If you work in health care in BC, chances are good that your organization has recently undergone, or is currently preparing for, an accreditation survey. Since most surveys were postponed during the pandemic, health authorities have had a heavier survey schedule this year catching up on the backlog.

Preparing for an accreditation survey and sustaining compliance with requirements can be a challenge. The bar is intentionally set high to encourage health care systems and teams to stretch to achieve top results.

How can PSLS help?

Well, both PSLS and accreditation have a laser focus on patient safety! They also promote continuous quality improvement and using measurement—such as data and benchmarks—to learn more about safety concerns and inform improvement efforts.

In a nutshell, you could say that PSLS helps programs gain a better understanding of issues impacting patient safety, and accreditation assesses what they are doing about it.

What’s data got to do with it? 

In order to assess organizations’ quality and safety processes, surveyors are trained to ask not only what teams are doing, but why they do it. How was the priority determined? What informed the process? And what has the impact been?  

This is where PSLS and other data sources come in handy.

“When leaders regularly review PSLS data, they have a better understanding of patient safety issues in their area,” explains Rodrigo Batista, Patient Care Manager at Providence Health Care (PHC). “We review contributing factors of incidents reported in PSLS, then incorporate details from the health record to get a better understanding of what’s going on.”

Providence Health Care was accredited by Accreditation Canada last fall. The process included an on-site survey for teams to demonstrate their compliance with standards developed by Accreditation Canada and its affiliate Health Standards Organization.

To illustrate its approach to patient safety, PHC shared a number of initiatives that focused on measurement and featured PSLS data.

Engaging with the numbers

How do you share PSLS data in an engaging and informative way?

This is a question that Rodrigo and the Quality & Safety team at PHC have found some interesting answers to.

For instance, they developed a patient journey poster for rehabilitation staff, patients, and families at Holy Family Hospital, a 126-bed extended care facility in Vancouver, BC. It focused on two questions: what are the main safety issues and what is important to patients, families, and staff?

First, Rodrigo analyzed PSLS data to learn which incidents staff report most frequently. The answer was typical: falls and medication events. He then took a deeper dive to find out what was contributing to these incidents in the rehabilitation program, and what information might be helpful to reduce them.

“When we first put up the poster, patients let us know that it was too big and placed too high up on the wall to comfortably read from a wheelchair, so we reduced the size and placed it lower down,” says Rodrigo. “It’s important that patients and families are informed about risks and how we can work together to improve their safety.”

Other initiatives at PHC include monthly and annual PSLS summaries. Because PSLS is both voluntary and subjective, Rodrigo uses data from Data Analytics and Cerner to get a more fulsome picture. He also includes examples of typical incidents and safety ideas from reporters and handlers.

Summaries are shared with programs such as Mental Health, as well as working groups focused on a specific issue, like medication safety or violence prevention.

Once teams have the information, it can be challenging to know what to do next. Staff in clinical roles are focused on patient care and can sometimes benefit from extra support. In his previous role of Patient Safety Leader & PSLS Coordinator, Rodrigo was able to participate in some improvement projects from beginning to end. Other quality and safety experts, such as PHC’s Performance Improvement Consultants (PICs), are another fantastic resource to help implement and sustain projects.

“PSLS is an excellent tool that allows PICs to start understanding the current state of a perceived issue,” says Ramses Prado, PIC, PHC. “We can identify potential causes, learn how often specific situations are happening, and observe patterns within those situations. PSLS helps us to go from an anecdotal to a data-driven approach to promote and act on the quality of care and safety of the population we serve.”

Demonstrating compliance

PSLS data can also be used to demonstrate compliance with Accreditation Canada’s Required Organizational Practices (ROPs).

“Patient safety incident management and disclosure ROPs require organizations to have a system to report, learn from, and disclose incidents,” says Liz Flores, Director, Quality, Safety and Accreditation, PHC. “We utilize accreditation to highlight our process for incident management.”

Although accreditation criteria require health authorities to have policies related to incident management, policies are not enough: staff also need to be aware of how to report and learn from incidents. Some may feel that PSLS is too time consuming, but a report doesn’t have to be perfect—just enough information to start the conversation.

“PSLS is one tool we use to promote a patient safety culture. We also use tools that complement PSLS, such as mortality reviews,” adds Liz. “When staff see PSLS being used in a practical way, it fosters a safety culture, and lately we’ve seen a resurgence in interest in PSLS, particularly from physicians.”

The future of patient safety

So, is health care any safer than it was twentyish years ago when quality and safety were new programs and Accreditation Canada introduced its safety-focused ROPs?

Many of us would agree that there have certainly been substantive improvements, particularly related to technology. However, evolving environmental challenges coupled with an increasingly complex health care system mean that there is still a lot of work to be done.

Accreditation standards and criteria have evolved, too. An increased focus on patient and family involvement and new standards, such as the made-in-BC Cultural Safety and Humility Standard, demonstrate a shift in direction.

“If we focus on equity and invite patients to report safety incidents and participate in incident reviews, we can learn more about what patients are going through and how we can make their health care journey safer, together,” says Liz.

Since its first implementation in 2008, PSLS has partnered with BC’s health authorities to work toward its mission of making health care safer, which includes supporting quality and safety initiatives like accreditation.

Congratulations to all BC health organizations who have successfully been accredited and continue to strive toward making health care safer for all!

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