To provide care within a safe and secure environment—it is one of the key values of our CIUSSS. When patient safety lapses do arise, it is the responsibility of the healthcare team—both clinical and non-clinical members—to handle the situation with professionalism.
An interactive, daylong workshop on patient safety recently offered at the Jewish General Hospital reminded staff to involve yet another vital player on their team.
“The patient should always have a voice, they are not just the recipient of a service,” speaker Mark Daly told participants, echoing the theme of the conference, Safety is Everybody’s Business: Applying and Teaching Patient Safety Competencies. To create the safest possible environment, the patient must be included as a fundamental part of the team, which means keeping them routinely updated, and engaging them in any decision-making related to their care.
Mr. Daly, who is Director of Faculty Development for the Office of Interprofessional Education at McGill University*, addressed other key characteristics of a strong team. He asked participants to propose attributes of an effective team leader. Audience members suggested they favour someone who is:
- A leader by example
- Guided by a clear vision
Mr. Daly agreed that a successful leader will clearly define the group’s goals, as well as assign tasks and adapt the patient’s care plan as necessary. He emphasized the importance of reviewing the team’s performance afterward—celebrating achievements, but also considering what may need to change to bring about improvement. “Feedback should be timely, respectful and specific,” he counseled workshop participants who were from CIUSSS West-Central Montreal, CIUSSS West Island Territory and the McGill University Health Centre.
Teams thrive in an environment of mutual support. “Are you creating a culture where staff are comfortable reaching out for help or speaking up when they run into a problem?” Mr. Daly pointed out that a secure environment for staff is a safer one for patients.
An interactive approach to patient safety
Throughout the workshop, participants worked in groups to discuss hypothetical patient safety scenarios, similar to ones they might experience on the job.
One scenario involved a female stroke patient with a low comprehension of French or English. She had been recently discharged home following a two-month stay in an intensive functional rehabilitation unit. Her speech was slurred to the extent that even her son had trouble understanding her. She lived alone, with her son 30 minutes away. The CLSC nurse determined she would receive 15 hours of care per week to assist her with activities such as bathing and laundry.
One morning, the woman had difficulty getting out of bed. Due to the language barrier and trouble communicating, she could not alert the CLSC worker who saw her later that day. That evening, after using the washroom, she was unable to get off the toilet, and remained there for 10 hours before her son found her.
Staff pointed to some of the safety hazards in the scenario that should have been addressed. “It’s not clear who’s managing this patient or who is the point of contact,” noted one participant. “There’s a lack of communication between the rehab and homecare teams, no continuity of care,” said another. “They neglected to identify the basic communication needs of the patient, there should have been a plan for an interpreter,” yet another suggested.
Working through patient safety dilemmas in a workshop setting can help staff be better prepared to deal with them in their workplace, indicated Mr. Daly.
“We want participants to understand how to address situations in a safe setting with us,” he says. “That way, when they’re in front of a patient or a colleague, they can apply some of the tools and ideas they picked up in the workshop.”
Teaching tools and techniques are available online for staff interested in learning more about patient safety concepts and, in turn, teaching colleagues.
*The workshop, based on a framework by the Canadian Patient Safety Institute, was organized by the McGill University offices of Faculty Development, Continuing Professional Development and Interprofessional Education, in collaboration with his CIUSSS West-Central, CIUSSS West-Island and MUHC partners.