Collaborate, communicate and educate: Moving beyond blame to patient safety

By Steven Cassel and Sandra Kagoma

Safety is a priority for all hospitals. Provincial legislation and government bodies mandate that hospitals properly train staff, implement safe practices, use safe equipment and medical procedures, maintain sterile environments and report on a selection of patient safety indicators – to name a few. Even with this, adverse patient events can arise. The Brant Community Healthcare System (BCHS) took action to implement a full Patient Safety Program two years ago commencing with two major initiatives.

The first initiative arose from the patient safety culture survey. The BCHS identified a gap in communication between frontline staff and the Senior Leadership Team (SLT) with respect to patient safety. To understand and address this gap, BCHS launched a comprehensive patient safety walkabout initiative during the 2015 Patient Safety Week that included senior leaders.

A common misconception is that patient safety is about reminding people to be more careful, but patient safety isn’t about cautioning health care staff to be more careful. In fact, health care professionals are some of the most careful people on earth. Improving patient safety is about changing the culture in health care from one of blame to one where we examine our systems from beginning to end to reduce the opportunities for mistakes. It’s not about who caused the incident but what caused the incident.

Guided by this philosophy the BCHS Patient Safety SLT Walkabouts were designed and implemented as a tool for leaders to visibly demonstrate patient safety as a high organizational priority, and learn from direct care providers and physicians about near misses, errors and hazards that compromise patient safety at the point of care.

During an hour-long prescheduled visit to an area of the hospital a member of the Patient Experience and Quality Outcomes team  partners with a member of senior leadership  to discuss with care providers and physicians the issues that have caused or could cause harm to patients. Concerns raised during these conversations are recorded, entered into a database and addressed by Group Leads, with results reported back to staff. This assures care providers and physicians that concerns raised are heard and addressed, which assists in closing the communication gap between staff and SLT.

This past summer while on an SLT walkabout through the Oncology department, two patients receiving chemotherapy treatments recognized that patient safety was being discussed with senior leadership and staff. These patients also wanted to share their safety concerns regarding poor visibility in the small oncology treatment rooms, which could hinder care providers from responding to issues the patients may encounter. This provided a patient perspective that is needed when addressing safety. These interactions with patients allowed the BCHS to incorporate the patient’s voice in future walkabouts at BCHS – completing the communication loop within the full circle of care.

Reports of these walkabouts are made available to everyone in the organization through the BCHS Intranet. Everyone is encouraged to discuss patient safety to break down communication barriers and move away from a culture of blame, towards a just culture.

During the 2016 Patient Safety Week, BCHS Board members will also participate in these walkabouts. This brings another level of leadership into the safety conversation, reinforces that the concerns of frontline staff and patients are being heard and further enhances the role of the BCHS Board on patient safety.

The second initiative is a customized patient safety education program for frontline staff, leadership and physicians – conducted on-site by BCHS Patient Safety and Professional Practice Leaders. This includes the seven steps to patient safety:

  • Promote and build a patient safety culture;
  • Report BCHS patient safety concerns/adverse events through Riskpro software;
  • All staff and physicians will support and lead patient safety;
  • Establish a framework that recognizes costs of failure and benefits of reliability;
  • Involve patients;
  • Learn and share safety lessons; and
  • Implement solutions to prevent harm.

To date BCHS has educated nearly 500 of the approximately 1,800 frontline staff, leadership and physicians.

This in-house BCHS program has received encouraging reviews from staff and senior leadership as seen by the evaluation results, as well as participation and engagement of staff. Over the next year BCHS aims to measure objective outcomes that could be tied to the implementation of the program – such as medication errors and falls.

The BCHS is happy to share their program with other hospitals to increase patient safety, improving channels of communication throughout hospitals, and switching from a culture of blame to a just culture.

Steven Cassel is Patient Safety & Professional Practice Leader) and Sandra Kagoma  is Value Stream Leader, Patient Experience & Quality Outcomes at Brant Community Healthcare System.