Patient Safety Plan

The first year of the Plan’s implementation focused on creating a solid foundation for future improvements. The action items helped establish the organizational knowledge base needed to begin a shift to being more proactive in safety.    

Year Two focused on “Moving to Safety Two: Creating and Building Purposeful Connections”, acknowledging that many actions are carried over from Year One due to unexpected health system challenges. With a new focus on the purposeful connection to Safety Two, Team LHSC is taking the time needed to learn about Safety Two, creating a strong collective knowledge base, helping ensure the success of our journey.    

Year Three of the Patient Safety Plan focuses on “Empowering Our People in a Proactive Approach to Safety” and aims to build off the success and momentum of Year Two. While Year Two remained focused on building a foundation of Safety Two thinking, Year Three will focus on achieving sustainability of Safety Two thinking within our processes as well as continue the organizational spread of proactive safety principles. Year Three will have a unique focus on collaborative partnerships across Team LHSC. This collaborative approach will ensure that everyone— from those who deliver, support or seek health care— will understand their vital role in maintaining a proactive approach to patient safety.

Year Three actions were developed in partnership with patient partners using the consultative and collaborative principles of the Health Quality Ontario Patient Engagement Framework. 

• Senior Leadership will establish roles and competencies for leaders regarding Safety Two. ​☒​Ongoing ​☐​Complete
• Develop training on the principles and tools regarding Safety Two that includes a refresher on existing Change Management education to reflect these principles. This training is to be rolled out to all formal leaders. Consideration to be given to providing education to Board of Directors as well.  ​☒​Ongoing ​☐​Complete
• Continue to provide mandatory training and ongoing support in the use of the Just Culture Framework to ensure all leaders are competent in its application.  ​☒​Ongoing ​☐​Complete
• Create and maintain an electronic Quality and Patient Safety Resource package for Leaders. Toolkit to include details regarding process, roles and responsibilities on Disclosure of Harm, Quality of Care Review process, Accreditation (new process), Safety Two/Resilience Engineering, Just Culture and other appropriate topic areas as defined.  ​☐​Ongoing ​☒​Complete
• Identification of Accreditation Required Organizational Practices leaders to support Accreditation monitoring and implementation of quality improvement projects where necessary. ​☐​Ongoing ​☒​Complete
• Ensure Safety Two language is incorporated into the Executive Management System training.  
• Redesign the Purposeful Rounding initiative to include elements of Continuous Improvement of Care, Patient Safety and principles of Safety Two thinking.  

• Incorporate principles of Safety Two into existing learning programs including corporate and unit level orientation, staff and leader education. Inclusion of Safety Two resources on the LHSC internal Learning Hub.  ​☒​Ongoing ​☐​Complete
• Perform an analysis of the results from the 2023 Accreditation Survey so that areas for improvement can be identified in addition to successes.   ​☐​Ongoing ​☒​Complete
• Support clinical teams in the ongoing development of safety initiatives based on available data, clinical observations, successes and expertise.  ​☒​Ongoing ​☐​Complete
• Collaborate with the Continuous Improvement of Care (CIC) team to incorporate Safety Two principles into CIC training and daily management systems.  ​☒​Ongoing ​☐​Complete
• Complete Continuous Improvement of Care education and implementation in all remaining program areas across the organization. Target completion date of corporate roll out is Summer 2024. ​☐​Ongoing ​☒​Complete
• Focus on the development and completion of Continuous Improvement of Care education as it relates to the Executive Management System.  
• Work collaboratively with the Performance team to ensure that quality improvement and safety initiatives are evidence-informed and have effective mechanisms for measurement and evaluation applied. This includes ongoing working with Health Disciplines and Nursing Practice Excellence, specifically for recommendations related to pressure injuries and falls  
• Work collaboratively with Patient Engagement and Canadian Surgical Technologies & Advanced (CSTAR) to incorporate patient partners and the patient and family voice into simulated learning across the organization.  

• Develop a process, in partnership with the Quality and Patient Safety Council, to share patient safety learning opportunities across the organization.  ​☒​Ongoing ​☐​Complete
• Leaders to include a question related to patient safety during Purposeful Rounding. Leverage ongoing unit tours and visits to ensure patient safety topics are discussed.  ​☒​Ongoing ​☐​Complete
• Utilize people-centred care principles to ensure all patients, their families, staff and health-care providers are treated as equal members of the health-care team in order to enhance communication.  ​☒​Ongoing ​☐​Complete
• Incorporate a safety question into status exchanges or staff huddles, with the goal of increasing open communication with respect to safety concerns.  ​☐​Ongoing ​☒​Complete
• Develop a process to provide Quality and Patient Safety Council with corporate safety trends for review at monthly meetings. Council to action tasks resulting from trends appropriately (such as working groups, committees, leaders).  ​☐​Ongoing ​☒​Complete
• Develop a process of Quality of Care Committee to share learnings from Quality of Care reviews across the organization to allow for spread of learning.  ​☐​Ongoing ​☒​Complete
• Initiate quarterly Patient Safety Forums for all staff, with a focus on creating an environment for open and transparent conversation and education related to various Patient Safety Topics.  
• Develop a repository of Serious Safety Event review recommendations that is available organizationally to provide opportunities for organizational learning and collaboration.  

• Change the name of Adverse Event Management System (AEMS) to reflect its purpose as a learning tool.  ​☒​Ongoing ​☐​Complete
• Convene a working group to address shifts in policies, procedures, corporate education from referencing the AEMS System to the new tool name. ​☒​Ongoing ​☐​Complete
• Optimize the use of the tool by identifying barriers to recording patient safety incidents and develop a plan to address barriers. ​☒​Ongoing ​☐​Complete
• Develop a process for identification and monitoring of trends that include reporting of near misses and no harm events. ​☒​Ongoing ​☐​Complete
• Establishment of a process for the Quality and Patient Safety Council to review emerging issues and trends from frontline staff, leaders, providers and safety incident data for ongoing monitoring and prioritization of corporate quality and patient safety activities. ​☒​Ongoing ​☐​Complete
• Prepare leaders, staff and physicians for the implementation of new reporting system for safety events (formally referred to as adverse events) through focused education. ​☒​Ongoing ​☐​Complete  
• Revise the Quality of Care review process for responding to Serious Safety Events, inclusive of group Quality of Care Reflective Review meetings to opening discuss system improvements.  ​☐​Ongoing ​☒​Complete
• Develop process for the consistent engagement of patients and care partners in Quality of Care review process.  ​☒​Ongoing ​☐​Complete
• Create process of safety events related to patient falls to be reviewed and actioned by the Corporate Falls Steering Committee, and reported on quarterly basis to the Quality of Care Committee.  ​☐​Ongoing ​☒​Complete
• Create a process for "Closing the Loop for Serious Safety Events". ​☐​Ongoing ​☒​Complete
• Ongoing preparation of leaders, staff and physicians for implementing a new reporting system for Safety Events through focused education (formally called Adverse events).  
• Work collaboratively with Patient Relations to ensure that patients and their care partners are engaged in the Serious Safety Event review process along the continuum. This will include closing the loop with patients and their families.  
• Monitor and measure the use of the Closing the Loop leader checklist to determine its utility and where further advancements in safety event transparency can be made.  

• Ensure ongoing adherence to Accreditation Canada’s Required Organizational Practices, Priority Processes and Standards of Care.  ​☐​Ongoing ​☒​Complete
• Identify and educate leaders on Always Events (preventative actions) that correspond to the prevention of Never Events. This should include reviewing the effectiveness and adherence to Always Events following the occurrence of Never Event.  ​☒​Ongoing ​☐​Complete
• Develop and initiate a process to ensure all policy reviews include a change to Safety Two language and processes.  ​☒​Ongoing ​☐​Complete
• Ensure ongoing endorsement of staff and physicians regarding research endeavors that support the development of evidence based best practice and improved reliability of care.  ​☒​Ongoing ​☐​Complete
• Address opportunities for improvement identified in the February 2023 Accreditation survey.  ​☐​Ongoing ​☒​Complete
• Focus on performance and effectiveness of the implementation of Accreditation Standards, Required Organizational Practices and Priority Processes.  ​☐​Ongoing ​☒​Complete
• Support clinical areas to submit Leading Practices to the Health Standards Organization.  ​☒​Ongoing ​☐​Complete
• Develop a process to conduct and use the results of common cause analysis to ensure a more comprehensive understanding of patient safety trends.  

• Ensure ongoing and regular communication to leaders and physicians of available support for Just Culture. Communication should highlight available resources including the six online learning modules for Just Culture. ​☒​Ongoing ​☐​Complete
• Explore the feasibility of incorporating Just Culture training into orientation for new staff, leaders and physicians, in collaboration with Human Resources and Workforce Wellness and key stakeholders. ​☒​Ongoing ​☐​Complete
• Provide leaders with the competencies, capacity, and education to identify system factors and support staff in accordance with the Just Culture model; including the initiation of quarterly “Just Culture Hot Topics” where case studies will be discussed. Effective application of the Just Culture model, and education on Just Culture tools and resources will also be covered. ​☒​Ongoing ​☐​Complete
• Leverage pre-existing Continuous Improvement of Care mechanisms, such as status-exchanges, through which staff are able to share safety concerns openly. ​☐​Ongoing ​☒​Complete
• Leverage pre-existing staff support programs, and opportunities for debrief, through which all staff are able to access help following the occurrence of a significant safety incident. Ensure that these programs are communicated to all staff, leaders, physicians and union partners. ​☒​Ongoing ​☐​Complete
• Utilize the results of the quarterly pulse surveys, Wellbeing at Work Surveys to inform a corporate strategy to improve psychological safety for leaders, staff and physicians. ​☒​Ongoing ​☐​Complete
• Develop a Peer-to-Peer support program to create a safe environment to assist staff following their involvement in a Serious Safety Event.  
• Explore opportunities to utilize an evidenced-based approach to safety measurement and monitoring encompassing all potential incidents of harm, both physical and psychological.