Closing the loop to celebrate our successes

The Hand Hygiene kiosk at the CIUSSS Safety Fair, held at Jewish General Hospital. From left: Helen Kondylis, Assistant Head Nurse; and Marilyn Mahone, Head of Emergency Response and Civil Security.

Have you really seen your project through if you haven’t closed the loop?

It is important to celebrate and reflect back on our accomplishments before moving forward to the next phase of a project or a new one, says Chantal Bellerose, Coordinator of Quality, Risk Management, Accreditation, Clinical Ethics and Patient Experience.

Closing the loop, she explains, is the purpose of the annual CIUSSS West-Central Montreal Safety Fair, where kiosks are set up to publicize the progress and results of safety and quality initiatives, as part of Safety Week celebrations.

Members of the Quality teams at the CIUSSS Safety Fair Patient Experience kiosk, held at the Jewish General Hospital. From left: Elisabet Serra, Clinical Activities Specialist for Quality, Evaluation, Performance, Ethics and Archives; Chantal Bellerose, Coordinator of Quality, Risk Management, Accreditation and Patient Experience; Larry Berlin, Patient Partner; Sophie Leduc, Clinical Activities Specialist for Quality, Risk Management and User Experience; Lora Socciarelli, Patient Partner; Paula Calestagne, Patient Experience, Quality and Safety Advisor; Anne Desmarais, Nursing Consultant for Infection Prevention and Control; and Lianne Dzygala, Chief of Quality and Risk Management for the Acute Care sector.

“All year, we work hard to report any incidents or accidents, as well as compile our extensive data,” notes Ms. Bellerose.  “We identify risks and put in place measures to keep users as safe as possible. Staff should be celebrated and thanked for their part in this process, because they truly make a difference.”

Staff share their projects not only with passersby but with each other, which can open the door to collaborations.

“These presentations give insight into the many activities that are ongoing in all of our CIUSSS sites,” says Ms. Bellerose, who is also the Associate CEO responsible for Support, Evaluation and Performance Programs. “It’s about spreading the knowledge about these initiatives, too, the Fair is a large learning event! When you return to your unit or your department afterwards, you’re inspired to do more, better, differently. The Fair brings staff and our partners together.”

“I enjoyed a series of wonderful encounters with competent and engaged staff,” remarked Linda Fortier, a CIUSSS West-Central Montreal board member who visited the exhibit. “Each kiosk takes you to a different universe, and each person is passionate about their project.”

Patient partners hosted a kiosk to raise awareness about their involvement with various CIUSSS quality and trajectory teams. Ms. Bellerose adds that the teams are always looking to increase their standards for measuring success, so that they can offer the best user experience possible. The results of user experience questionnaires, notes Ms. Bellerose, lead to improvements.

“We’re always raising the bar,” she says. “We can’t improve what we don’t measure.”

A sampling of the innovative practices and accomplishments of safety and quality teams

Hand Hygiene audits
Hand hygiene is considered the single most important way to reduce healthcare-associated infections and save lives. The best method for measuring compliance with accepted hand hygiene practices is to use direct observation or audits. The compliance target for the CIUSSS is 80 per cent. This year, rehabilitation centres have reached hand hygiene compliance rates of 88 per cent.     

Purposeful rounds program in SAPA long-term care
To reduce the incidence of falls, purposeful rounds was implemented in all seven long-term care sites to improve the safety of residents. These are structured, hourly rounds for residents at high risk of falling. A reduction of 100 falls was recorded from last fiscal year.

The Medication Safety kiosk at the CIUSSS Safety Fair, held at the Jewish General Hospital. From left: Sonia Boccardi, Senior Consultant in Nursing; Cendrella Mhanna, Quality intern; Elisabet Serra, Advisor, Quality Risks.

Medication safety for patients, families and staff
Staff should educate patients on their medications, and patients and families should be encouraged to ask questions about them. Rx Vigilance, an online resource for healthcare providers to look up pharmacological information, as well as medication information sheets for patients, has helped to increase engagement in medication safety.

JGH control measures
Ideal practice recommends minimal control measures, or restraints. The goal is to reduce the number of control measures used to three to four per cent in the hospital. So far, a decrease has been observed for physical restraints. Bedrail use posters have also been distributed.Over two hundred staff members have benefitted from monthly refresher courses on these topics.

Nursing Performance Measurement and Analysis
Graduate students in Nursing have aimed to reduce falls, and injuries from falls, by engaging nurses and PABs on the Medicine Care unit in continuous quality improvement. Staff have been asked to put forward ideas on the topic. Support from Medicine staff and leaders has been positive, and the next step is to implement workshops based on their ideas. 

Know your cytotoxic risks
To keep staff and patients safe from exposure to hazardous drugs, knowledge on proper use of Personal Protective Equipment (PPE) is crucial. The instructional pamphlet, Hazardous drugs and times for protective handling of patient exreta has been distributed to all CIUSSS sites.

Confidential information and private lives require protection. To bring awareness to cybersecurity and privacy, ongoing training and an awareness campaign have been put in place. To streamline the management of confidential information, medical records have been reorganized to improve the confidentiality of user experience when personal information is requested.

Optimization of IV practices
To optimize and harmonize intravenous-related practices, training and education on all infusion pumps is provided. Plum 360 and Sapphire & Sapphire Plus pumps, all with drug libraries, have been implemented. There has been a 99 per cent compliance rate for the Plum 360 drug library.

How to work safely
This initiative aims to promote a healthy and safe workplace to improve the well-being of staff, and educate them on optimal practices to achieve these goals. All CIUSSS sites have been inspected for indoor air quality. Coaching and training sessions have been organized for staff, including Principles for Moving Clients Safely for caregivers and Nonviolent Crisis Intervention Training.

Heightened safety measures to ensure safe care and intra-hospital transport of adult non-ventilated patients on oxygen
The goal is to develop hospital-wide processes and tools at the JGH for the safe care and transport of adult patients requiring therapeutic oxygen. Policies on the safe intra-hospital transport of adult non-ventilated patients on oxygen and a second on the safe handling have been developed. Various safety tools, including a guideline for safe handling, transport and storage of cylinders were developed. The next phase is to adapt these practices across the CIUSSS.

Safe identification of users
Education material has been created, including posters and a video, underlining the importance of identifiers. The goal is to improve practices both among staff and users.