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The Quebec situation: a view from the trenches

OCHU conference on The Epidemic of Medical Errors, June 4th, 2012

Presented by Marc PineaultCoordinator – Quality and Risk Management

St. Mary’s Hospital Center

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• I have no vested financial interests in any activity that promotes patient safety

• The views in this presentation are my personal views and do not bind or represent my employer’s views

Disclaimer

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Outline of the presentation

• Introduction and Quebec context• Legislative measures• The good• The challenges• Future perspectives… or what we need

to win the war

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Introduction and Quebec context

• Quebec healthcare system in a nutshell Regulatory framework is based on Canadian

Healthcare Act – 5 conditions The government regulates the size of the

coverage basket of services (RAMQ) Hierarchy is centralized at the MSSS level, and

regional delegation through regional health boards (18)

95 CSSS (85% of which have a hospital but also include CLSC’s, LTC facilities), geographically based

CHA, Institutes, and 4 University Hospitals

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Introduction and Quebec context

• Quebec healthcare system in a nutshell (continued) 2000 private clinics and family medicine groups Over 3000 community organizations Long-term care facilities Rehabilitation centers Youth protection Private institutions (private long-term care,

community pharmacies, non-institutionalized resources, etc.)

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The Quebec Context

• In the world,

• To Err is Human• Australian study• UK study

• The Quebec stories and study

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Legislative measures adopted in 2003

Became mandatory to:• Disclose accidents to patients and family• Have a Board of Directors by-law for

disclosure• Define support measures for patients

and family• Report incidents/accidents• Put in place measures to prevent

recurrence

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Legislative measures adopted in 2003

• Create a risk management committee• Create a local registry of

incidents/accidents• Follow an accreditation process (since

2011, mandatory to be accredited)• Transmit a summary of the report to

authorities (since 2011, made public)• Annual report must contain risk

management activities conducted during the year

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Legislative measures adopted in 2003

• In addition to a local registry, a national registry was to be put in place

• This took over 8 years to accomplish!!!

• And what did we learn? You’ll soon see…

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The good

Improvements were observed in increased transparency: • With victims and families through the disclosure process (CMPA, CPSI guidelines, etc.)

• Through the development of a structured reporting system

• In institutions, through the accreditation process, the reporting of results, and the obligation to report on risk management activities in the annual report

Disclaimer: none of these claims are necessarily scientifically-based but are based on experience

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The good (continued)

• Focus on patient safety has increased in health institutions through the local registry, through the activities of the risk management committees, and through the accreditation process that focuses on patient safety

• The increase in expertise on patient safety within health institutions has also increased the responsiveness of organizations to correct and prevent adverse events

Disclaimer: none of these claims are necessarily scientifically-based but are based on experience

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The good (continued)

Some tools to support institutions:

• Training for risk management committees

• Purchase and adaptation of the Australian human factors and patient safety program called ErroMed©

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The good (continued)

Infection control:

• Mandatory reporting and public disclosure of infection rates for C-diff since 2005.

• Standardized ratio of infection control personnel per hospital bed established

• Effort put into guidelines and methods of prevention

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The challenges

• Disclosure: despite efforts, telling patients that something went wrong remains taboo in many areas and with many professionals

• Accreditation process: the cycle has been increased to 4-years, posing a risk that institutions will not pay attention to patient safety issues during 2 of the 4 years in the interval between visits

• Expertise in patient safety within institutions has not been recognized by the Ministry (i.e. risk managers and patient safety officers)

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The challenges (continued)

Reporting system:

• The focus on reporting and the birth of the national registry has put emphasis on the management of reporting forms, and less on prevention

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The challenges (continued)

“National” registry:

• 179,011 events were reported in 6 months• 10% were incidents, 65% were accidents, and

25% were undetermined• Falls and medication were the 2 highest

reported events• 1/5 events required only monitoring• 1/10 events required non-specialized

interventions• 2/100 events required specialized interventions• 4/1000 events required increased level of care

or increased the length of stay

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The challenges (continued)

“National” registry:

• But what does this mean?

• Validity of the data• 25% undetermined severity!• Rates?• What do institutions report?

• What’s the purpose vs what was the legislator’s intent 10 years ago?

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The challenges (continued)

Tools to increase patient safety:

• Risk management committee training quickly outdated and was finally upgraded in 2011; many senior trainers dropped off

• Human factors training program was not sufficiently supported and has lost momentum through high turnover at the MSSS level

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The challenges (continued)

Infection control:

• Efforts seem to not be heard by some professionals

• Uneven attention to the risks involved

• Inter-institution transfers seem to remove ownership of problem

Disclaimer: none of these claims are necessarily scientifically-based but are based on experience

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Future perspectives: what the Ministry is hinting

• Continue presenting numbers; no communicated plan as to how to improve the report

• Based on the frequency, create “expert groups” to find solutions

• Human factors is still in limbo, after 7 years, decisions based on erroneous information from the Regional Health Authorities

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• Support for training in Human Factors and patient safety

• Data that is meaningful

• Recognition that some issues are solvable at the Ministry level; but that most are at the institution level

Future perspectives: what the Ministry is hinting

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Future perspectives: what the true stakeholders need

• To stop looking at humans as being the problem; to err is human; to implement a culture of why’s not who’s

• Transforming Dr Seuss’s Whoville into Whyville

• Empower the front liners to be able to implement change instead of implementing more centralized control

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Thank you for your attentionMerci beaucoup de votre écoute