5. Quality Improvement

Since the year 2000, the Canadian healthcare system has been making great efforts to improve patient safety on a system-wide basis. This lesson looks at the progress of these efforts, and what still needs to be accomplished. We’ll also discuss blame culture and just culture, and how they affect you as a healthcare provider.

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Reporting

According to the CPMA, reporting is “the communication of information about an adverse event or close call by healthcare providers, through appropriate channels inside or outside of healthcare organizations, for the purpose of reducing the risk of reoccurrence of adverse events in the future.”

Reporting an adverse event or close call is a policy for healthcare organizations across Ontario. It is an important part of the mechanism each organization has in place to identify and understand what went wrong, and what could go wrong in the future.

When incidents are reported, that data is gathered and passed on to various organizations, including the Ontario Ministry of Health and Long-Term Care, Health Quality Ontario, and Accreditation Canada.

Healthcare professionals at the point of care—interacting directly with patients and their families—play an enormous role in making this patient safety mechanism work. By actively reporting adverse events and close calls, they allow organizations to learn and change.

Is Patient Safety Improving?

Change is occurring very slowly in Canada’s healthcare sector. In 2015, over ten years after he and Peter Norton published the 2004 Canadian Adverse Events Study (CAES), Ross Baker published a follow-up report called Beyond the Quick Fix: Strategies for Improving Patient Safety. In it he analyzed how successful the Canadian healthcare system had been at improving patient safety since the CAES first came out. In the report, Baker outlines some of these improvements:

• The federal government funded the creation of the Canadian Patient Safety Institute (CPSI).
• Provinces have invested heavily in patient safety reporting.
• CPSI launched Safer Healthcare Now!, a patient safety resource for frontline healthcare providers, healthcare organizations, and health quality committees and councils.
• Healthcare organizations across Canada have invested in measuring and assessing adverse events, and finding ways to reduce them.
• Healthcare organizations have also invested in providing training, equipment, and reviews of current practice in order to reduce adverse events.

The result? Baker concluded that ten years later, although there has been a shift towards a culture of patient safety, “many Canadian healthcare organizations still struggle to address key patient safety issues. Harm experienced by patients, and the impact on families, staff and organizations continues despite better measures of the number and impact of these events, and efforts to change unsafe practices.”

Baker suggested that the key to improving patient safety lies in creating more effective work environments and high performing teams.

Patient Involvement

In the video above, Pam Marshall points out that, “if you’re going to continue to have human beings in the system providing care and making decisions and judgements, then we’re going to get it wrong sometimes.” In Ontario, one important step healthcare providers are taking to improve patient safety is to actively involve patients in their own care, keeping them informed about what is taking place, and encouraging them to ask questions and participate in the decision-making process—to be at the centre of the healthcare team.

To implement this process when it comes to adverse events, many organizations have put patient relations teams in place. These teams work with patients, families and healthcare providers when an adverse event occurs. Their role is to create an environment of open communication for everyone involved, ensuring that patients and families have proper disclosure throughout the process; and also that they feel heard and involved. The patient relations team offers advice and support to the healthcare provider throughout the disclosure process as well.

Litigation

Although the fear of litigation exists in Canada, in reality, litigation is not as common here as it is in the United States. In other healthcare systems, people often take legal action in order to cover the cost of care that may be required because of an adverse event. But because we have universal healthcare in Canada, that need is diminished.

According to Pam Marshall, one reason someone might take legal action in Ontario is because they feel unsatisfied with the disclosure and apology process—that they weren’t given the facts they needed, or those facts were delivered in an insensitive manner. Sometimes, if the financial provider of a family has died and the family needs to replace that income, there may be a lawsuit. Fortunately, the healthcare community in Ontario has a very strong settlement focus, and most of the time cases get settled out of court.

Insurance

Even with the rare cases that end up in court, healthcare providers have access to insurance coverage. All hospitals for example, are insured, and many of them are covered by the Healthcare Insurance Reciprocal of Canada. Nurses are covered under their hospital’s insurance. Physicians, who are privileged and not employed by hospitals, are covered under their own organization, the Canadian Medical Protective Association (CMPA). Other healthcare providers have access to liability protection—for example, the Royal College of Dental Surgeons of Ontario covers dentists registered in Ontario under the Professional Liability Program.

From a Blame Culture to a Just Culture

Throughout this course, you will have noticed that in Ontario and across Canada, there has been a dramatic shift over the last number of years in the way adverse events are handled—a move from a blame culture to a just culture:

• Instead of placing blame on an individual healthcare provider, we now understand that most adverse events occur because of a flawed system, and the healthcare provider is seen as the “sharp end” of that system.
• We see healthcare providers involved in adverse events as potential “second victims” who also need support.
• Instead of shielding patients and families from the facts surrounding an adverse event, we now try to keep them as informed as possible throughout disclosure, involving them in the process.
• We believe that an apology, sincerely offered, is appropriate and healing for patients, their families, and for healthcare providers.

The research has shown that the idea that punishment and blame improves healthcare is wrong. In fact, the opposite is true: proactive education and balanced accountability has been found to be much more effective. For example, if an adverse event occurs because a healthcare provider lacked a certain type of training, then changing the system so that the provider has access to training, and making the provider accountable for getting trained is a much more effective response than simply punishing or firing the provider.

By working towards a just culture and understanding that patients, their families and the entire healthcare team are all on the same side, over time we can hope to minimize adverse events and improve patient safety.