quality improvement and reporting of medical errors

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


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


…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


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


…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


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


• 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


…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


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


...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


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


…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


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


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?


…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?



• 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



• 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


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


…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


…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


…RHPA

• These processes are based on the behaviour of the individual and are often termed the “bad apple approach”

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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


…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


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


The Two Solitudes

• Quality improvement of the system• Quality improvement of the

individual


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


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


Organizational Factors Necessary to Support Teamwork

• A clear organizational philosophy that values teamwork

• Management structure

• Resources

• Education

• Feedback


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


• 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


Moving Forward to Effective Teamwork – Can We Do It?


Nobody wants to continue with the “Blame and Shame” Game…

BUT

Looking ONLY at system safetyflaws is not sufficient


“Concentrating exclusively on systems is an initial over-reaction to the data on medial errors.”

-Dr. R. Salvata, University of Washington


“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


Finding and Fixing competency problems of individual health care professional can and should also lead to system improvements.


Commercial airline pilots are required to demonstrate their current competence

yearly.

That is NOT the case with health care professionals.


Hospital credentialing and privileging programs today are inadequate.


JCAHO is just now beginning to require stronger credentialing and privileging programs as part of their accreditation standards, BUT…


Ability to rely on JCAHO accreditation still is a long way off.


The time has come to require all health care professionals to periodically demonstrate their current competence as a condition of re-licensure.


Mandatory continuing education is NOT

the answer.


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


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:


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



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



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


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


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


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: [email protected]

Website: www.cmrto.org

…Speaker Contact Information


David Swankin

Citizen Advocacy Center

1400 16th Avenue NW, Suite 101

Washington, DC 20036

Phone: 202-462-1174 Fax: 202-265-6564

E-mail: [email protected]



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: [email protected]

Website: www.weirfoulds.com


quality improvement and reporting of medical errors

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