Episode 1 – Dr. Doug Cochrane
Patient Safety in the Canadian Healthcare System
The patient safety movement has led to positive change across the Canadian healthcare system. We speak with Dr. Doug Cochrane, Provincial Patient Safety and Quality Officer for British Columbia, who explains how and where these improvements have been made and offers insight on the future of healthcare in BC.
Transcript: Full episode 25:32
DR. COCHRANE: The reality is that we, as a result of our care, can affect the health of people adversely. Now, recognizing that particular thing, I think was one of the most important aspects of health care evolution in Canada.
JESSE ST. MARS: That is the voice of Dr. Doug Cochrane, one of the leading patient safety voices in Canada. We sat down with Dr. Cochrane to talk about patient safety and the healthcare system. Stay tuned for an important discussion on adverse events and how this is impacting the evolution of healthcare. I’m Jesse St. Mars.
MICHELLE PRESTON: And I’m Michelle Preston. This is Patient Safety Voices.
MICHELLE PRESTON: Today we’re speaking with Dr. Doug Cochrane. He’s an expert in the field of patient safety and a respected healthcare leader in British Columbia and throughout the global patient safety community. Dr. Cochrane is chair of the BC Patient Safety & Quality Council and he was chair of the BC Patient Safety & Learning System Steering Committee for several years. Dr. Cochrane, thank you for joining us.
DR. COCHRANE: Thank you
MICHELLE PRESTON: So we’re talking about patient safety, which has gained a lot of interest in Canada over the past 10 or 15 years. We have the Canadian Patient Safety Institute, which has been around for about 13 years. The Canadian Adverse Events Study was done about 12 years ago, and of course here in British Columbia we have the Patient Safety & Learning System, which has been around since 2008.
MICHELLE PRESTON: So, Dr. Cochrane, why is patient safety such a matter of concern? [1:50]
DR. COCHRANE: Well, you know I think, as I think about the patient safety movement it actually predates the creation of the Canadian Patient Safety Institute (CPSI). There was seminal work done in the province of Quebec, the Francoeur report, done many years before the Baker/Norton report that assessed patient safety and looked at adverse events affecting patients in Canada. And I think both the Francoeur report and the Baker/Norton report showed us that in Canada we were no different than jurisdictions in the United States and in Europe where adverse events affect patients all the time, and these harm patients and they result in their death. And, for the most part, these were events that were largely preventable. They were certainly preventable in today’s terms, they may not have been thought to be preventable at the time when these studies were done, but the reality is that we, as a result of our care, can affect the health of people adversely. Now, recognizing that particular thing, I think was one of the most important aspects of healthcare evolution in Canada, because prior to that we didn’t recognize this as a particular entity or an event, and we chose to see Canada, because of our equitable medical system, our publicly funded health system, as different than in the United States, or in Britain, or in Australia. And, in reality, the systems of care were fundamentally no different and were absolutely not safer. So, we then had a subsequent study, it actually I think was about 2012, where Anne Matlow and a group of people looked at pediatric care. Now, that had not been done and still has not been repeated as far as I know, but the same observations were made, the observations that the systems of care are actually putting patients at risk. And while we enjoyed many patients getting better and being successfully treated and their illnesses mitigated or cured or reversed, there were many, many who were harmed by the care we offered them, and provided both adults now and children. So, from a healthcare system point of view, this whole issue is very important from many perspectives. As a patient and as a family, to have a patient harmed as a result of the treatment, because of, in essence, design failures, or knowledge limitations, or communication issues, or what have you, is absolutely tragic. And, in some respects, I think probably is viewed as unacceptable. To have a health system that builds in a product defect rate of 7% to 10% is probably also unacceptable. Now, I’m not a great fan of Lean and I’m not a great fan of, sort of, the manufacturing analogy to healthcare because I don’t think it’s quite the same, it’s certainly much more straight forward, but the reality is that you would not run any kind of other business tolerating a defect rate without making the attempt to understand it. And, in fact, I think that’s what actually happens, one of the key fundamental parts of process engineering and Lean methodology and so on, is to actually understand the process well enough so that you can look at where there are problems and you can correct them.
JESSE ST. MARS: What are some of the basic requirements of providing that safe care? Are there any critical protocols or systems that healthcare organizations should have in place to improve exactly what you’re talking about right now? [5:55]
DR. COCHRANE: Well, the key one that is absolutely central to all of this is the Patient Safety & Learning System (PSLS). So, you need the culture to allow people a safe environment in which to report and describe the events where the system fails, because if you don’t have that you don’t know and you only see the end result of a tragically injured or deceased patient where our care has failed. So, we need to understand where the system has weaknesses and every system, every system, healthcare included, that you can think of, has ways of understanding where it has weaknesses. So, PSLS was designed specifically with that in mind. It only would be successful in an environment where people care – where the environment is safe to recognize mistakes, to recognize errors, to recognize system flaws and then, more importantly, to act on them, and PSLS is part of that process, it is not all of the process. There’s a policy foundation that exists now in all of the health authorities that all of the boards have recognized and have endorsed that allows people the opportunity to, without reparation, without consequence to them, to bring this information forward. And then actually there is the obligation upon the boards, the executive, the Ministry of Health, the Patient Safety & Quality Council, to act on this information and to improve the system in which we are working. That obligation is in fact the foundation of making the system better. So, if we started out with the idea that we put patients at risk, that we do harm, and we set aside, I think as we did probably for many reasons, that information and failed to learn, nothing much will change. If we take that information and we consistently and relentlessly look for solutions, test those solutions, and implement those solutions things will actually improve for patients. So, the best example of this, not the only one, but the best example focuses specifically on a type of infection that occurs after the insertion of a central line – an access to a blood vessel that’s given for chemotherapy, or nutrition, or other purposes. And central line infection was recognized to be a major source of morbidity and death in highly compromised people in intensive care units. And it was with Peter Pronovost’s leading work initially at John Hopkins and then in Michigan that we recognized that what we thought was unchangeable, or was due to the nature of patients, was actually changeable if you put to it a standard protocol of how to manage the insertion of the line because the insertion of the line was when the infection occurred. When those results came out and when they were shown to be generalizable in other jurisdictions, we had a key example of how understanding and learning fed back to make the environment for patients, the care for patients, safer. So, if you think about protocols, it’s not that I’ll just do this in this particular condition. It’s actually that I’m in an environment that is willing to learn and is willing to build knowledge on the foundation of what is already learned. That is actually what makes things safer and that’s actually the protocol – it’s not just I wash my hands or I do something else that is recognized to help a particular condition.
MICHELLE PRESTON: So, Dr. Cochrane, how can organizations begin to foster the kind of environment that you’ve been talking about? So, an environment that promotes reporting and learning from adverse events to allow staff the ability to learn without fearing punishment perhaps from doing something wrong during the care of a patient or almost making a mistake of some kind and instead seeing the opportunity that these situations can potentially provide. What is your advice on that? [10:45]
DR. COCHRANE: What I’m talking about is a fundamental sense of commitment and belief that a system would have that is providing healthcare. So, in sort of non-technical terms that’s the policy foundation that it is the culture in the environment. It is the written word and the unwritten word that says this is how we will behave in our environment, our health authority, our institution, our ward, our operating room, our community care setting. So, this is a cultural thing because it reflects the commitment we’re willing to make to patients. So, the creation of a safe environment for reporting without retribution. The ability of that reporting to be respected from a patient’s perspective and, in fact, as some health authorities have already done, used patients to provide information about adverse events, and then the commitment to learning. So, I see the fundamental aspect of this as being foundational to what we, at least as I personally feel, as Canadians would have in our health system. It is our responsibility, it is our obligation, and our system should allow that to happen and to flourish. So, having said that, then you can build in individual disease areas or preventative programs or, in specific medical conditions, ways to improve. You take the evidence, you create a body of knowledge, you ensure that you’re doing what you think you’re doing. That’s with measurements, that’s with understanding, and then you say, ok fine, can we make it better? And you know in BC we’re really really lucky in contrast to other provinces at the present time. The measurement tools we have in cancer, in renal care, in transplant care, in surgery in general, are beyond compare. We actually have good data around the specifics of medical conditions and we’ve got many researchers who look at that data and do research studies on it. But we also have people who are willing to take that information and improve the system and that’s true both in cancer and renal in particular, and is coming along as the surgical providers learn more about their comparative performance.
JESSE ST. MARS: Is one of these new tools or one of these new learnings, they came up with last year in September 2015, the first Pan-Canadian Never Events list was released. Was that a significant step or an example of this that you’re talking about, or how has that maybe even helped our Canadian healthcare system, what’s your thoughts on that? [14:07]
DR. COCHRANE: Well, you know, probably it’s helped the Canadian healthcare system because it did put a stake in the ground. But I’ll take us back to the formation of the health authorities here in British Columbia and, at that time, building on work that had been done in Saskatchewan about mandatory reporting, it described a series of events that needed to be reported to, in their case the Ministry of Health, and that was a risk mitigation sort of approach. What we did is we took that list, we looked at it from the perspective of British Columbia and we took the policy framework that was already in place, it had already been created, it was founded already, and said ok, let’s look at events which we think we can prevent with best care and therefore, if they were to occur, likely represent a failing of the system in some way. It might be an individual, it might be a communication issue, it may be an information transfer problem, but it would actually be something that would normally be correctable. And so we had that list. We had that list in every health authority and we had it 10 years before this list came out. So, I think in British Columbia the Never Events list, although I was a contributor to it, was sort of an after the fact thing that was more relevant perhaps for other jurisdictions. We had it here in BC and I’ll tell you the bar was set far higher in BC with regard to never events and the requirements for reporting at various levels and the requirements for action at various levels than it was in other provinces.
MICHELLE PRESTON: I’d like to come back to the PSLS (BC Patient Safety & Learning System) just for a moment. So, there’s recognition here in British Columbia as you say to collect this information about patient safety events. We have about 750,000 records in our database, we have lots of examples of wonderful work that’s happening across the province in local areas, we profile a number of those stories on our blog. What is your advice for taking that learning and that improvement and spreading it beyond the local setting to promote more of a system-wide level change? [16:23]
DR. COCHRANE: Well, that’s a great question because it’s sort of the next stage for the learning system (PSLS), it is the spreading of the learning. And when I was the Chair of CPSI we wrestled with the same issue, this was around patient safety alerts, a different mechanism by which we could learn about adverse events and what people had taken action with. As I reflect on PSLS, I think there’s a fundamental change that probably still needs to be made with regard to sharing of information. When the original design in British Columbia was organized it was health authority specific. There was a need to keep that information whole, and intact, and secure within the context of the health authority system. Now, PSLS from an information technology perspective has tools that will allow that to happen, but what we were never allowed at the provincial level for PSLS to do is to actually look at everything, unless it was by specific request and it came to the Steering Committee. So, I think that the Patient Safety & Learning System as an entity has a unique opportunity to see things across health authorities and see problems that are common across health authorities. So, amongst those 700,000 records, there are a portion of them, probably a small proportion that are highly impactful on patients and probably highly context specific. There are many though that reflect process problems in how our healthcare system works. That group of problems that generally are either near misses or have low impact on patients or no consequence to them are actually the information necessary for system leaders to actually take and improve those systems. So, I think PSLS needs to, from the perspective of appropriate process, ensure or recommend to the existing Steering Committee that this is something that we should do, obtain agreement from the representative health authorities, and then start to feed into organizations where this kind of information is relevant. So, if we have a provincial lab organization here in British Columbia, then lab related activities would actually focus there. You would have to be open and honest enough and secure enough to say, well, you know, at the BC Children’s Hospital or at Bulkley Valley Hospital, here are the kinds of problems happening in the lab, how can you, central lab organization in British Columbia, help that? Here are patient safety events that relate to actually the care of patients in a general medical or pediatric sense, come to the Quality Council (BCPSQC) and say, look, here are areas where I think you need to put some attention. Because our working system is telling us this is where issues occur and when things fail. And there are many other partners, I think, or collaborators or conspirators that you could actually work with to spread it because PSLS per say will never be able to do that.
JESSE ST. MARS: You talked about sharing some of this information across some of the health authorities and as a provincial system we have that opportunity to report and learn as a province. I’m wondering if we can do that nationally or even in a larger scale with some of the information we’re collecting. You talked about being the Chair of CPSI and with the alerts, could you see any connection there in how we could share some of our information here in BC abroad nationally or maybe even worldwide in some sense? [20:57]
DR. COCHRANE: Well, I think the way to share nationally and worldwide is actually patient safety alerts through CPSI, and there’s a well-defined specific event related process for doing that. It’s been a topic of discussion for as many years as patient safety alerts has been a part of or in existence. And, at some point in time, the health system in British Columbia, the confidence in the health system in British Columbia will allow us to be open and that will happen.
MICHELLE PRESTON: Final question, Dr. Cochrane, is healthcare in Canada getting safer in your opinion, and how can we keep moving in that direction? [22:03]
DR. COCHRANE: I have no doubt that it is far safer and I say that just from the perspective of seeing the attention that people are paying to the nature of care, the process of care, the outcomes of care, in essence the quality of care. I think it has a different view than it did, say 15 or 20 years ago when the primary driver of healthcare was actually the Accreditation Canada organization that came along and said we need to up your bar here health system and so we’ll setup an accreditation process. I think Francoeur, Baker/Norton, Matlow, the creation of the BC Patient Safety & Quality Council, the support that was received by the health authorities for PSLS. All of these things are a reflection of tools and techniques that actually have improved care. There’s no doubt that this is a never ending journey and so there’s lots to be done, there’s more to be done. We have the philosophy I believe, we certainly have the policy framework. Whether we have the belief system and the culture to do it and to move it to a different level, I don’t know, but if you walk into the Intensive Care Unit at BC Children’s Hospital, and I’m sure this is true of many other Intensive Care Units, and you see that the time from the last ventilator-associated pneumonia, in other words someone who gets pneumonia after being on a ventilator and they didn’t have it before, as being 300 or 500 days. Or, you see the time from the last line infection, or accidental extubation, I mean these are ICU type parameters, but if your child is there or if your mother is there in an ICU these are highly relevant. These are parameters that have improved dramatically, not just because we didn’t know what they were, but because we did start and they are a whole lot better. If you look at the system overall, we’ve touched small areas, we’ve touched areas upon which we have evidence and where we can make change. The interesting future areas are where are the areas that we think we cannot influence, and where’s the thinking, the innovative thinking that will allow us to actually put that barrier aside and actually continue to improve care. So, it is absolutely better, there is no doubt, and we know it’s better. It’s not as good as it could be, maybe it will never be as good as I would wish it to be, but we’ll always be moving in the right direction.