Rethinking Patient Safety
- Topics
- Cultural Safety
- Aging in place
- Patient engagement
- Audience
Community organization
Healthcare leader
Point of care provider
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Safety is much more than the absence of harm
Strengthening patient safety is fundamental to excellent healthcare and has been a recognized priority in Canada for more than 20 years. Historically, patient safety efforts have focused mostly on measuring and responding to physical harm. However, safety is much more than the absence of harm. And as recent data show, we still have a way to go before we get there.
Globally, 10 percent of patients are harmed and over 3 million people die every year from healthcare, according to the World Health Organization. Closer to home, The Canadian Adverse Events study of 2004 found an overall rate of patient harm of 7.5% in hospital settings, with 37% of adverse events deemed preventable. More recent data reported by the Canadian Institute for Health Information found one in 17 hospital stays in Canada involved at least one harmful event in 2022-23. The data highlight the urgency of improving patient safety as rates in recent years have been higher compared to pre-pandemic numbers. The majority of the data available focuses on physical harm rather than all forms which also includes psychological, social and spiritual harm.
Healthcare Excellence Canada plays an important role in shaping the way patient safety is defined and understood. Initially through the work of the Canadian Patient Safety Institute (CPSI) and now as HEC, we are supporting a transformative shift from seeing safety as the absence of harm to a more holistic approach to fostering safe, inclusive care. One of the primary ways we are doing this is by working to apply the leading framework for measuring and monitoring safety, to see what lessons can be learned about its application in Canada.
A framework for expanding the definition of safety
The release of the Measurement and Monitoring Safety Framework (MMSF) catalyzed a major change in the way safety is defined and practised and has informed and influenced Healthcare Excellence Canada’s approach. Created by Professor Charles Vincent and colleagues at The Health Foundation in 2013, the MMSF proposed shifting away from focusing on the absence of harm towards adopting a broader view of safety. This new view examined the sources of resilience and capabilities that enable safe care and endorsed a less reactive approach to improving safety.
Shifting from rethinking towards acting on patient safety
How we act to create safer care is just as important as how we conceptualize it. That’s why Healthcare Excellence Canada has developed the following resources to help you rethink and act to improve patient safety in healthcare settings.
Rethinking Patient Safety Discussion Guide
Healthcare Excellence Canada published Rethinking Patient Safety, a Discussion Guide for Patients, Healthcare Providers and Leaders during Canadian Patient Safety Week 2023 to encourage everyone across the continuum of care to enable safer care. The guide explains Healthcare Excellence Canada’s approach to patient safety that fosters a curious mindset and shifts away from seeing safety as simply the absence of harm. This resource also aims to spur discussions around patient safety and what is means for you.
How Safe is Your Care?
The release of "How Safe is Your Care? Measurement and monitoring of safety through the eyes of patients and their care partners" provides important insights into how patients and their care partners see safety. The report offers guidance on how to effectively engage patients and care partners in all aspects of measurement and monitoring of safety and provides recommendations outlining how to strengthen provider and patient partnerships in support of safer care.
A timeline of patient safety
Important work has taken place to evolve our understanding of patient safety, what it means to different stakeholders, and how to foster it. While there has been tremendous progress, more work is needed to refine this understanding and address harm. As early adopters and leaders on the MMSF in Canada, Healthcare Excellence Canada and partners have a role to play in this effort—one that we hope you will join—so that we can truly transform to the presence of safety. Together.
1999: A report titled To Err is Human: Building a Safer Health System was published by the Institute of Medicine. The report explores patient deaths due to medical error and concludes that the problem is not necessarily people, but the system in which people work.
2001: The Institute of Medicine in the US releases Closing the Quality Chasm: A New Health System for the 21st Century. This report outlined the Six Aims for Improvement (Safety, Timeliness, Effectiveness, Efficiency, Equity, Patient-Centredness).
2004: The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada by Baker, Norton et al., is the first Canadian study to provide a national estimate of the incidence of adverse events. The study found that 7.5% of 100 admissions resulted in an adverse event, of which 36.9% were preventable.
2013: The release of the Measurement and Monitoring of Safety Framework (MMSF) catalyzed a major change in the way safety is defined and practiced. Created by Charles Vincent and colleagues at The Health Foundation, the MMSF presented an approach for shifting away from focusing on the absence of harm towards adopting a broader view of safety.
2015: Beyond the Quick Fix: Strategies for Improving Patient Safety published by the Institute of Health Policy, Management and Evaluation at the University of Toronto concluded that despite the growing understanding of the safety threats and efforts made to identify safety practices, there is still effort needed to broaden and link efforts to improve care and care environments.
2016: The Canadian Institute for Health Information (CIHI) releases the Hospital Harm Indicator. This indicator measures the rate of acute care hospitalizations with at least one occurrence of unintended harm during a hospital stay that could potentially have been prevented.
2017: The Canadian Patient Safety Institute (CPSI), now Healthcare Excellence Canada, began working with healthcare teams from across the country to advance our knowledge and experience of the MMSF in Canada.
2023: Healthcare Excellence Canada and Patients for Patient Safety Canada released Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders which summarizes learnings and ideas suggesting a new way of approaching patient safety.
Measurement and Monitoring of Safety Framework
The release of the Measurement and Monitoring Safety Framework (MMSF) in 2013 catalyzed a major change in the way safety is defined and practiced and has informed and influenced Heathcare Excellence Canada’s approach. Created by Professor Charles Vincent and colleagues at The Health Foundation, the MMSF proposed shifting away from focusing on the absence of harm towards adopting a broader view of safety. This new view examined the sources of resilience and capabilities that enable safe care and endorsed a less reactive approach to improving safety.
The MMSF offers many advantages when it comes to how we think about safety. It:
creates a more holistic view of safety.
changes our safety focus – moving away from a focus on past harm.
provides a shared and consistent understanding of safety.
changes the way we think about safety.
helps us move away from managing risk to managing safety.
moves us from assurance and accountability reporting to a "practice of inquiry."
empowers everyone to take a proactive role in safety.
promotes a culture of collective responsibility for safety.
promotes an understanding that staff and patient safety go hand in hand.
places value on soft intelligence (e.g. listening, observing and perceiving).
recognizes the value that patients and caregivers have in creating safety.
How it works
MMSF is made up of five dimensions that healthcare leaders, providers, patients and families can use to understand and improve patient safety. The framework assesses and evaluates safety from "ward to board" by providing a comprehensive and accurate real-time view of patient safety. It helps users move from "assurance" to "inquiry" by shifting away from a focus on past cases of harm towards current performance, future risks and organizational resiliency.
"The framework for the Measurement and Monitoring of Safety helps people rethink their understanding of safety in their own clinical environment," says Dr. Baker. "What we saw during the demonstration project is that staff were really engaged by this idea that they can have an active role in promoting and maintaining safety."
Armed with a series of valuable questions, you can make better decisions about the safety of the care you provide. The primary questions are:
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Applying the framework in Canada
In 2017, the Canadian Patient Safety Institute (which amalgamated with the Canadian Foundation for Healthcare Improvement to form Healthcare Excellence Canada in 2021), began working with healthcare teams from across the country to advance our knowledge and experience of the MMSF in Canada. Following a successful demonstration project led by Dr. G. Ross Baker at the University of Toronto, a subsequent learning collaborative was launched in 2018 with 11 teams from seven provinces. With expert faculty and mentoring over 18 months, each team used the MMSF to develop a more comprehensive approach to delivering safer care.
An evaluation in 2020 concluded that the collaborative successfully built the capacity of teams to understand and implement the MMSF in their local settings. Participants reported positive impacts on stakeholder groups' knowledge and behaviours, healthcare processes and patient outcomes.
"We started out in the safety world really worrying about past harm and I think that was really important because it raised peoples' understanding about the magnitude of the safety issues. But it is insufficient because people don't go to work thinking about past incidents; they go to work thinking about the patients they are going to see today. So that is part of the shift now is that we are putting safety into a much more relevant context for the staff on their units doing their daily jobs. I think we can still build on that. We can build a broader sense of how units function, and how units interact with other units."
- Dr. G. Ross Baker, PhD, Professor, Institute of Health Policy Management and Evaluation, University of Toronto
Learn more:
Measuring and monitoring safety: A patient and care partner perspective
The evaluation showed that the MMSF improved safety practices and was well-received by frontline teams, senior leaders and board members. Limited attention, however, had been paid to how patients engage with this wider view of safety.
The release of How Safe is Your Care? Measurement and monitoring of safety through the eyes of patients and their care partners provides important insights into how patients and their care partners see safety. The report offers guidance on how to effectively engage patients and care partners in all aspects of measurement and monitoring of safety and provides recommendations outlining how to strengthen provider and patient partnerships in support of safer care.
Learn more:
Evaluation of the MMSF Collaborative
May 2020
Authors: Joanne Goldman, PhD | Scientist, Centre for Quality Improvement and Patient Safety, Faculty of Medicine, University of Toronto, Leahora Rotteau, PhD, Cand | Program Manager, Centre for Quality Improvement and Patient Safety, Faculty of Medicine, University of Toronto
The Measurement and Monitoring of Safety Framework (MMSF) consists of five dimensions, and a series of prompting key questions, that guide users to comprehensively and conceptually view safety. These five dimensions and related questions address: past harm, reliability, sensitivity to operations, anticipation and preparedness, and integration and learning.
In October 2018, the Canadian Patient Safety Institute (CPSI), now Healthcare Excellence Canada, launched a patient safety improvement project under the leadership of Maryanne D'Arpino of CPSI (Executive Lead) and Dr. G. Ross Baker at the University of Toronto (Academic Lead). This program, a learning collaborative with expert faculty and mentorship, aimed to enable the implementation of the MMSF amongst 11 teams from seven provinces across Canada over an 18-month period with the aim of each team developing a more comprehensive approach to safety and the delivery of safer care. This report presents findings from an evaluation study funded by CPSI that aimed to examine the effectiveness of this Collaborative.
This study used a qualitative approach based on interview, observation and documentary data collection methods. In-depth semi-structured interviews were conducted with team members. One-day site visit observations were conducted at five sites; observations of learning sessions were conducted and relevant documents were collected. Thirty-six team members participated in the interviews. A total of 29 hours was spent at site visits; in addition to approximately 33 hours in learning session 3, the closing congress and all-team virtual meetings.
Overall participants provided positive feedback about the in-person learning sessions. They particularly valued the expert presenters, multifaceted approaches used to teach the MMSF, and the structure created for learning within and between participating teams.
While some participants felt 'overwhelmed' at the amount of information in the first learning session, the majority felt positive about the framework from the outset. The first learning session set in place the need for a shift in thinking about safety from an absence of harm to presence of safety, to thinking about changing culture, and that it would take time to understand and implement the MMSF.
The coaching by CPSI senior program managers played key roles in participants' understanding and implementation of the MMSF. The coaches were responsive and accessible between site visits. They provided ongoing education and support; and were instrumental in providing the feedback necessary for ongoing implementation of the MMSF. Some participants would have wanted more coaching and more clarity about coaching and team accountability expectations.
Team members used a range of teaching strategies and methods to support the implementation of MMSF into practice. These included teaching about the framework to groups of stakeholders (e.g. healthcare providers and senior leadership).
Quality improvement (QI) consultants, physicians and boards began teaching about the framework by integrating its language into day- to- day communication and using it to discuss specific safety or patient care issues. Team members made decisions about how to teach the framework to stakeholder groups, taking into consideration issues such as availability, number of people involved, professional roles and interest. There were different perceptions about the effectiveness of teaching the MMSF and whether it’s necessary to teach the framework itself or if it’s sufficient to teach and implement tools and processes informed by the framework.
Teams were encouraged to focus on MMSF implementation strategies that were context specific and allowed for the integration of the framework into the daily clinical and administrative work of the units or targeted areas. Teams consequently used a variety of strategies. These included the use of the MMSF to inform the following processes and activities: safety huddles, health care processes, safety incidents and reports; meetings; communication; patient and family focused initiatives; and board and senior leadership level activities. Each strategy had success in targeting different stakeholders and effecting change in different ways.
The MMSF teams consisted of individuals with varied professional backgrounds and roles at local, regional and provincial levels. This variability allowed for sharing of diverse perspectives and multiple avenues to teach, implement and spread the MMSF. However, variability in engagement with the collaborative and movement out and into the teams over the 18 months were challenges. A small number of teams had patient, family and board representation who were seen to bring valuable perspectives to the team and its work. Physicians were a more difficult group to engage.
The majority of participants were supportive of wider spread of the MMSF yet there was variability in their opportunities for spread beyond their implementation site(s). While a small number remained focused at the original site of implementation, the other teams demonstrated varying levels of spread: unplanned spread; planned individual or team efforts which led to pockets of uptake in the organization or region; planned and coordinated widespread efforts to spread the MMSF across an organization and region. Challenges to spread included limited dedicated resources, uncertain authority to influence spread, the need for alignment with wider-level processes and frameworks and healthcare organizational and regional restructuring.
The majority of participants reported positive impacts from MMSF implementation. These included changes in thinking about safety which impacted on behaviours and practices; healthcare staff engagement in prevention, identification and management of safety issues; patient, resident and family engagement in safety; and improvements in healthcare processes
The MMSF collaborative was successful in teaching the teams about the MMSF and coaching them to implement the framework in their local settings. Participants perceived the MMSF work as having positive impacts on stakeholder groups' knowledge and behaviours and on healthcare processes and patient outcomes. These findings support further education and implementation of the MMSF; however, these efforts would need to address the facilitators and challenges identified in this report to ensure a more systematic and comprehensive spread throughout healthcare organizations and regions.