February 20, 2007

Hospital Risk Management


Risk Management: A shared interest?

Keynote address speaking notes
Hospital Risk Management Conference

Ms. Raymonde Saint-Germain
Québec Ombudsperson

InterContinental Hotel, Montréal
February 20, 2007

Risk management: a shared interest?

Each year, more than nine out of ten Quebecers see a healthcare professional at least once.

To maintain or regain physical and mental health throughout our lives, each of us will need to have recourse to the care and services our public system offers.

At the heart of this system are human beings, people like you and me, but also people who are frail and at risk.

Given the very nature of our public healthcare network, risk is everywhere. Healthcare professionals must adapt on all levels, dealing with the arrival of new technologies, new methods, and new approaches. In this shifting atmosphere of ever more complex procedures, incidents, accidents, and errors occur. Many of you live with this reality every day.

Health and social service workers know this all too well—and are increasingly open to managing risk. There is no way around it. The greater our awareness, the more compelling our results will be. Today’s conference, by spotlighting promising new avenues, seeks to address this issue. Many measures have already been identified, and for some all that remains to be done is to put them into practice. This is a team effort, and we’re all invited to take part to the extent of our respective interests.

The health and social services complaints investigation system is a beacon for those concerned about healthcare safety. Complaints are valuable signals. They provide us with important clues on how to reduce and eliminate risk. Among the recommendations I have made is one calling for more rigorous and better structured risk management.

I applaud the organizers and co-chairs of this conference, Mr. Jean-Pierre Ménard and Dr. Micheline Ste-Marie, who have convened top caliber specialists and managers to discuss risk management. Today and tomorrow, all these noted participants will share their expertise and commitment so that we can better tackle this looming challenge.

How do we do it? Where do we start? Who should be involved? These are three short questions that need very pragmatic answers.

An objective look at the facts

Since April 2006, the Québec Ombudsman has been called on to play a leading role. My office has taken on responsibilities for health and social services that, before then, had been assumed by Le Protecteur des usagers. It is now our job to correct and prevent situations that could harm patients. But prevent and correct how?

Our organization, which reports directly to the National Assembly, investigates complaints and reportings involving agencies and institutions in the health and social services network. Our political and administrative independence allows us to take an objective look at facts brought to our attention, and to act with complete impartiality.

The Québec Ombudsman has an educational duty towards the members of Parliament. I am able to intercede before problems actually occur and suggest improvements to bills and regulations in the general public interest.

A constructive approach

To ensure just and equitable treatment for all parties concerned, I draw on the expertise of a solid team of professionals and technicians with training in law, nursing, psychology, education, criminology, social work, and business.

The Québec Ombudsman’s efforts to fight inequity would be far less effective if it were not for its constant concern for prevention. We are not looking for guilty parties. We do not see ourselves as disciplinarians. We want to find the causes of system dysfunctions and to correct them and prevent them from happening again, for the benefit of one and all.

I know for a fact that the complaints filed with the Québec Ombudsman are only the tip of the iceberg. How many people don’t complain because they feel vulnerable while receiving care or are afraid of reprisal? The reason I insist on making the complaint system visible is because it’s our early warning system. It engenders the questioning and awareness that are essential to assuring and maintaining a reliable network of services. It is a window on the healthcare and social services network that lets us detect certain breakdowns in service delivery.

What if it had been your father?

Let me illustrate what I’m saying with an example.

Let’s suppose that I work as a nurse in a long term care facility where your father is hospitalized. During one of your visits, you come to tell me he’s complaining of pain and discomfort. You’ve noticed some red blistering in several places on his body and you think it’s an allergy. I haven’t observed these symptoms, but I can confirm that your father is taking a new medication.

I wonder about it. I was the one who had given him the first dose of the antibiotic, as prescribed by his attending physician. I replay the events in my mind. My nurse colleague from the earlier shift had ordered the medication at the pharmacy and made a note in the file. She therefore must have performed the routine verifications. But it says allergies right in the patient file. I feel it’s my fault for not having noticed the red blisters. Yet I still feel I did my job properly. I can’t blame myself for anything.

Shortly after this, your father falls twice on the same day. This causes his condition and health to deteriorate. Oddly, you only learn of this by chance. How do you feel? What do you do in such a situation?

In actual fact, the man’s children filed complaints because they were worried about the quality of their father’s care and the attention he was receiving and were unhappy they hadn’t been told of the two accidents he had had.

And in actual fact, the nurse then was faced with a fairly difficult environment, a climate of suspicion, insecurity, and blame.

Our investigation following receipt of this complaint revealed a series of small errors that followed in succession. First, the patient’s drug allergies had not been written on the prescription pad used by the attending physician. The doctor had used the antibiotic’s commercial name rather than its generic name in prescribing the drug. Because of the name used, the nurse had not been able to find the drug in the CPS, the Compendium of Pharmaceuticals and Specialties. As a result, she drew no connection with the allergies noted in the file. She ordered the drug presuming that the pharmacy would identify what it was and mention related allergies. Finally, treatment began. The nurses did not suspect a possible allergy, since in theory verification had been made BEFORE the drug was ordered from the pharmacy.

As for the patient’s falls, the lack of communication and failure to enter certain information in the file exacerbated the tension and further eroded the bond of trust the family had with the institution.

In this example, we identified the individuals responsible for the miscues—actually, professional errors. But the important—and most helpful—thing for better managing potentially dangerous situations in future is ascertaining the sequence of errors.

I didn’t choose this case randomly. Many of the recommendations we made concerned risk management, notably the need for the facility to have a medication management policy that clarified the roles and responsibilities of all involved and that was monitored and updated as required to reflect the situation at the institution. We also asked personnel to improve patient record keeping. We wanted any information related to patients’ state of health to be clearly and explicitly written down. We further recommended that all employees be reminded of the rights of patients’ families to be told about incidents or accidents that could have an impact on the health of their loved ones.

In risk management, three steps are fundamental: problem awareness, cause analysis, and appropriate steps in response given all the interdependencies in play. Often, taking action is a responsibility shared by multiple parties. We saw it here between the doctor, the nurses, and the pharmacist. Progress is possible when we clearly re-establish the chain of responsibility in such a way that each party plays his or her role and interdependence is optimized.

The advantage of transparency

Disclosure of incidents and accidents is the key to having a system that works. I am aware that this is a sensitive issue that demands honesty and courage on the part of those involved. It requires transparency. But, whether we’re in the patient’s shoes or those of a healthcare professional, we see that transparency has many advantages. Why? Because it generates trust. I chose to present things from the nurse’s perspective just now because I regularly have the opportunity to hear the point of view of the patient, whose right to information I wholeheartedly defend.

However, for risk management recommendations to be realistic, I know we have to consider all the human factors at play, including those that concern caregivers, managers, and support personnel. The free flow of information, open and honest communication, clear procedures, and well-documented files—these are the foundations of safe practices. Lost trust from a lack of communication is the cause of many complaints—I can testify to that.

Different forms of risk

Both Québec’s healthcare and social services systems have undergone multiple and substantial changes in the past years. Ambulatory care, mental health deinstitutionalization, and updated missions for certain facilities that work with the young and the elderly are, in themselves, reforms. They have had an impact. You, the healthcare managers and professionals, have had to adapt to this.

Clienteles have increased, in number and vulnerability. Professional resources are becoming scarce. The area covered is enormous. And these are only some of the constraints you have had to deal with.

Reorganization has also spawned new environments and transformed existing ones as we have sought to achieve a new equilibrium. I’m thinking of—among others—the expansion of home healthcare services, the proliferation of private accommodation facilities, and development of new intake facilities for youth. All these changes have an impact on risk management.

The complaints we receive show that risk can take different forms depending on the care environment. My work as ombudswoman extends beyond the hospital setting. It requires me to take a broader, more global view—a view I would like to share with you.

An aging population

Québec is experiencing a substantial demographic decline. In 2006, persons 65 and older represented 14.1% of the population. About 8% of them were in healthcare facilities. Nearly 10% received home healthcare services. The aging of the population puts added pressure on the system and exacerbates certain problems. Many adjustments are required. This group—the frail elderly—needs sensitive, caring support.

Until last year, private nursing homes were not subject to any form of quality control, and sad cases of mistreatment made newspaper headlines. With Bill 83 and its requirement of certification, this should no longer be the case. Under this new measure, those living in these homes will be able to bring their complaints to the Québec Ombudsman.

In 2005–2006, Le Protecteur des usagers fielded 116 complaints against public and private nursing homes. Among the 237 stated reasons for these complaints were drug administration errors and falls, both of which were contained in the example I gave you earlier. Quality of service, including the cleanliness and safety of the premises, was also questioned.

When comprehension comes into play

Intellectually handicapped or troubled patients with developmental disabilities who attend rehabilitation centers have limited comprehension abilities. Many of them now live within the community. So risk can sometimes come in unexpected forms.

I’m thinking of one complaint in particular. While walking in a wooded area, a caregiver lost sight of a young, intellectually handicapped person for whom she was responsible. With a colleague, she began a search. Time went by and the young man hadn’t been found. The center alerted the police three hours later. Another hour went by before the personnel informed the parents their son had disappeared.

To make a long story short, the incident didn’t have any serious repercussions on the patient’s health because the young man emerged unscathed. We could have sighed in relief and thought nothing more of it. However, as you can imagine, that wasn’t the way the parents of this child felt. Their confidence was seriously shaken. Why were there such delays? The parents were not satisfied with the action of the professionals responsible for their son’s safety and filed a complaint. This is the kind of file that can end up at the Québec Ombudsman’s.

In this case, the center took disciplinary measures against the two caregivers and beefed up its safety measures for outings. Investigation of the situation showed that at the time of the incident, decisions were mostly improvised. With a view to better managing risks in such circumstances, the Québec Ombudsman went one step further in its intervention. We demanded that the center revise procedures to be followed in cases of flight, unauthorized absence, or disappearance, to make them more precise. We also recommended that the procedures be distributed and covered with all personnel to make sure they were fully understood.

Young people in need of protection

Youth centers take in young people in need of protection. To keep them safe, we must have a clear understanding of the risk potential this environment presents for this already fragile clientele. For example, some young people tend to engage in the same kind of abusive behavior that they have suffered, and their peers may be the targets. To minimize risk, it’s essential that these young people undergo evaluation.

Communication also plays an important role. One complaint that comes to mind was from a parent who suspected that a minor daughter living at a youth shelter had been sexually attacked—a serious charge. In the interest of this child, it was imperative to quickly get to the bottom of the situation. But the mother had to complain several times before a proper investigation was conducted. It revealed that the girl had no individualized service plan. There was a persistent communication problem between caregivers, namely those at the CLSC, the rehabilitation center for the intellectually handicapped, and the special needs school, and this put the young girl’s safety at risk.

It is difficult to both protect young people and control the risks they pose to other young people. Caregivers and managers of youth facilities have a demanding mission. In my interactions with them, I see that they have the interest of the young people in their care at heart. The solutions they come up with are often both creative and relevant.

Promising progress

Concern over improving and preserving the quality of healthcare and social services is the reason for the Québec Ombudsman’s interest in risk management. I have chosen to share with you some examples of shortcomings that were brought to light after complaints were filed. Not out of negativity, or to be alarmist. Dramatizing and sensationalizing the issue provoke distrust and fear. That’s not what we’re looking for. My objective is rather to shed light on the importance of prevention, which for me is synonymous with effectively managing risks.

Transparency, to be of benefit, must serve a constructive purpose. The network is overflowing with competent and devoted employees. Of course, they rarely make the news. I sincerely hope that this conference brings out the best of the progress that’s been made. There are some wonderful successes. I’ll cite as evidence the case of a health and social services center where the Québec Ombudsman recently intervened after a complaint regarding a patient infected by MRSA (methicillin-resistant Staphylococcus Aureus ).

After an alarming increase in the number of hospital-acquired infections, this center implemented an action plan that was exemplary in its approach to preventive practices. Managers identified measures covering equipment, personnel, information, and training.

A security guard was assigned to make sure hygiene rules were adhered to: washing of hands was mandatory for anyone entering the center. To help prevent infection, nursing staff were increased so they could devote 50% of their working hours to overseeing enforcement of these rules in all care units and the emergency room.

Managers invested in new equipment: antiseptic gel dispensers, automatic flush toilets, and automated sinks and paper towel dispensers. To strengthen these measures, a vast handwashing campaign was added along with training for nursing personnel on prevention of hospital-acquired infections.

The results spoke for themselves. In 2004–2005, the incidence of hospital-acquired infection at this institution was four times the average rate in Québec. Today, it is slightly below the average.

The domino effect

I would like to touch upon another cause of accidents I feel can be avoided. You know it well. It’s the domino effect.

The health and social services network is composed of interrelated areas. Making a decision in one area impacts the others. Good decision making requires good overall vision. Let’s take the example of elderly persons who, while waiting for rooms to become available in long-term care facilities, occupy beds in short-term facilities. They find themselves in an environment that doesn’t suit their condition. Despite everyone’s best intentions, the protocols and organization of short-term care aren’t necessarily compatible with those of a client group like the frail elderly. For example, special approaches have been developed for patients with cognitive impairment, but these approaches may not be available to patients in short-term facilities, where they are not easy to apply.

In circumstances like these, risk management can be particularly difficult. Personnel may have no other recourse than physical or chemical restraints—a highly debatable choice from a personal dignity standpoint.

The shortage of beds in care units increases pressure on emergency facilities. For five years, the percentage of unnecessary trips to emergency rooms leading to occupation of a stretcher for 24 hours or more has remained above 20%. Yet we know that an overcrowded emergency unit presents a very high degree of risk for both patients and caregivers.

Another domino effect: recently, some regional agencies adopted special temporary measures with the goal of relieving hospital emergency room congestion. Among other things, they rented space in private facilities and converted single rooms into double ones. Obviously, this is a case that requires extra vigilance and very careful risk assessment Private facilities must be able to provide a safe and secure environment for patients. In other words, the facilities must meet established standards, and personnel must have had adequate training. This type of transfer also requires appropriate medical follow-up. The host facility must have timely access to everything it needs to care for its new patients. We have seen complaints in the past of situations where patients were moved, but their medical files didn’t follow until days later!

Managing risk is more than just a logistical or mathematical match between a patient and a bed. It requires careful planning and coordination of every aspect of care delivery, not just internally, but by outside resources, too.

Toward creative management

In citing examples, I’ve tried to illustrate for you some of the things we can learn in investigating patient complaints. There is, however, something I haven’t touched on yet: the effect of workload on the quality of service. Some examples point quite compellingly to the lack of human and financial resources.

Administratively, nothing is simple in this respect. However, I am convinced that development of a safe environment is more a question of priorities than money. The adage that “an ounce of prevention is worth a pound of cure” really applies here. The fact is that in the long term, effective risk management will inevitably pay dividends. The recommendations that the Québec Ombudsman makes after investigating a complaint are often easy to implement. I’ve brought up several of them during my presentation: good record and file keeping, information for patients and their families, disclosing incidents and accidents, adequate patient assessment, personnel training, and coordination between healthcare professionals.

In many of these cases, these steps serve as catalysts for more targeted risk management actions. Promising initiatives thus stem from creative management.

In this regard, service accreditation boards are very sensitive to the issue of patient well-being in care delivery. For example, the Canadian Council on Health Services Accreditation promotes nearly 20 organizational practices aimed at improving institutional safety. These practices—considered essential and held up as standards—are a valuable tool for identifying dangerous conditions and reducing risks.

A necessary culture change

There is blatant inequality in the implementation of legally prescribed measures. Our daily work at the Québec Ombudsman proves it. I sincerely hope that your discussions at this conference will lead to implementation of these measures. In this vein, I offer two issues for your consideration.

The first is philosophical. Implementation of true risk management in the hospital environment brings with it a major challenge, that of effecting a profound culture change within our health system. This is no strictly technical undertaking. It involves more than applying rules and protocols. We must take a carefully considered approach that will lead to a gradual change in our attitudes and to consistency in our efforts. Our main motivation in this is that our efforts will be for the common good. We are both dispensers and potential users of the health and social services network.

The second issue is a practical one. If applied, the new measures set out in the Act respecting health services and social services will promote safe service delivery. We must however continue to adopt practices that truly support this objective. This will require widespread mobilization of all stakeholders. All levels are interdependent: the local complaints and service quality commissioner, the Québec Ombudsman, the risk management committee, the oversight and service quality committee, and ultimately, the board of directors. Each link in the chain is important. I am convinced that our pledge to work together can bear fruit.

As the touchstone of a reliable healthcare network, risk management must enjoy the backing of all healthcare professionals. It is my hope we will soon see obvious progress toward this obligation’s becoming a priority throughout the network.

A network that inspires confidence

To ignore complaints, deny mistakes, or cover up incidents and accidents increases the level of risk. But instead we must break the silence and shatter taboos. We must practice prevention, so that incidents don’t turn into accidents, and repeated accidents don’t become misconduct. Transparency is the key to bringing about a culture change that is in everyone’s best interest.

In this regard, holding a conference like this is a stimulating way to strive together toward this objective. It is our hope that you are able to re-create this stimulation in each of your working environments.

Managing risk is an investment.