CPSI competencies and CanMeds2013.......... Map learning topics to U of C medical school curriculum Focus on completing learning outcomes for 21 remaining learning topics 37