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Specific Action Plans:

To help UHN create solutions for improving patient and workplace safety, action plans have been developed for the following four major streams of activity:

  1. Reduce Hospital Acquired Conditions (HACs)
  2. Increase reporting and analysis of Serious Safety Events (SSE)
  3. Reduce the number of incidents that result in preventable harm to workers
  4. Foster a culture to promote speaking up for safety by learning and implementing error prevention tools, recognizing the role of patients and staff.
  • Build a foundation of resilience by embedding safety behaviours, error prevention tools, and harm prevention strategies into daily practice
  • Develop a comprehensive approach to identifying and learning from patient and worker safety events
  • Create a culture where staff and patients can embrace safety as a core value
Q1
  • Engage patients and caregivers in HAC implementation plans
Q4
  • Complete the first phase of HAC implementations
  • Improve reporting and classification of Serious Safety Events: develop an education program to emphasize the importance of reporting events
  • Continue to develop and implement a comprehensive workplace injury prevention program
  • Foster a culture which promotes speaking up for safety, by learning and implementing the error prevention tools, and recognizing the importance and the role patients and staff play in the process

Caring Safely has made significant progress to date as we move into the implementation phase of many of its 2017/18 initiatives. We are focusing on building a foundational safety culture, preventing harm from occurring to both patients and workers, as well as responding to and learning from serious safety events. For example, five out of seven Caring Safely Leadership Methods education modules have been delivered. A standardized Cause Analysis Program to address both patient and worker serious safety events has been developed, and is being recognized for it’s unique approach; the Caring Safely team has been invited to present this framework at the upcoming HPI Safety Summit in October. We have also begun to weave the patient perspective into our harm prevention work by inviting Patient Partners to participate in our HAC activities and various meetings, including our Safety & Quality Committee of the Board.

Achievements

  • Developed a standardized Cause Analysis Program to analyze incidents, determine root causes and corrective actions to reduce serious safety events for patients and workers
  • Developed site-based HAC implementation plans for FY 2017/18
  • New online incident reporting system with single user interface for reporting both patient and worker incidents launched on April 1st, 2017
  • Finalized workplace serious safety event classification criteria
  • Established site-based Quality of Care Committees at all four hospital sites
  • Participation from Patient Partner in film on Caring Safely story; sharing their story on experienced harm at UHN

Attention Needed

  • Complete remaining Caring Safely leadership modules and make-up sessions
  • Develop framework for Safety Coach program expansion to reinforce safety behaviours
  • Continue targeted HAC-specific implementations based on 2017/18 HAC Implementation Plan
  • Initiate testing of the Cause Analysis Program including one patient Root Cause Analysis pilot at each site
  • Test various ways of sharing system learnings from patient Serious Safety Events between the site and UHN Quality of Care Committees
  • Continue to develop and implement workplace Cause Analysis Program

Past Reports:

Charlie Chan (Lead)

Executive Vice President and Chief Medical Officer

Mike Nader

Executive Vice President and Chief Operating Officer

Emma Pavlov

Executive Vice President Human Resources and Organizational Development, and Michener Operations

  • Emily Musing
  • Wing-Si Luk
  • Brenda Perkins Meingast
  • Jeanette Maclean
  • Diana Elder
  • Michelle Lorello
  • Kerseri Scane
  • Laura Williams
  • Dan Girard
  • Shirin Ansari-Tadi
  • Michelle Benitez

*names are still being added/confirmed