quality improvement and reporting of medical errors sharon saberton, registrar, college of medical...
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Quality Improvement and Reporting of Medical Errors
Sharon Saberton, Registrar, College of Medical Radiation Technologists, Ontario
David Swankin, President and CEO, Citizen Advocacy Center, Washington, DC.
Debbie Tarshis, Lawyer, WeirFoulds LLP, Toronto, Ontario
2006 Annual Conference
Alexandria, Virginia
Council on Licensure, Enforcement and Regulation
Expect the Unexpected: Are We Clearly Prepared?
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Agenda
• Legal Framework for moving to a culture of safety through quality improvement and reporting of medical errors
• The current process in Ontario and a different model for consideration
• Linking the individuals’ performance and the system as a whole
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Why Patient Safety
• U.S. Institute of Medicine estimated that 44,000 to 98,000 people die in hospitals each year as a result of adverse events
• NHS study in Britain found that adverse events occurred in 10% of hospital admissions, at a cost of £2 billion annually in additional hospital stays
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Why Patient Safety
• 2004 Canadian study estimated that in 2000, of the almost 2.5 million annual admissions to hospitals in Canada, about 185,000 were associated with an adverse event, of which close to 70,000 were potentially preventable
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Systems Approach to Patient Safety
• Majority of adverse events do not result from recklessness on part of health practitioner, but from basic flaws in way health system is organized
• Individual practitioner not a potential culprit to be blamed and punished but one participant interacting with many others in a highly complex environment
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Systems Approach to Patient Safety
• Analysis of adverse events – do not limit to occurrences at “sharp end”,
where practitioners interact with patients and each other in process of delivering care
– must include considerations of role played by “blunt” or remote end of system (regulators, administrators, policy makers and technology suppliers) who shape environment in which practitioners work
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Common Themes of Patient Safety Analysis
• Essential to find out about errors and injuries to patients– To undertake systemic analysis of what has gone
wrong
– Develop effective strategies to prevent, reduce and ameliorate harm
– Disseminate lessons learned more widely through health system for implementation elsewhere
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
• Disclosure will be “chilled” if risk of negative repercussions
• Prospect of legal liability for negligence is major impediment to openly disclosing errors and systemic analysis– Recovery of damages conditional on finding
of fault
…Common Themes of Patient Safety Analysis
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Common Themes of Patient Safety Analysis
• Information gathered and activities undertaken as part of quality assurance or patient safety initiatives should be insulated from disclosure or use in civil litigation and other types of legal proceedings
• Culture of “blame and shame” must be changed to culture of openness, problem-solving and safety
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Reporting and Investigation of Critical Incidents
• Should reporting and investigation be mandatory?
• Canadian jurisdictions that have adopted mandatory reporting– Saskatchewan– Manitoba (not yet in force)– Quebec– Alberta
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
...Reporting and Investigation of Critical Incidents
• Define “critical incident” ie. what must be reported and investigated
• What institutions have obligation to report and investigate
• To whom must report be made– Regional authorities? Government?
• Nature of information that is shared
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Healthcare Quality Improvement Legislation
• To create a confidential environment where– designated persons can collect, analyze and
share information
– data and opinions associated with discussions are protected from disclosure in legal proceedings
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Healthcare Quality Improvement Legislation
• All Canadian jurisdictions have some form of protection for quality of care information but legislation varies in– What type of health care body can establish
committee– Whose communications are protected– What communications and information are
protected– What committees are protected– What is the subject of communication at issue– Who is seeking quality assurance records
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Legislation on Privacy and Confidentiality of Personal Health
Information
• Need to be able to collect, analyze and share information
• Need to protect the privacy and confidentiality of individuals
• Standardize privacy and confidentiality legislation– To facilitate access to patient-safety data
while respecting privacy of patients
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Role of Professional Regulatory Bodies
• How best to advance patient safety goals in ways that are consistent with regulators’ obligations to protect public and ensure practitioners provide safe, quality care?
• Should regulatory body be involved at the review stage of a specific patient case?
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Role of Professional Regulatory Bodies
• Would collaborative review facilitate a multi-disciplinary determination of contributing factors and one set of recommendations to enhance individual and/or system performance?
• How can regulatory Colleges encourage practitioners to move from a culture of “blame and shame” to a culture of patient safety?
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Role of Professional Regulatory Bodies
• Greater focus on practitioners’ improvement through education and remediation rather than blame and punishment
• Changes to standards of practice and codes of ethics regarding reporting of hazardous situations, adverse events or near misses
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…Role of Professional Regulatory Bodies
• Regulatory bodies as recipients of information regarding lessons to be learned from adverse events or near misses
• Regulatory bodies as organizations to disseminate lessons learned to practitioners
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Regulated Health Professions Act, 1991 (RHPA)
The intent of the RHPA is to protect the public interest, and to ensure that individuals have access to quality service by health professionals of their choice
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…RHPA
• Provides a complaints procedure which aims at ensuring that a thorough investigation of a complaint is conducted
• If the Complaints Committee determines that an accusation of professional misconduct should be referred to the Discipline Committee, a hearing is held before a panel of the Discipline Committee
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…RHPA
• Mandatory Reporting is considered an essential professional obligation and ensures that instances of professional misconduct, professional incompetence or sexual abuse or concerns regarding incapacity are brought to the attention of the College
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…RHPA
• These processes are based on the behaviour of the individual and are often termed the “bad apple approach”
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
RHPA – Quality Assurance Program
Quality Assurance programs are mandated inthe legislation. The goals of Quality AssurancePrograms are to: • Assure the public of the quality of regulated
health professionals by maintaining members’ performance at a level consistent with the Standards of Practice
• Promote continuing competence among members
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
…RHPA - Quality Assurance Program
• Focuses on the performance of the individual
• Does not link to the system as a whole
• Based on the belief that quality improvement of the individual will add value to the quality of the system
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Barriers to Healthcare Renewal
• There is no standardized privacy and confidentiality legislation to facilitate access to patient-safety data while respecting privacy of patients
• Legislative and regulatory framework has created boundaries that prevents disclosure of quality assurance information to the health care system
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
The Two Solitudes
• Quality improvement of the system• Quality improvement of the
individual
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
A Different Model - Teamwork
• Many reports in Canada are calling for improved collaboration as a key strategy in healthcare renewal
• A healthcare system that supports effective teamwork can improve the quality of patient care, enhance patient safety and reduce workload issues that cause burnout among healthcare professionals
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Structures Necessary to Support Teamwork
• Team objectives
• Roles and responsibilities of team members
• Mechanisms for exchanging information
• Co-ordination mechanisms for team activities and staffing
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Organizational Factors Necessary to Support Teamwork
• A clear organizational philosophy that values teamwork
• Management structure
• Resources
• Education
• Feedback
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
System Factors Necessary to Support Teamwork
• Consistent government policies and approaches
• Health human resource planning
• Regulatory/legislative frameworks that do not create barriers
• Models of funding and remuneration that encourage collaboration
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
• Teaching hospitals exploring new practice models
• Aboriginal communities
• Remote primary care centres serving specific populations
• Disease based groups such as seniors, diabetic care and individuals requiring mental health services
Some Successful Canadian Initiatives
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Moving Forward to Effective Teamwork – Can We Do It?
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Nobody wants to continue with the “Blame and Shame” Game…
BUT
Looking ONLY at system safetyflaws is not sufficient
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
“Concentrating exclusively on systems is an initial over-reaction to the data on medial errors.”
-Dr. R. Salvata, University of Washington
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
“I don’t see safety failures overall as a dichotomy---either as systems problems or as performance problems. Performance problems are systems problems, too.”
-Dr. Lucian Leape,Harvard School of Public Health
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Finding and Fixing competency problems of individual health care professional can and should also lead to system improvements.
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Commercial airline pilots are required to demonstrate their current competence
yearly.
That is NOT the case with health care professionals.
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Hospital credentialing and privileging programs today are inadequate.
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
JCAHO is just now beginning to require stronger credentialing and privileging programs as part of their accreditation standards, BUT…
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Ability to rely on JCAHO accreditation still is a long way off.
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
The time has come to require all health care professionals to periodically demonstrate their current competence as a condition of re-licensure.
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Mandatory continuing education is NOT
the answer.
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
CAC’s Framework for State Legislature Action:
1. Eliminate continuing education requirements
2. Mandate that as a condition of relicensure, licensees participate in continuing professional development programs approved by their respective health care boards
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
3. Mandate that continuing professional development programs include (a) assessment; (b) development, execution, and documentation of a learning plan based on the assessment; and (c) periodic demonstrations of continuing competence
…CAC’s Framework for State Legislature Action:
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
4. Provide licensure boards with the flexibility to try different approaches to foster continued competence
5. Ensure that the board’s assessments of continuing competence address knowledge, skills, attitudes, judgment, abilities, experience, and ethics necessary for safe and competent practice in the setting and role of an individual’s practice at the time of relicensure
…CAC’s Framework for State Legislature Action:
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
6. Require that boards evaluate their approaches to gathering evidence on the effectiveness of methods used for periodic assessment
7. Authorize licensure boards to grant deemed status to continuing competence programs administered by voluntary credentialing and specialty boards, or by hospitals and other health care delivery institutions, when the private programs meet board-established standards
…CAC’s Framework for State Legislature Action:
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
1. Reporting and investigation of critical incidents
1. Should reporting and investigation be mandatory?
2. What institutions have obligation to report and investigate?
3. To whom must the report be made:Regional authorities? Government?
4. What is the nature of information that is shared?
Questions for Discussion
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
2. Role of professional regulatory bodies1. How best to advance patient safety goals in
ways that are consistent with regulator’s obligations to protect public and ensure practitioners provide safe, quality care?
2. Should regulatory body be involved at the review stage of a specific patient case?
3. Would collaborative review facilitate a multi-disciplinary determination of contributing factors and one set of recommendations to enhance individual and/or system performance?
…Questions for Discussion
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
3. Will moving forward to effective teamwork improve both the quality of the system and the individual?
4. What strategies can be implemented to move from a culture of “blame and shame” to a culture of patient safety?
…Questions for Discussion
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Sharon Saberton
College of Medical Radiation Technologists of Ontario
170 Bloor Street West, Suite 1001
Toronto, ON M5S 1T9
Phone: 1-800-563-5847 Fax: 416-975-4355
E-mail: ssaberton@cmrto.org
Website: www.cmrto.org
…Speaker Contact Information
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
David Swankin
Citizen Advocacy Center
1400 16th Avenue NW, Suite 101
Washington, DC 20036
Phone: 202-462-1174 Fax: 202-265-6564
E-mail: davidswankin@cacenter.org
…Speaker Contact Information
Presented at the 2006 CLEAR Annual ConferenceSeptember 14-16 Alexandria, Virginia
Debbie Tarshis
WeirFoulds LLP
Suite 1600, Exchange Tower, P.O. Box 480
130 King Street West
Toronto, ON M5X 1J5
Phone: (416) 947-5037 Fax: (416) 365-1876
Email: dtarshis@weirfoulds.com
Website: www.weirfoulds.com
…Speaker Contact Information
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