Participant Manual p. 1 SAY:

Presentación del tema: "Participant Manual p. 1 SAY:"— Transcripción de la presentación:

1 Participant Manual p. 1 SAY: Good morning and welcome to everybody. We are very happy to be here and are looking forward to the next 2 days together. It promises to be an action-packed workshop! Full of theory, exercises, and hands on practice. Introduce yourselves: name, position at Accreditation Canada, any other relevant detail. Indicate where the washrooms are located, and ask the participants to place their cellphones in “vibration” mode for respect to their peers. Encourage them to participate and share their experiences or ideas whenever the opportunity, since knowledge exchange is very important for this 2 day session. Also let them know that there will be some flipping around the manual to the different slides, exercises, and documents. Explain that this is because all the topics are interrelated and physically going back and forth between exercises or slides helps the participants to draw those connections. Mejora de la calidad en servicios de salud: Seguridad de los pacientes y prácticas organizacionales requeridas This symbol will indicate when flip charting is required throughout these speaker notes

2 Objetivos Definir qué es la seguridad de los pacientes.
Participant Manual p. 2 Definir qué es la seguridad de los pacientes. Identificar problemas relacionados con la seguridad de los pacientes en su organización. Entender qué es la cultura de la seguridad y cuál es su rol en ella. SAY: So we have 3 main goals today: To present who we are at Accreditation Canada and our link to Patient Safety To explore and identify the issues within your organization related to patient safety To understand what is a culture of safety, its drivers, and identify your role in promoting it within your workplace. Facilitator: Go back to the flipcharts about expectations that you colleague is preparing and go through them together with the participants. Address any expectation that is not covered in the program agenda. Leave the flipcharts handy because you will go back to them at the end of Day 2.

3 El proceso de acreditación y la seguridad de los pacientes
Participant Manual p. 3 El proceso de acreditación y la seguridad de los pacientes SAY: Now, let’s go right into the first part of our session today, the relationship between Accreditation and Patient Safety.

4 Seguridad de los pacientes: definición
Participant Manual p. 6 ‘‘La reducción y atenuación de actos inseguros en el sistema de salud, y el uso de prácticas recomendadas por su probada capacidad de producir resultados óptimos para los pacientes’’. En suma, la seguridad del paciente consiste en trabajar en forma constante para evitar, gestionar y dar respuesta a los actos inseguros en el sistema de salud. This is an animated slide, with only the title appearing first. DO NOT click until after the discussion. SAY: Today, we will be focusing on patient safety. Whatever type of organization you work in, patient safety must be made a priority! Although much of the patient safety research and documentation in health care has been centered around the acute care sector, the focus has been gradually turning to other sectors. Safety is a concern for anyone and everyone who receives care and/or services. Large group discussion: Ask participants : How would you define “patient safety”? What is patient safety all about? Take 2-3 minutes to receive and discuss comments from the participants. The co-facilitator should write down key ideas/words on a flipchart entitled “Patient Safety” Now CLICK the mouse. Show and read the definitions and tie these to the remarks made by the participants. Points: Safety is about freedom from accidental injury. We accidentally injure people all the time! Zero is where we should be heading. Safety must become a fundamental principle of the way we operate. To help sort through the confusion, the Canadian Patient Safety dictionary was produced. It was prepared by a working group of the national steering committee on Patient Safety, in conjunction with the royal College of physicians and Surgeons of Canada. The dictionary is available in English and in French (some say that the French one is better). It can be found on the website at Next Slide… Diccionario Canadiense de Seguridad de los Pacientes

5 La acreditación y la seguridad de los pacientes (1)
Participant Manual p. 6 La acreditación de Accreditation Canada es una herramienta para mejorar la seguridad de los pacientes: Los estándares se basan en evidencia e incorporan prácticas de punta Las prácticas organizacionales requeridas aumentan la seguridad de los pacientes Las medidas de desempeño permiten monitorear el progreso SAY: The Accreditation Canada accreditation program gives you a structure and a way to demonstrate that you are working to improve patient safety. If you are part of the accreditation program, you are working to meet standards of excellence. The Accreditation Canada standards are evidence-based. The ROPs are part of the Standards therefore also evidence-based and further enhance patient safety. And, if an organization meets the standards that are related to patient safety, then it should be delivering safe care and services; and, the risks to patient safety are reduced.

6 La acreditación y la seguridad de los pacientes (2)
Participant Manual p. 7 Mejoras permanentes = riesgos reducidos La hoja de ruta ayuda a establecer prioridades e introducir mejoras El informe de evaluación menciona las prioridades sobre las que se debe actuar SAY: If the Quality Improvement strategy is adequately implemented, then patient safety risks decrease A good way of monitoring if this is happening is through the Quality Performance Roadmap. The QPR is an accreditation tool that guides organizations in monitoring progress, setting priorities and making improvements. And also through the report that organizations receive after the on-site survey visit as guidelines for action

7 Competencias claves en materia de seguridad de los pacientes
Aplicar los conocimientos, valores y aptitudes claves en el trabajo cotidiano Trabajar en equipos Comunicarse de manera eficaz Identificar eventos adversos, darles respuesta, reportarlos y darlos a conocer Say: Over the next 2 days we will discuss many aspects of patient safety. As we start to look at the link to accreditation, I’d like you to consider four key competencies that we believe are central to organizational success with patient safety. Applying knowledge to everyday work: the knowledge, skills and values we discuss over the next couple days will only be really successful if the are integrated into your day to day work. I’d like you to consider ways you can integrate everything you learn during this course to your everyday work. Working together: patient safety is best improved by improving teamwork. Again, as we move forward, consider how you can share what you learn with your teams, and improve how you work together with others. Communication: communication within and between teams is essential for accreditation and improvement of patient safety. Consider how you can communicate what we learn with others in your organization. Recognizing, responding to, reporting, and disclosing adverse events: we will discuss how to improve patient safety culture in your organization, including responding to adverse events in great detail over the next two days.

8 Competencias para el trabajo en equipos
Exercise 1 – Team Competencies (15 minutes) Objective: To identify learning goals related to teamwork competencies. Length: 15 minutes Individually (7 minutes) Reflect on your personal learning goal for improving your teamwork competency. Refer to the attached tip sheet if you wish. Write down one strategy you can implement to help you improve this teamwork competency throughout this session. Write down one strategy you can employ after the session to share what you learned with other team members. As a table group (8 minutes) 4. Share your personal learning goal for improving teamwork competency. 5. Discuss how you can support each other to achieve these learning goals. 6. Be prepared to share back as a large group.

9 Equipos exitosos Claridad de objetivos Plan de trabajo
Funciones definidas Reglas bien establecidas Procedimientos claros para tomar decisiones

10 Equipos exitosos (2) Comunicación clara y abierta
Conductas beneficiosas para el equipo Participación equilibrada Respeto Uso de evidencia Evaluación

11 Dimensiones de la calidad
Participant Manual p. 7 DIMENSIONES ESLOGAN POBLACIÓN OBJECTIVO Trabajar con las comunidades para anticipar y satisfacer las necesidades. ACCESIBILIDAD La prestación de servicios oportunos y equitativos. SEGURIDAD Mantener a la gente a salvo. VIDA LABORAL Appoyar el bienestar en el entorno de trabajo. SERVICIOS CENTRADOS EN EL CLIENTE Poner los clientes y las familias en primer lugar. CONTINUIDAD DE LOS SERVICIOS Experimentar servicios coordinados y sin fisuras. EFICACIA Hacer los corrector para lograr los mejores resultados posibles. EFICIENCIA Hacer el mejor uso de los recursos. This slide is animated. Participants have this slide enlarged as a document in their manuals. Here is Accreditation Canada’s Quality Framework, which helps to guide the focus of all of our standards. There are 8 dimensions, found here on the left hand side column, each with its own tag line to help clarify what the dimension means. For example, “Safety” [click] has an icon, and a tag line that simply states “keeping people safe”. These quality dimensions are built into the standards and all the standards are tagged to a specific dimension of quality. Let’s see an example.

12 Estándar Participant Manual p. 8 This slide is animated SAY:
Here is a screen shot of the Managing Medications standard 5.0 and criteria 5.1 and 5.2 Since this standard is about clearly and legibly labeling all medications, it is directly related to patient safety. Therefore you can see the quality dimension icon [click] at the left hand side.

13 Ámbitos relacionados con la seguridad de los pacientes
Ejercicio 2 Participant Manual p. 8 Ámbitos relacionados con la seguridad de los pacientes Facilitator: Make sure that the participants go to their Exercise page for this moment and ask them to not come back to the slide section until the exercise is finished. SAY: Within patient safety topic, Accreditation Canada works with six main Patient Safety areas. They are Communications, Medication Use, Worklife, Safety Culture, Risk Assessment, and Infection Control. Exercise 2 Patient Safety Areas Total Time: 15 minutes Pairs (8 minutes) Ask the participants to get together in pairs and read the patient safety area title on the left hand column of the table in their exercise sheets. For each Patient Safety Area they should discuss what they think the goal is. They should write their answer in the right column. Change Pairs (7 minutes) Ask the participants to rotate pairs and compare their answers with the other person’s. They can revise their first ideas and complement each other. Note: The correct answers will be revealed in the next slides

14 Ámbitos de la seguridad de los pacientes
Participant Manual p. 9 Ámbito Objetivo Comunicación Mejorar la efectividad y la coordinación de la comunicación entre los prestadores y de éstos con los pacientes en el continuo de atención y cuidados. Uso de medicamentos Garantizar el uso seguro de los medicamentos de alto riesgo. Vida laboral Generar un ambiente de trabajo, incluido el entorno físico, que contribuya a la seguridad en la prestación de servicios. SAY: For Accreditation Canada, there are six (6) patient safety areas which are outlined for you on the next two slides. As you can see, for each patient safety area, there is an overall goal. We will refer to these Patient Safety Areas during the two days of this session.

15 Ámbitos de la seguridad de los pacientes (2)
Participant Manual p. 9 Ámbito Objetivo Cultura de la seguridad Generar una cultura de la seguridad dentro de la organización. Evaluación de riesgos Identificar los riesgos para la seguridad que son inherentes a los clientes de la organización. Control de infecciones Reducir el riesgo de infecciones asociadas a los servicios de salud y su impacto en el continuo de atención y cuidados. Facilitator: Ask the participants to check the answers from their Exercise 1 with this chart. Depending on time, ask different participants to read each of the Patient Safety Area Goals.

16 La seguridad de los pacientes en su organización
Participant Manual p. 9 La seguridad de los pacientes en su organización SAY: So now, lets start drawing some connections between these patient safety areas and your organization. But first lets do a small exercise to make sure that we are in the same page in terms of patient safety vocabulary Facilitator note: This section features the WHO report on the International Classification of Patient Safety Concepts – if you aren’t familiar with this framework, it would be advisable to review it before presenting this section.

17 Categorías relevantes en lo clínico
Tipo de evento Consecuencia para el paciente Cuasi evento Evento adverso Evento centinela Daño Magnitud del daño Tipo de evento y consecuencia para el paciente Say: In the diagram in your participant manual, you’ll notice that the WHO has grouped several concepts using different shapes. The concept groups represented by triangles are the “clinically meaningful” categories: Incident Type and Patient Outcome. Say: These categories include a number of terms that refer to the questions ‘what happened” and “what was the outcome”. Patient outcomes generally refer to harm or degree of harm. For example, harm could include physical impairment, disability, illness, suffering, or death. Say: You will also notice that these categories are highly related, with most incident types being defined by the patient outcome. For example, a near miss is an event that does not reach the patient, or reaches the patient but does not result in harm to the patient, whereas an adverse event does reach the patient and cause harm. Accreditation Canada also includes the term sentinel event (an adverse event that results in permanent disability or death) in the standards, as it has proven useful and meaningful to distinguish these incidents in the Canadian health system. Say: We’ll talk more about how incidents are defined in the standards and how you can interpret this. Ask: Does your organization use any specific terms to define incidents internally or externally? Facilitate a 5 minute discussion about incident related terms used by the organization. Take note of these so you can relate them to Accreditation Canada’s terminology to help relate them together.

18 Información descriptiva
Factores/peligros contribuyentes Ej. falla en el sistema Características del paciente Ej. diagnóstico primario Características del evento Ej. dónde y cuándo Say: The second major category I would like to look at includes terms that describe patient safety concepts. These are the concepts in the round ovals in the diagram. Say: These terms are especially useful when trying to understand a patient safety incident. Contributing factors, patient characteristics, incident characteristics and organizational outcomes all relate to information that will allow you to better understand how an incident occurred, and hopefully how it could be prevented in the future. Say: These are good concept categories to keep in mind when we discuss incident analysis tomorrow. Consecuencias para la organización Ej. mayor uso de recursos

19 Resiliencia sistémica
Detección Ej. alarmas Factores atenuantes Ej. barreras Acciones de mejoramiento Ej. informar Acciones para reducir riesgos Ej. análisis de causa raíz Say: Finally, the third major category of concepts identified by the WHO includes what they term “system resilience” Say: System resilience is a concept area that is related to predicting, mitigating, and responding to patient safety incidents. This can be at the level of detection, which is to say precautions that can help alert us that an event has happened, or about to happen; mitigating factors are precautions that are meant to help prevent an incident from reaching a patient, for example keeping high concentrations of electrolytes out of service areas to prevent overdose. Say: Once an incident has occurred, ameliorating actions are actions that help improve the situation for the patient. For example, disclosure of the incident and it’s known factors to the patient and family can significantly improve their feelings of safety, and ability to participate in the analysis to prevent the incident from happening again. Finally, actions to reduce risk typically include system changes, or analyses to discover causes of the incident. This might include incident analysis like root cause analysis after an incident, or different prospective analysis tools to prevent incidents. Say: You’ll see some of these terms come up this afternoon when we talk about safety culture, for example disclosure and barriers. And we’ll see others tomorrow when we look at the ROPs and incident analysis.

20 Ejercicio 3 Participant Manual p. 14 SAY: We will now give you a few minutes in your table groups to identify patient safety issues in your organization. We will also link them to the patient safety areas that we mentioned before. You should be specific and relate this exercise to any adverse events that may have happened in the past. EXERCISE 3 Patient Safety Issues in your organization Total Time: 30 minutes PART A In groups of three … (10 mins) Ask the participants to think of one or two patient safety issues that have happened in their organization related to any of the four patient safety areas that Accreditation Canada works with (Communication, Medication Use, Worklife, Safety Culture, Risk Assessment and Infection Control). Ask them to explain what happened and to list as many factors as they can think of that were involved in the incident. Facilitator: Please emphasize that this exercise is not to point fingers or make anybody feel uncomfortable. The point to make is that in every error or adverse event involving patient safety, there is usually more than one party involved. This exercise is also useful to identify which patient safety area tends to have the most failures when prioritizing action plans. IF the participants are still not comfortable in working with Patient Safety issues directly related to their organization, they can come up with any from previous experience even if it doesn’t relate to their current workplace. As a large group… (10 minutes) Prepare a flipchart entitled: “Issues in Patient Safety Areas” that will have the name of the 6 patient safety areas in a list (Communication, Medication Use, Worklife, Safety Culture, Risk Assessment, Infection Control). While one facilitator asks a few of the groups to share their answers with the larger group, the other facilitator will write a dot next to the patient safety area that each of the groups mention in their examples. When you are coming close to the 8th minute of sharing with the larger group different examples, draw the group’s attention back to the flipchart and let the participants know how many mentions of each patient safety area are there. Ask them why they think this information important. Answer: This is baseline information to create and collect patient safety indicators, to prioritize action plans, and to increase awareness among staff when working on safety culture that you will talk about shortly. Stop the exercise here. You will come back to PART B in slide 38. Identificar problemas relacionados con la seguridad de los pacientes en su organización

21 Estudio de caso Paciente masculino de 53 años Historial: diabetes
Participant Manual p. 10 Paciente masculino de 53 años Historial: diabetes derrame cerebral infección por estafilococo aureus resistente a la medicación úlceras en las piernas insuficiencia cardíaca Ingresado para tratamiento de ulceraciones y celulitis en ambas piernas SAY: Let’s work now with a case scenario to link the patient safety areas that we just covered with everyday life in health care organizations: The patient is a 53-year-old male with a history of diabetes, stroke, drug resistant staphylococcus aureus infection, leg ulcers, and heart failure, who was admitted for treatment of ulcerations and cellulitis of both legs. next

22 Estudio de caso (2) No responde al tratamiento
Participant Manual p. 11 No responde al tratamiento Desarrolla isquemia distal bilateral peor en pierna derecha gangrena en pierna derecha Cirugía programada amputación a la altura de la rodilla pierna derecha SAY: The patient failed to respond to the treatment regimen and developed distal ischemia bilaterally, worse in the right lower extremity than in the left. With the development of gangrene in the right lower extremity, the patient was scheduled for a below-the-knee amputation on the right side. next

23 Estudio de caso (3) Preparación quirúrgica: Al momento de la cirugía:
Participant Manual p. 11 Preparación quirúrgica: El cirujano marcó la pierna derecha con X Al momento de la cirugía: Pierna derecha cubierta Pierna izquierda preparada con gasa para la operación SAY: Prior to the surgery, the surgeon had marked the right lower extremity with an “X.” At the time of surgery, the patient’s right lower extremity was covered, and the left lower extremity was draped for the surgery. (This entire explanation ignores the concept that teams and systems have within them latent factors that produce hazards). next

24 Estudio de caso (4) Explicación del cirujano:
Participant Manual p. 12 Explicación del cirujano: Pensó que había marcado la extremidad que correspondía operar No encontró la “X” en la pierna izquierda y la derecha estaba cubierta El cirujano amputó la pierna izquierda a la altura de la rodilla SAY: Although the surgeon thought he had marked the appropriate limb preoperatively, he did not find the “X” on the left limb, and the right limb was covered. The surgeon proceeded with a below-the-knee amputation of the left lower extremity. next

25 Estudio de caso (5) Error descubierto en postoperatorio
Participant Manual p. 12 Error descubierto en postoperatorio Se amputó también la pierna derecha a la altura de la rodilla El paciente termina doblemente amputado SAY: Postoperatively the error was discovered. The patient underwent a below-the-knee amputation of the right lower extremity and became a double amputee.

26 ¿Qué fue lo que se hizo mal?
Participant Manual p. 13 ¿Qué fue lo que se hizo mal? ASK: So, what went wrong? Collect a few answers. SAY: This description has been completely physician centric and didn’t explain how the nurses covered the wrong leg, what happened with the orderlies who moved the patient, what the anesthesiologist was doing, how the supply technician puts the pens used to draw the Xs into the pre-op area, who thought up the policy of Xs to begin with, what happened with the surgeons training in that hospital, etcetera.

27 Participant Manual p. 14 La seguridad requiere nuevos modos de pensar y de actuar y el compromiso de transformarla en prioridad por parte de TODOS los niveles de la organización SAY: Back to the health care sector, safety requires a commitment from everyone in the organization. The organization has to undergo changes, which will not be easy in all cases and systems but everyone needs to make patient safety a priority.

28 ¿Por qué ocurren los errores?
Participant Manual p. 15 Factores sistémicos Factores humanos This is an animated slide SAY: Well, the first step for increased patient safety is to identify the issues. The second step is to identify the reasons why errors occur. ASK: What are some reasons why errors occur in your organizations? (remember, no blaming! Objective reasons.) collect a few answers So we have [click] System Factors and [click] Human Factors. System factors [click] Read the bullets and comment if any if you have experience or anecdotes that relate Human factors [click] If an Adverse Event occurs, 70-80% of the time there is a human factor involved. We need to apply knowledge about human factors to the development of systems, interfaces and work environments (Croskerry) Many errors (eg., diagnostic errors) are largely cognitive errors Read the human factors column and again, if you have any anecdote related, please share it with the participants Lets take a look at some examples. I will present you the issue and you tell me if it is a human or a system factor for an error to occur. And then let’s see which of the four patient safety areas it falls under. Conocimientos insuficientes Conocimientos mal aplicados Trabajo en equipo no alcanza niveles óptimos Fatiga Distracciones Falta de capacitación Confiar en la memoria Escritura ininteligible Complejidad de los procesos de atención y cuidados de la salud Complejidad de los ambientes de trabajo Falta de coherencia y uniformidad en las prácticas de gestión Mantenimiento diferido Tecnología inadecuada

29 Personal cansado/recargado de trabajo
Participant Manual p. 15 This slide is animated ASK: Tired and overworked staff, is it a human or system factor? – wait for an answer from the participants- Answer: HUMAN. Which patient safety area does it belong to? [click] Answer: WORKLIFE Ámbito de la seguridad: Vida laboral

30 ¿Letra o número? Comunicación Ámbito de la seguridad:
Participant Manual p. 16 This slide is animated ASK: What about this hand-writing? – wait for an answer from the participants- Answer: HUMAN. Which patient safety area does it belong to? [click] Answer: COMMUNICATION Comunicación Ámbito de la seguridad:

31 Medicamentos distintos en envases parecidos
Participant Manual p. 16 This slide is animated ASK: Look-alike drug packaging? – wait for an answer from the participants- Answer: SYSTEM Which patient safety area does it belong to? [click] Answer: MEDICATION USE Uso de medicamentos Ámbito de la seguridad

32 Comunicación Ámbito de la seguridad Participant Manual p. 17
This slide is animated ASK: Miniature text in packaging – wait for an answer from the participants- Answer: SYSTEM Which patient safety area does it belong to? [click] Answer: COMMUNICATION If any question about why communication: refer to the Patient Safety areas goals and communication states: “Improve the effectiveness and coordination of communication among providers and with the recipients of services across the continuum” That small print is definitely not being effective in transmitting whatever is written there to all patients or care providers. Comunicación Ámbito de la seguridad

33 Vida laboral Ámbito de la seguridad: Participant Manual p. 17
This slide is animated ASK: Messy medicines cabinet? – wait for an answer from the participants- Answer: SYSTEM Which patient safety area does it belong to? [click] Answer: Worklife If any question about why worklife: refer to the Patient Safety areas goals and work life states: “”Create a worklife and physical environment that supports the safe delivery of services”. Note: This could be also HUMAN if the people in charge of organizing the meds are too tired or rushed to do so. As we said before, it is never only one reason. Ámbito de la seguridad: Vida laboral

34 Capas sucesivas de defensas
Modelo del queso suizo Participant Manual p. 18 Algunos agujeros debidos a fallas activas Tell participants that a full page version of this slide can be found in the Participants Manual. SAY: This slide depicts what psychologist James Reason calls a “Swiss cheese model” of defenses and barriers in the pathway from the commission of an error to a potential adverse event.* Every step in a process has the potential for failure, to varying degrees. In this model, the ideal system is compared to a stack of slices of Swiss cheese. The holes are opportunities for a process to fail, and each of the slices is a “defensive layer” in the process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a defense against potential error impacting the outcome. Every now and then, an accident occurs – for this to happen, the holes need to line up for each step in the process allowing all defenses to be defeated. Each slice of cheese is an opportunity to stop an error. The more defenses you put up, the better. Also the fewer the holes and the smaller the holes, the more likely you are to catch errors that may occur. (* This model also has been elaborated by Richard Cook of the Cognitive Technologies Laboratory at the University of Chicago.) Sources: Reason J. Human errors: Models and management. BMJ 2000; 320: PELIGROS Otros agujeros debidos a condiciones latentes Capas sucesivas de defensas

35 (se recetó el medicamento incorrecto) Evento adverso evitado
Al filo de la navaja Participant Manual p. 19 Disparador (se recetó el medicamento incorrecto) 1a. Línea de defensa (enfermera/o distraída/o) Falla latente (escaso personal) 2a. Línea de defensa (farmacia) Falla latente (no hay seguimiento de Rx) 3a. Línea de defensa (enfermera/o atenta/o) SAY: In this example, the trigger is a prescribing error. The first nurse is distracted because the unit is understaffed, and the pharmacy doesn’t pick up the error because there’s no tracking system. However, at the third (bottom) defense barrier, a vigilant nurse detects the error and the adverse event is averted. Falla latente (escaso personal) Evento adverso evitado Fuentes: Reason J. Error humano: Modelos y gestión, BMJ, 18 de marzo de Cook R. Universidad de Chicago,

36 No se trata de saber Quién causó el accidente, sino Qué lo causó.
Participant Manual p. 19 No se trata de saber Quién causó el accidente, sino Qué lo causó. Read the slide EXERCISE 2 Patient Safety Issues in your organization PART B (10 minutes) Ask the participants to go back to their Exercise 2 sheets to Part B. They should select one of the examples that they worked on and identify the different layers of factors that contributed for the error happening. Ask them to specify if those factors were system or human-related and if possible also the patient safety area that they refer to. Encourage the participants to go back to slide 37 as an example if need be. Collect a couple of examples to share with the large group. Let the participants know that this exercise is a tool that they can take back to their workplaces to use with their colleagues for awareness purposes and to engage everybody in continuous quality improvement. Remind them: The point is not to find who to blame, but to identify factors and address them. “Los errores médicos resultan habitualmente de la interacción compleja de múltiples factores. Rara vez se deben a la falta de cuidado o la inconducta de tal o cual persona.” Lucien L. Leape, M.D.

37 Eventos adversos Participant Manual: p. 26 La falibilidad (capacidad de errar) es parte de la condición humana No podemos cambiar la condición humana, pero sí podemos cambiar las condiciones en que trabajan las personas y las condiciones bajo las cuales los pacientes son atendidos Di: Ésta es una cita de James Reason, profesor de la Universidad de Manchester: lectura de diapositivas ... Di: Una vez más se está revisando la idea de revitalizar la cultura. Diapositiva siguiente ...

38 La cultura de la seguridad
Participant Manual p. 20 La cultura de la seguridad Large group brainstorm ASK: What is the meaning of culture? Collect some keywords and write them on a flipchart entitled: CULTURE Remind the participants not to worry about word-smithing but instead to come to a general agreement about what culture is. Next Slide…

39 ¿Qué es la cultura? Es el conjunto de actitudes, valores, objetivos y prácticas compartidos que caracterizan a una institución, a una organización o a un grupo. SAY: What about this definition of culture? Can we agree that this is representative of culture? Simply put, culture is a shared understanding of “how we do things around here”, it is reflected in values, beliefs, assumptions, rituals, language, and myths. It also strongly affects behaviour. Another definition of culture might be “The choices we make without knowing they are choices.” The reason we spend so much time focusing on Safety Culture is because by reflecting on these unconscious decisions we may be able to identify areas where we can improve outcomes for patients. Next Slide…

40 La aspiración de Accreditation Canada
Crear una cultura de la seguridad en su organización SAY: This is Accreditation Canada’s expectation, but you may be asking yourself what is the connection between Safety Culture and the accreditation process. The purpose of the accreditation process is to commit to improving the quality of health care. In order to do so, accreditation will assist us and guide us through a process that will allow us to identify what the gaps are in our organization and how we can put in place systems to help us improve our services and close our gaps. Having said that, throughout the accreditation process you may identify policies and procedures that need to be outlined or implemented. While you and your organization may feel that implementing a particular policy is very important, you may never know to what extent the policy is really implemented throughout the organization. The key to understanding whether a policy is successfully put into action is understanding the culture underlying the inner workings of your organization. Is the staff aware of the new policy? Does the staff understand the policy? Does the staff agree with the new policy? Is the policy a priority for everyone? Will they want to comply with it as they go through their day? The answers to these questions are all greatly affected by the culture in your organization. Next Slide…

41 Usted cometió un error Problema evitado ¿Se notará? ¿Puede ocultarlo?
Ocúltelo antes de que nadie sepa Sí Sí Tápelo No Problema evitado Sí ¿Puede culpar a alguien más o a las circunstancias? No This is an animated slide, with the various points of the flow chart ;logically appearing as blocks at the control of your mouse. PLEASE practice the clicks on this slide before presenting to the group. SAY: Here’s an example of a common situation in healthcare. This slide and the next show two very different ways that someone faced with having made a mistake could approach the problem. As I go through the slides, pay attention to what choices the person considers, and which choices the person does not consider. Go through the whole animation. SAY: Of course, this is a bit of a caricature, but sadly, this is what happens in many organizations. We need to change this; however the change is one that must happen at the level of culture. ASK: What stood out to you about the questions the person asked himself? Expected answers: The person was only concerned with his image. The questions all wondered about the personal implications. The culture centred around who was at fault SAY: This scenario is one taking place in a culture of blame, where the only things the person considers is who is at fault, and how that will reflect on him. Contrast this scenario, with the next one…link to next slide. Next Slide… ¿La admisión del error puede dañar su carrera? No Sea el primero en dar su versión Siéntese a esperar que pase el problema Sí

42 Usted cometió un error Problema resuelto
Hágase cargo del problema y evalué las posibles consecuencias Corríjalo e informe a las personas afectadas Investigue por qué ocurrió el error Dígale de inmediato a un superior Coopere pare corregir el error y revisar los procedimientos Comparta su hallazgo y mejore el proceso Busque aprender de su error Usted cometió un error Sí ¿Pueden ser graves? No ¿Hay una falla en el sistema? Problema resuelto Say: Here we have a very different approach to the same problem. ASK: What differences do you notice about the questions the person asks herself in this example? Expected responses: The questions focus on the impact on the patient The focus is on how to prevent the same mistake from happening again Say: A system based on a culture of safety would look like this! That’s a hugely different paradigm! The questions that the person asks when making decisions are completely different in this case – and will lead to much better outcomes for patients as the organization learns from mistakes. Say: The fundamental difference here is truly culture. In a culture of blame, the options that are seemingly available to the person are completely different than those available in a culture focused on patient safety. This is the reason we devote so much focus to safety culture. Culture make it more or less likely that people consider certain options. If options that favour patient safety aren’t supported by an organization’s culture, you’re unlikely to see behaviours that favour patient safety. Next slide… 18

43 Una cultura de la seguridad…
… requiere nuevos modos de pensar y de actuar y un compromiso de hacer de la seguridad una prioridad por parte de todos los niveles de la organización. Say: Safety requires a commitment from everyone in the organization. The organization has to undergo changes, which will not be easy in all cases and systems but everyone needs to make patient safety a priority. Say: Here’s a quote from Don Berwick, former President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI) and current Administrator of the Centers for Medicare & Medicaid Services (CMS): “Improving safety is hard, not easy. A hospital that wants to make patients truly safer has to involve almost all departments, support systems and patterns of activity. Dozens of habitual systems have to change: rounds, record-keeping, meetings, training programs, policy manuals and review procedures, to name but a few….” Donald Berwick, editorial in The Washington Post, July 29, 2003 Next Slide…

44 La cultura de la seguridad
“Uno no cambia culturas – uno revitaliza culturas existentes. No se puede tomar una compañía que ha existido por años y simplemente evacuar su cultura y gotearle una nueva en su lugar. Lo que uno hace es recuperar la energía que todavía hay allí.” ( Henry Mintzberg, citado por The Globe & Mail, el 30 de octubre de 2007, página B2). “La cultura, que es de verdad el componente más intangible de cualquier organización, puede considerarse como la base de apoyo para introducir mejoras en la calidad y la seguridad.” Dr. Graham Lowe SAY: Welcome back! I hope you had a good break! Because we know that sometimes after lunch one feels like having a nap, we are going to continue our conversation about safety culture right away with a hands-on exercise. However before we do, I want to share with you a couple of words to re-introduce the topic of safety culture to you. Read slide quotes or ask one of the participants to read them for the group.

45 PARTE A: Moldeando una cultura de la seguridad “ideal”
Ejercicio 4 EXERCISE 3: Shaping the Ideal Safety Culture PART A Part manual pg. 72 PARTE A: Moldeando una cultura de la seguridad “ideal” EXERCISE 4: Shaping the “Ideal” Safety Culture Time: 60 minutes Facilitator: Create 2 identical flipcharts with a model of the ladder diagram for the participants as visual aid (Please see facilitator exercise sheet for reference) PART A (30 minutes) – although the time assigned is 25 minutes, there are 5 extra minutes as buffer. Ask the participants to brainstorm characteristics of their ideal safety culture. (i.e. no blame culture, good communication, no silos, staff engagement at all levels, teamwork, use of root cause analysis, etc). The other facilitator will write these keywords/ideas on a flipchart. (5 minutes) Let the participants know that for the sake of this exercise, you will select two of these characteristics. Write one of those 2 characteristics at the top of the ladder on one of the flipcharts as the goal to reach, and the other characteristic at the top of the other ladder flipchart. Divide the large group in two and assign each half to recreate one of the flipcharts at the front in their exercise sheet (they have the ladder diagram there already) portraying a characteristic of safety culture as the goal. Ask them to brainstorm ideas on how could that characteristic be achieved in their organizations. Ask the participants to write each of those ideas as one of their ladder rungs. (10 minutes) 4. Randomly select a few people from each half of the group and ask them for one of their ideas. Write them in each of the stair’s rungs as steps to achieve their ideal safety culture. Write their answers in your front sample flipchart rungs. (10 minutes) SAY: This is a technique that you can use within your departments to engage all levels of staff with culture building. Remember that staff will be more committed to cultural change if they are involved in the process as opposed as if they are imposed new ways of behaving or doing things. This ladder is a nice way to begin developing action plans in your teams. Where are we now? (we are in the bottom rung of the ladder) Where do we want to be? (in the top rung of the ladder). What steps do we need to put in place to move us in that direction? Link with next slide (PART B: Slide 53 )

46 Plan de mejora de la calidad
Ámbito de mejora/ problema Acciones críticas a ejecutar Personas involucradas Objetivo (plazo) Responsable Instrumentos de evaluación Resultados Próximos pasos SAY: Each rung at your ladder in the previous exercise is an action that could be moved to a template like this. A Quality Improvement plan is a tool that Accreditation Canada recommends to its client organizations to use in order to document QI strategies and monitor progress. Lets go through each of the columns. Area of Improvement / Issue: As the name says, is the area that needs attention in order to achieve QI Critical Actions to Take: Steps or actions to put in place in order to achieve the goals proposed in column 4 People involved: Refers to who is going to develop those critical actions to take. Who is involved and who does which task Goal: Objective of the strategy in order to improve the issue on column one. The date is very important since it is very easy to have a “to do” list and never go through it Responsibility: Is not the same thing as people involved. This column refers to the person(s) who are accountable for the strategy to work as it is supposed to. It is usually the person(s) above in hierarchy from the people involved, managers, coordinators, or leadership representatives. Evaluation Tools: Performance measurements that will provide evidence of success or failure. We will explore them today after lunch Results: This column is to record the results of your critical actions. These results are the ones you will evaluate in order to decide… Next steps: You either implement this strategy, revise it, or discard it.

47 Plan de mejora de la calidad (2)
DOCUMENT: QI Plan sample Part manual pg. 103 Ámbito de mejora/ problema Acciones críticas a ejecutar Personas involucradas Objetivo (plazo) Responsable Instrumentos de evaluación Resultados Próximos pasos Mejorar la comunica-ción entre departa-mentos This slide is animated This slide is also available at the participant manual’s documentation section SAY: Lets link the quality improvement plan with the previous exercise that we worked with about safety culture. In our efforts to build a culture of safety, lets pretend that one of the goals that we have at the top of our ladder is to Improve communication among departments [click] . Your critical actions to take will include [click] to run inter-departmental workshops on safety culture The people involved [click] in the initiative will be Departments X, Y, and Z who will participate in the workshops, and Human Resources who will organize the workshops. There are two goals [click] to be achieved in 3 months: 1) is to increase cooperation in patient safety practices among departments, and 2) to break departmental silos. The responsible [click] for this particular action to take is the director of HR. Please note that he/she might not be attending or preparing the workshops personally, but he/she is in charge on making them happen. The evaluation tools [click] will be indicators (eg. how many inter-departmental initiatives related to safety culture have been developed before/after the workshops), and more qualitative collection tools such as interviews with staff from departments X,Y,Z. Results [click] will come after three months of course, lets pretend that here the results is that 2 new initiatives related to safety culture have been put in place with inter-departmental collaboration: a poster campaign and a checklist for running root cause analysis on medical errors. So the next steps [click] will be maybe to keep running those workshops twice a year, and any other that you can think about? Facilitator: Depending on the time and group’s mood, they can practice coming out with a QI Plan based on the ladder’s exercise or they can take it back to apply in their own departments. Realizar un taller interdepar-tamental sobre cultura de la seguridad Departa-mentos X, Y, Z Recursos Humanos Aumentar la cooperación en materia de seguridad entre los departa- mentos Romper los silos depar- tamentales (3 meses) Director de Recursos Humanos En tres meses, dos nuevas iniciativas sobre seguridad en vigor, con participa- ción de los tres depar- tamentos Talleres bianuales ¿Algo más? Indicadores Entrevistas con el personal

48 Ahora es su turno EXERCISE 3: Steps to an Ideal Safety Culture PART B Part manual pg. 74 PARTE B: Plan de mejora de la cultura de la seguridad Ámbito de mejora/ problema Acciones críticas a ejecutar Personas involucradas Objetivo (plazo) Responsable Instrumentos de evaluación Resultados Próximos pasos SAY: Now it is your turn to practice the development of Quality Improvement Plans. EXERCISE 4: Shaping the Ideal Safety Culture PART B (30 minutes) Facilitator: Pick a different rung of any of the two ladders you worked with in PART A of the exercise. Ask the participants to develop a QI plan for it with the template they have in their exercise sheets. 1. In small groups (no more than 4 participants)ask the participants to develop a quality improvement plan for the other initiative that you have assigned them from the sample flipchart ladder:_________________________ . Note that all the participants should be working on the same area for improvement so at the end of the exercise when you bring the group back to do it together, everybody is working on the same topic and they can complement each others’ ideas on the same initiative. (20 minutes) 2. Bring the large group together and ask a few small groups for their ideas on each column. The rest of the group can complement their own QI plans. (10 minutes)

49 Impulsores de la calidad y la seguridad
Trabajo en equipos Procesos justos Supervisión basada en el apoyo Buen liderazgo de los recursos humanos Un ambiente que favorezca el aprendizaje Los pacientes Y los empleados salen favorecidos… Se reduce el riesgo de errores Mejora la calidad del servicio Mejoran los resultados de Recursos Humanos Mejora la calidad de la vida laboral SAY: Let’s look at some of the drivers of quality and safety. These drivers were identified by Dr. Lowe through his research in safety cultures with the Health Sciences Association of Alberta (HSAA). He identified five major areas that drive safety culture in organizations, and they are listed in order of importance here: The first one here is Teamwork. Here we are looking at indicators such as; my co-workers are helpful and friendly, My co-workers treat me with respect, Communication is good among the people I work with, there is a high level of interdisciplinary collaboration, Fair Processes. The indicators here are for example, rules and policies are fairly applied, rules and policies are consistently applied, rules and policies are consistently applied, the hiring and competition process is fair, rules and policies make sense, work is assigned fairly and equitably Supportive Supervisor. Some of the indicators here can be listens to and acts upon your suggestions and ideas, encourages teamwork, encourages you to be innovative in how you do your job, supports your career development, provides timely and constructive feedback on your job performance, helps you achieve worklife balance. People Leadership. Examples of these indicators are actively seek employees’ ideas about how to do things better, take employees’ interests into account when planning changes, make employees feel valued for the contributions they make to patients and clients, effectively communicate to employees about changes that will affect them. Learning Environment. Take initiative in your job, learn new ways to do your job better, feel that you fully contribute your skills, knowledge, and abilities. SAY: You may notice an important link here between safety culture and worklife. There is a strong positive relationship between developing a positive work environment where staff have a quality worklife, and safety culture that results in improved outcomes for patients. All of these elements will provide you with a situation where both patients and employees win… you get reduced risk of errors, improved service quality, improved HR outcomes, improved quality of worklife. If you are building a safety culture you are building a high-level of quality.

50 Evaluando la cultura de la seguridad
“Si alguien que trabaja en su mismo sector comete un error que pone un paciente o cliente en riesgo, qué probabilidad hay de que…” El error sea reportado – 33.8% El equipo aprenda del error – 36.1% Sus colegas tomen las medidas necesarias para que no se repita – 35.7% La gerencia tome los recaudos necesarios para que no se repita – 33% Say: In terms of assessing safety culture in an organization, we have a number of tools. For example, surveys are effective at capturing data related to organizational culture. Dr. Lowe shared some results from a survey he did with the HSAA (Health Sciences Association of Alberta). He surveyed 12,000 members of the HSAA, asking a number of questions that began with “If someone working in your area made an error that put a patient or client’s safety at risk, how likely is it that…” and inserting the endings you see on the screen. On the screen you can also see the results: …the error would be reported: 33.8% said this would be very likely while 9.6% said very unlikely …the team would learn from mistake: 36.1% said very likely while 5.8% said unlikely …co-workers would take appropriate action to ensure it did not happen again: 35.7% very likely, 4.6% unlikely …management would take appropriate action to ensure it did not happen again: 33% very likely, 8.9% unlikely Say: Without commenting too much on the statistics themselves, you can see how this could be an effective measure of staff perceptions of the culture in their areas. Moreover, if similar questions are worked into surveys that you already conduct with your staff, this can be an effective way of measuring changes in these perceptions over time. Say: Another important point to stress is that many of the drivers of safety culture that we saw on the previous slide are also easily measureable indicators of safety culture. We saw that teamwork was an important driver of safety culture to improve, and this can be measured by capturing indicators such as whether people are treated with respect, the quality of communication, opportunities to discuss professional practice issues, etc. This goes for all five drivers of safety culture identified by Dr. Lowe. Say: Moreover, I cannot stress enough that you can’t simply take one of these areas as representative of “the safety culture” in your organization. These drivers build off one another, so it is very important that if you are attempting to assess safety culture that you select a variety of indicators that capture the full range of drivers seen on the last slide, as well as the perceptions of desired outcomes that you see here. This will give you a better idea of the whole picture, as well as highlight specific areas that might be dragging others. Next slide… 50

51 ¿Tiene su organización una cultura de la seguridad?
Ejercicio 5 EXERCISE 4: Does your Organization have a Safety Culture? Part manual pg. 75 ¿Tiene su organización una cultura de la seguridad? Exercise 5 Does your organization have a safety culture? TOTAL TIME : 30 minutes Flipcharts: For 1-30 participants , use 5 flipcharts: one for each of the drivers of safety culture as title. For participants, use 10 flipcharts: two for each of the drivers of safety culture as title. Post them on the walls, leaving as much room between one and another as possible. SAY: So now that we have had the chance to look at safety culture from the point of view of its importance and its drivers, we’re going to do an exercise to get you thinking about how you can assess safety culture in your own organizations. This exercise is designed to work as a job aid for you. What that means is that you will be able to collaborate on it with other members of your sector and cross sector to develop questions that you could use in your organization to assess safety culture. It is just another tool similar to the ladder exercise, that you can use to get an idea of which areas (safety culture drivers in this case) require priority to address. For some of you it may be a way of determining what the safety culture looks like in your organization and start your quality improvement plans from there. Facilitator Instructions If the group is 1-30 participants, divide the large group into five smaller groups. If the group is participants, divide the large group into 10 smaller groups. Assign one small group to each of the flipcharts posted on the wall. Explain the instructions for parts A and B – one a the time-. Instructions for Participants: Part A: Brainstorming (15mins) 1. With your group, move to the flipchart you have been assigned. 2. Brainstorm 3 or more questions that you could use to assess to what extent the staff in your organization perceives this driver to be in place. Write them on the flipchart on the wall, right under the title. i.e. Supportive Supervisor: 1) do you feel comfortable talking to your supervisor about your work-load and projects? 2) does your supervisor know your strengths and weaknesses and provide you with constructive feedback on your work? 3)if an adverse event happens, would you consider your supervisor as one of the first persons to inform? 3. Take a moment to read the questions developed by other groups. Part B: Developing a Questionnaire (10mins) 1. Once you have read the other flipcharts, work with your group to put together a questionnaire with 5-10 questions that would assess safety culture in your organization (with ideas from the flipcharts working with different drivers). 2. You may use questions developed by other groups. Be sure to pick questions relevant to your organization. Once the groups have finished their questionnaires, return to the large group. Ask: “What did you notice about developing questions to assess culture?” Expected responses: Different cultures in the organization might mean you have to ask the questions in different ways; Different indicators are more important for different organizations; It’s difficult to phrase the question so that it’s getting at the right aspect of culture; To get at culture you really need to talk to the people; etc… Ask: “Were there any differences you found as you tried to make your questionnaires specific to your organization?” Expected responses: Different types of organizations focused on different drivers; Even in the same sector, different organizations had different concerns; etc… 51

52 Cerrar la brecha Hacer de la cultura de la seguridad una responsabilidad compartida Los líderes deben crear las condiciones para una cultura de la seguridad y promoverla Apoyarse en los valores de su gente Crear una visión convincente de la calidad Integrar y coordinar todas las iniciativas sobre calidad SAY: All these exercises we have gone through during the afternoon are to help gain insight on what your organization is thinking and what the feelings or perceptions of safety culture are. Only then, once you gain this insight, can you move forward in either revitalizing the culture or making the shift. And so if we look at closing the gap, these are the 5 things that need to be there. We need to look at quality not just as a global outcome but also a quality of work life & work quality. You’ll notice here again the essential link between culture and quality worklife. Next Slide…

53 Liderazgo y cultura de la seguridad
¿Qué pueden hacer los gerentes y directivos para promover y mantener una cultura de la calidad? ¿Qué estrategias puede usar usted para involucrar a la alta gerencia en la promoción de la seguridad de los pacientes? SAY: I’d like to focus on the role of leaders for a moment. As we just saw, leaders in the organization must drive changes in culture. SAY: Unless leaders are committed to making sure that your organization is safety-centered, a culture of safety will not develop or be improved. We want 100% of respondents to strongly agree with one of Accreditation Canada’s safety climate survey tool statement “Senior management provides a climate that promotes patient safety”. Ask the first two questions on the slide: Direct the question first to Leaders (such as Board Members, Senior leaders, Managers, etc.), then open them up to others. Say: The goal is that all see safety as a priority, and understand that they have a role in creating and maintaining a safety culture. Group discussion. (5 mins) Ask : What strategies could you use as senior leaders in your organization to promote patient safety? What has worked for you? Next Slide…

54 Herramientas para liderar una cultura de la seguridad
Lecturas estructuradas Foros de discusión de lecciones aprendidas Designación de “campeones” de la seguridad Personal o equipos responsables de la seguridad de los pacientes Recorridos informales por los servicios y charlas espontáneas de los líderes con el personal Encuestas sobre la cultura organizacional SAY: Here are some other tools you could consider to leverage your position as a leader to help make patient safety a priority throughout the organization. Allow a few moments for participants to read the slide. ASK: What stands out for you on this list? Why? Collect a few answers Are any of these practices currently in place in your organization? Collect some answers Ask: How would you implement some of these suggestions in your organization? Collect some answers Most of these suggestions aim to demonstrate not just that you want people to do something, but that you want to engage your staff as well. Next Slide…

55 Etapas para garantizar la seguridad de los pacientes
Desarrollar y apoyar los principios de la seguridad de los pacientes Identificar las personas claves que deben involucrarse en el proceso Determinar pasos y actividades para elaborar e implementar el plan de seguridad de los pacientes Promover e implementar mejoras constantes a la seguridad de los pacientes SAY: Here are a few more tips for you to ensure Patient Safety involving the different topics we covered today Read the slide