academic. margot harvie
TRANSCRIPT
Looking East: How Can Alberta’s Blueprint Guide Us?
Margot Harvie RN BN MEd
Quality & Safety Education Lead
February 27, 2013
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Blueprint Project
• Vision • All those involved in
providing healthcare have a common understanding of key components of patient safety and quality and use this to continually invest in making patient care safer
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Blueprint Project
• Mission • Work collaboratively to develop a detailed
framework of learning outcomes and objectives and some priority supporting curriculum resources incorporating key messages about patient safety concepts/topics that can be used in educating all who work in the healthcare system about the principles and processes of patient safety
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Blueprint Project
• Project Partners • HQCA, Alberta Health Services, University of
Alberta, University of Calgary, University of Lethbridge, Mount Royal University, Northern Alberta Institute of Technology, Norquest College, Canadian Patient Safety Institute, BC Patient Safety and Quality Council, Manitoba Institute for Patient Safety
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Genesis of the Blueprint Project
2007 2008 2009 2010 2011 2012 2013
Patient Safety Curriculum: Gaining Consensus workshop 200 individuals providing feedback on initial model and framework
Patient Safety Curriculum Project Working Group Calgary Health Region - development of model
Blueprint Project Multi-year collaborative sponsored by the HQCA
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Healthcare System Safety Model
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Early lessons.....
• Curriculum Framework not the right terminology to use
• Simple is better!
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Patients
Personnel Environment / Equipment
Organization Regulatory Agency
Evolution of the Model
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UNSAFE ACTS
LOCAL WORKPLACE FACTORS
ORGANIZATIONAL FACTORS
LOCAL WORKPLACE FACTORS
ORGANIZATIONAL FACTORS
UNSAFE ACTS
PHYSICAL ENVIRONMENT
Crew
ORGANIZATIONAL ENVIRONMENT
REGULATORY ENVIRONMENT
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PHYSICAL ENVIRONMENT
Crew
ORGANIZATIONAL ENVIRONMENT
REGULATORY ENVIRONMENT
PHYSICAL ENVIRONMENT
Crew
ORGANIZATIONAL ENVIRONMENT
REGULATORY ENVIRONMENT
ENVIRONMENT / EQUIPMENT
PERSONNEL
THE ORGANIZATION
REGULATORY AGENCIES
PHYSICAL ENVIRONMENT
Crew
ORGANIZATIONAL ENVIRONMENT
REGULATORY ENVIRONMENT
Patient
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Health Care
Providing Receiving
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The Healthcare Encounter Safety and Quality Model
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The players The functions
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The Healthcare Encounter Safety and Quality Model
The Healthcare Encounter Safety and Quality Model
The Patient Safety Puzzle
The Patient Safety Puzzle
The Patient Safety Puzzle
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2007 2008 2009 2010 2011 2012 2013
September Principles Think Tank Meeting
May - First Steering Committee meeting
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Blueprint Project Structure
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A few things we learned...
• Individuals interested, but really needed core ‘working group’
• Collaboration takes time!
• Group writing is painful and time consuming, but very rich
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2007 2008 2009 2010 2011 2012 2013
Spring - Environmental Scan
September - Patient Safety Framework for Albertans Certificate in Patent Safety & Quality Course
June - Patient Safety Principles Document
First Event Analysis Think-tank
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Environmental Scan • Purpose • Determine extent to which systems approach
to patient safety integrated into healthcare provider education programs
• Determine what kinds of resources would be helpful in supporting integration of systems approach to patient safety
• Gather feedback about utility and content of Patient Safety Education Self-Assessment tool
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Environmental Scan • Method • Based on literature review, a draft Patient
Safety Education Self-Assessment Tool (PSESAT) was developed to assist post-secondary healthcare provider education programs in determining to what extent a systems approach to patient safety has been integrated into their curriculum
• Tool developed in collaboration with educators across Alberta
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Environmental Scan
• Tool • Three themes explored through tool items 1. Patient safety-related concepts taught in the
program with a focus on a systems orientation to patient safety
2. Leadership and organizational factors that support a systems approach to patient safety within an education program
3. Responding to close calls and adverse events involving students
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PSESAT
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Environmental Scan • Key Findings • Patient safety scale ratings were high
suggesting that patient safety is well-integrated into most programs, however it is not clear to what extent this reflects a systems oriented view of safety
• Respondents often stated that they did not completely understand the terms or concepts related to a systems approach that were embedded in the tool items
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Environmental Scan • Key Findings • A disconnect between educational programs
and clinical settings was evident which may hinder student practice of newly learned patient safety concepts
• Programs expressed interest in user-friendly resources to help them learn about the concepts of a systems approach to patient safety - case studies, interactive technology-based resources and networking opportunities
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Environmental Scan • Key Findings • Respondents recognized that the process of
completing the self-assessment tool may be its most important function
• Critically reflecting on the tool items as a group raises awareness of a systems oriented approach
• Suggestions to improve tool mainly centered on improving clarity of wording and developing a consistent rating scale
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Patient Safety Framework
Based on an understanding of what is required to make healthcare safer
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Certificate in Patient Safety & Quality
• Partnership with Office of Continuing Medical Education & Professional Practice, W21C University of Calgary & HQCA
• Third year of course - now using blended on-line and face to face format
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2007 2008 2009 2010 2011 2012 2013
May - Faculty Development Workshops
Patient Safety Conundrum Document
Completion of Patient Safety Principles Outcomes Matrix
Second Event Analysis Think-tank
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Faculty Development Workshops
• Opportunity identified in environmental scan • Help make the shift from “individual provider
responsibility for safe patient care” to an integrated “systems view of patient safety”
• Important step in addressing Strategy 5 in the Patient Safety Framework for Albertans
• about 30 participants - positive feedback
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Outcomes Matrix
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More learning
• HUGE project • Difficult to juggle big picture and deep dives • Can’t be done off the side of anyone’s desk • Lots of great ideas...
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2007 2008 2009 2010 2011 2012 2013
SSA:PSR June - Advisory Nov - Workshop
Full time Quality & Safety Education Lead hired
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SSA:PSR • Theory-based, developed
specifically for healthcare reviews
• Draws from aviation and human factors investigation techniques
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Yes - more lessons!
• Project needs more of a stakeholder group than a steering committee
• Still tons more work to do • Struggling with engagement vs getting the
work done • New process for completing learning outcomes
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2013..........
SSA:PSR February - pilot certificate course
Focus on completing learning outcomes for 21 remaining learning topics
Map learning objectives to CPSI competencies and CanMeds
Map learning topics to U of C medical school curriculum
What’s next?