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Quality Improvement and Patient Safety Forum 2016

Thank you to all those who attended the inaugural Quality Improvement and Patient Safety Forum 2016, held on October 19, 2016.

With support from Health Quality Ontario the IDEAS (Improving & Driving Excellence Across Sectors) team working in collaboration with the Centre for Quality Improvement and Patient Safety (C-QuIPS) brought together alumni and other like-minded individuals leading or actively engaged in quality improvement and patient safety work.

Read highlights from the day in “Agents of change in Ontario healthcare system combine to show their stuff”:


Read the story


  • Helen Bevan, Chief Transformation Officer of the National Health Service, England examined some of the latest evidence and methods for spread and sustainability of change.
  • Maitreya (Trey) Coffey, Associate Director and Site Director, Hospital for Sick Children, closed the day with a presentation illustrating the key personal and organizational learnings from SickKids’ first two years of Caring Safely, their transformative safety journey.
  • 20 breakout sessions providing a forum to share the latest quality improvement and patient safety research and learnings
  • The Primary Care Stream, hosted by Health Quality Ontario, included breakout sessions where practitioners could network and discuss practice-based improvement approaches.
  • IDEAS poster and projects awards recognized achievements from IDEAS alumni cohorts.

Learn more about applying to IDEAS Advanced Learning Program (Cohort 11).

Based on overwhelming interest, the IDEAS team has extended the application deadline for the next offering of the IDEAS Advanced Learning Program (Cohort 11) to Friday, Nov. 11, 2017.

Event program details below


Conference Schedule


TIME

SCHEDULE

8:15am – 8:45am

Registration and Breakfast

8:45am – 9:00am

Welcome

9:00am – 10:15am

Keynote Address: Helen Bevan

10:15am – 10:45am

Break

10:45am – 12:15pm

Morning Breakout Sessions

12:15pm – 1:00pm

Networking Lunch

1:00pm – 1:45pm

Posters - Shared Learning

1:45pm – 3:15pm

Afternoon Breakout Sessions

3:15pm – 3:30pm

Break

3:30pm – 4:30pm

Closing Keynote Address: Dr. Trey Coffey, MD, FAAP, FRCR(C)

4:30pm – 6:00pm

2016 Alumni Achievement Awards

Morning Breakout Sessions

Below are the morning breakout sessions.


Speaker: Dr. Noah Ivers

All too frequently, when quality improvement (QI) interventions are tested in trials, the effects are less than expected. This talk will review the empirical evidence for one of the most common QI strategies, audit and feedback, as an intervention to improve quality of care and summarize best practices in the design of interventions that include feedback of performance metrics. This presentation will also explore how those leading QI initiatives can simultaneously contribute to the underlying science regarding how the effectiveness of such interventions can be optimized. Finally, this talk will explore how the lessons from the literature regarding audit and feedback can inform adoption and implementation of changes related to funding reforms including Quality-Based Procedures. Participants will have the opportunity to apply learnings in a case study group activity.


Target Audience

  • Those interested in learning the evidence and science behind best practices in audit and feedback of performance data
  • Those interested in learning how to apply an audit and feedback intervention in a QI initiative

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Describe what is known about the impact of audit and feedback for improving quality of care
  2. List the evidence-based best practices for performance feedback
  3. Discuss “real-world” Ontario-based examples of audit and feedback

Speaker: Helen Bevan

Change is hard and challenging the status quo too often results in resistance, negativity and defeat. Yet it is through the passionate efforts of committed individuals who are prepared to risk being labelled trouble makers that improvements happen, so how then do we lead change that energizes and creates alliances around ashared purpose? This talk discusses leading change that connects individuals rather than isolates, promotes passion rather than anger, creates possibilities rather than problems and generates energy rather than depletes it.


Target Audience

  • Leaders
  • Administrators
  • Researchers
  • Healthcare providers

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Identify and apply tactics for being an effective change agent
  2. Describe powerful approaches to enable change

Speakers: Lee Fairclough/Dr. Jeff Turnbull

This workshop will describe the current context of health care in Ontario. As well, opportunities and challenges for the implementation of a culture of quality, across the province, will be examined. Health Quality Ontario's quality improvement (QI) strategy – including clinician engagement and accountability, regional quality tables, the implementation of Quality Standards – will be discussed. The audience will be engaged in a discussion of opportunities for ongoing engagement and partnership in advancing the goal of a culture of quality for all in Ontario.


Target Audience

  • Community
  • Healthcare providers
  • Policymakers and planners focusing on health care quality

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Outline the vision and elements of a quality healthcare system for Ontario and the challenges and opportunities associated with this
  2. Describe HQO's provincial QI strategy
  3. List the opportunities for partnership and engagement with HQO and other organizations in promoting a culture of quality in our healthcare system for Ontario

Speakers: Ruth Croxford/ Laura Maclagan

Moderator: Joe Mauti

Data is central to any quality improvement (QI) project, but sometimes people struggle to understand what to measure, and how to collect data (sample size, frequency, and variable definitions). This workshop will explain the 3 types of measures (outcome, process, and balance) that are used in QI. We will discuss the importance of operational definitions, and criteria for selecting from a number of possible definitions for a given measure. We will also discuss considerations of sample size (how much data to collect), subgrouping (how frequently data is collected) , and stratification. Concepts will be illustrated using case examples, and participants will learn how to construct run charts in order to learn from data. This will be an introductory presentation. It is not intended for experienced QI practitioners.


Target Audience

  • Healthcare professionals who are considering leading a QI project and are uncertain about how to plan their data collection
  • Executive sponsors who are interested in learning more about data in order to support their teams and interpret data

Learning Objectives
By the end of this workshop, participants will be able to:

  1. List 3 types of measures that are collected during a QI project and recognize different types of data
  2. Discuss the different sampling strategies
  3. Determine the sample size necessary to identify changes
  4. List  how to stratify and subgroup data to optimize learning to construct a run chart

Speaker: Dr. Patricia Trbovich

Moderator: Dr. Christine Shea

The complex, dynamic, and at times unpredictable nature of healthcare environments often place unreasonable demands on clinicians to be more accurate and efficient than is possible. Safety management should therefore focus on both a Safety-I approach (defines safety as the absence of errors) and a Safety-II approach (defines safety as the system’s ability to adapt under varying conditions).

This session will highlight the benefits of applying a combination of theoretical frameworks/approaches when identifying and developing error mitigation strategies. In particular, it will focus on strategies that provide clinicians with the tools to be the adaptive component in the larger healthcare system. By including these strategies in improvement efforts, our healthcare system can move from brittle (where negative outcomes occur as soon as unexpected situations arise), to resilient (where adaptive solutions emerge when unexpected situations are encountered).


Target Audience

  • Quality improvement specialists
  • Human factors practitioners
  • Risk managers
  • Patient safety researchers 
  • Anyone leading the design and implementation of interventions designed to modify healthcare systems/processes

Learning Objectives
By the end of this workshop, participants will be able to:

  1. List the difference between the approaches of Safety-I and Safety-II
  2. Map their current patient safety challenges against some of the latest thinking around intervention design.

Speaker: Dr. Amir Ginzburg

This session will take the attendees through the incident management continuum using an illustrative a case study (where the audience will assist in the immediate management of this patient safety incident). The elements of the continuum will be underpinned by key ideas of root cause categories and just culture. Legislation pertaining to incident analysis will also be discussed.


Target Audience

  • Quality Improvement/risk analysts and managers who carry out patient safety incident analysis
  • Healthcare providers who are interested in the steps involved with carrying out patient safety incident analysis

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Outline the principles, value and impact of patient safety incident analysis
  2. Apply just culture principles to the tension between individual and system accountability
  3. Discuss the intersection of legislation pertaining to incident analysis

Speaker: Dr. Chris Hayes

Moderator: Jennie Pickard

Evidence shows that achieving joy in work leads to more engagement, greater satisfaction (for both patients and staff), and better outcomes. However, evidence also shows that obtaining joy in work is often challenging, and increasingly care providers are reporting burnout, dissatisfaction, and a loss of purpose. In this session, participants will reflect on the attributes of a care environment that promote or inhibit joy in work and the important connection with person- and family- centered care and the achievement of the Triple Aim.


Target Audience

  • Front-line providers
  • Clinical managers
  • QI specialists
  • Healthcare leaders
  • HR specialists
  • Patients

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Outline the relationship between the Quadruple Aim and quality patient care
  2. Identify environmental attributes that promote joy in work, positive patient experience, minimize burnout, promote meaningful engaged professional and patient interactions and support achievement of the Triple Aim
  3. Describe strategies that create environments where professionals and patients thrive

Moderator: Joanne Goldman

This session consists of four "Top Abstracts" oral presentations. These abstracts were chosen from the over 75 poster abstract submissions. Each presenter will have 10 minutes to present followed by 5 minutes of questions and discussion.

The four presentations are:

Targeted deprescribing in an outpatient hemodialysis unit: A study to decrease polypharmacy
Presenter: Marisa Battistella, BSc Phm, Pharm D, ACPR, University Health Network, Leslie Dan Faculty of Pharmacy, University of Toronto

Enhancing patient experience with follow-up diabetes care while increasing efficiencies using quality improvement methods
Presenter: Margaret De Melo, RD, CDE, MSc, Toronto Western Hospital, University Health Network

Use of Patient-Oriented Discharge Summaries (PODS) at time of discharge from the clinical teaching unit improves transitional care by targeting patient education and access to timely follow-up
Presenter: Erin Spicer, MD, Western University

Reduction of severe intraventicular hemorrhage in the micropremature population
Presenter: Sabrina Wong, NNP, Sunnybrook Health Sciences Centre


Target Audience

  • Quality improvement specialists
  • Health care service researchers
  • Front line service providers
  • Organizational leadership

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Discuss current QI projects and findings
  2. Learn about new QI initiatives that can be applied to their own workplace settings 

Speaker: Laura Williams

Moderator: Aman Sium

Participants will experience first-hand the wealth of knowledge gained from patient and caregiver partnerships through this dynamic workshop, co-facilitated by patient and family advisors. Using established patient engagement principles and QI methodologies, participants will partner with HQO advisors to discover how these voices can join to improve the health system. Participants will learn tangible skills that they can bring into their work and leave feeling confident in their ability to partner with patients, their caregivers and other healthcare professionals from across the health system.


Target Audience

  • QI initiative leads who carry out the scale up plans   
  • Front-line staff and health leaders who are looking for enhanced knowledge on how to bring the patient and family voice into QI work at their organization

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Embed patient engagement principles and leading practices in QI projects
  2. Discuss opportunities and challenges of bringing the patient/caregiver voice into QI

Speaker: Dr. Brian Wong

The session will begin with a brief overview of the evolution of patient safety and QI education over the past 15 years, with specific focus on the expected competencies that health professionals should have with respect to patient safety and QI. Participants will then work together to explore and practice different approaches to teaching patient safety and QI, including facilitated small group learning, case-based learning, and project-based learning.


Target Audience

  • Patient safety and QI leads with an interest in education.
  • Health professions educators with an interest in patient safety and QI

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Reflect on the overlap between patient safety, QI and health professions education
  2. Teach others about patient safety or QI

Afternoon Breakout Sessions

Below are the morning breakout sessions.


Speaker: Dr. Noah Ivers

All too frequently, when quality improvement (QI) interventions are tested in trials, the effects are less than expected. This talk will review the empirical evidence for one of the most common QI strategies, audit and feedback, as an intervention to improve quality of care and summarize best practices in the design of interventions that include feedback of performance metrics. This presentation will also explore how those leading QI initiatives can simultaneously contribute to the underlying science regarding how the effectiveness of such interventions can be optimized. Finally, this talk will explore how the lessons from the literature regarding audit and feedback can inform adoption and implementation of changes related to funding reforms including Quality-Based Procedures. Participants will have the opportunity to apply learnings in a case study group activity.


Target Audience

  • Those interested in learning the evidence and science behind best practices in audit and feedback of performance data
  • Those interested in learning how to apply an audit and feedback intervention in a QI initiative

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Describe what is known about the impact of audit and feedback for improving quality of care
  2. List the evidence-based best practices for performance feedback
  3. Discuss “real-world” Ontario-based examples of audit and feedback

Speakers: Jerome Leis/Christine Soong

Moderator: Brian Wong

The session will begin with a brief didactic presentation highlighting implementation principles and strategies. Attendees will work in small groups to apply theory to address common challenges facing resource utilization implementation. Participants will have the opportunity to share their own experiences in reducing unnecessary use of resources.


Target Audience

  • Front line clinicians
  • Quality improvers
  • Early adopters of Choosing Wisely Canada

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Describe the key elements of the Choosing Wisely campaign that can support implementation of initiatives to decrease unnecessary use of resources
  2. Implement changes in their local setting to address a resource overuse problem

Speakers: Lee Fairclough/Dr. Jeff Turnbull

This workshop will describe the current context of health care in Ontario. As well, opportunities and challenges for the implementation of a culture of quality, across the province, will be examined. Health Quality Ontario's quality improvement (QI) strategy – including clinician engagement and accountability, regional quality tables, the implementation of Quality Standards – will be discussed. The audience will be engaged in a discussion of opportunities for ongoing engagement and partnership in advancing the goal of a culture of quality for all in Ontario.


Target Audience

  • Community
  • Healthcare providers
  • Policymakers and planners focusing on health care quality

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Outline the vision and elements of a quality healthcare system for Ontario and the challenges and opportunities associated with this
  2. Describe HQO's provincial QI strategy
  3. List the opportunities for partnership and engagement with HQO and other organizations in promoting a culture of quality in our healthcare system for Ontario

Speakers: Ruth Croxford/Laura Maclagan

Moderator: Joe Mauti

During the workshop, we'll cover the lifetime of a Statistical Process Control chart, from collecting baseline data to learning from PDSA cycles, to monitoring the process afterwards to ensure that improvements are sustained.

The workshop will also examine considerations of sample size, subgrouping, and stratification – all of which are important in order to ensure that you can learn as much possible from the data you worked so hard to collect.


Target Audience

  • Quality improvement (QI) teams who are interested in moving beyond run charts to use statistical process control (Shewhart) charts to learn more from their data
  • Executive sponsors who want to learn more about learning from charts

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Select the correct type of statistical process control (SPC) chart
  2. Create, update and interpret SPC charts
  3. Describe the process of learning from data over the lifetime of a QI project – from collecting baseline data through tests of change to sustaining the improvements

Speaker: Dr. Kaveh Shojania

The breadth of fields relevant to quality improvement (QI) and patient safety and the wide range of sources in which new research appears can make it difficult to keep abreast of important developments in QI and patient safety. In this session, the presenters will discuss the most notable research of the past year and address how the evidence-based QI and patient safety interventions and effective strategies identified in these papers can be translated into practice.


Target Audience

  • Patient safety leaders and specialists
  • Quality improvement leaders and specialists
  • Policy advisors
  • Organizational leadership
  • Front line service providers
  • Patient leaders in the home and community, primary care, and acute care sectors

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Gain a thorough understanding of where is the QI and patient safety movement headed and what new issues will emerge
  2. Learn new strategies that can be applied to their own practice

Speaker: Dr. Patricia Trbovich

Moderator: Christine Shea

The complex, dynamic, and at times unpredictable nature of healthcare environments often place unreasonable demands on clinicians to be more accurate and efficient than is possible. Safety management should therefore focus on both a Safety-I approach (defines safety as the absence of errors) and a Safety-II approach (defines safety as the system’s ability to adapt under varying conditions).

This session will highlight the benefits of applying a combination of theoretical frameworks/approaches when identifying and developing error mitigation strategies. In particular, it will focus on strategies that provide clinicians with the tools to be the adaptive component in the larger healthcare system. By including these strategies in improvement efforts, our healthcare system can move from brittle (where negative outcomes occur as soon as unexpected situations arise), to resilient (where adaptive solutions emerge when unexpected situations are encountered).


Target Audience

  • Human factors practitioners
  • Risk managers
  • Patient safety researchers
  • Anyone leading the design and implementation of interventions designed to modify healthcare systems/processes

Learning Objectives
By the end of this workshop, participants will be able to:

  1. List the difference between the approaches of Safety-I and Safety-II
  2. Map their current patient safety challenges against some of the latest thinking around intervention design.

Speaker: Dr. Amir Ginzburg

This session will take the attendees through the incident management continuum using an illustrative a case study (where the audience will assist in the immediate management of this patient safety incident). The elements of the continuum will be underpinned by key ideas of root cause categories and just culture. Legislation pertaining to incident analysis will also be discussed.


Target Audience

  • Quality Improvement/risk analysts and managers who carry out patient safety incident analysis
  • Healthcare providers who are interested in the steps involved with carrying out patient safety incident analysis

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Outline the principles, value and impact of patient safety incident analysis
  2. Apply just culture principles to the tension between individual and system accountability
  3. Discuss the intersection of legislation pertaining to incident analysis

Speaker: Dr. Chris Hayes

Moderator: Jennie Pickard

Evidence shows that achieving joy in work leads to more engagement, greater satisfaction (for both patients and staff), and better outcomes. However, evidence also shows that obtaining joy in work is often challenging, and increasingly care providers are reporting burnout, dissatisfaction, and a loss of purpose. In this session, participants will reflect on the attributes of a care environment that promote or inhibit joy in work and the important connection with person- and family- centered care and the achievement of the Triple Aim.


Target Audience

  • Front-line providers
  • Clinical managers
  • QI specialists
  • Healthcare leaders
  • HR specialists
  • Patients

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Outline the relationship between the Quadruple Aim and quality patient care
  2. Identify environmental attributes that promote joy in work, positive patient experience, minimize burnout, promote meaningful engaged professional and patient interactions and support achievement of the Triple Aim
  3. Describe strategies that create environments where professionals and patients thrive

Speaker: Laura Williams

Moderator: Aman Sium

Participants will experience first-hand the wealth of knowledge gained from patient and caregiver partnerships through this dynamic workshop, co-facilitated by patient and family advisors. Using established patient engagement principles and QI methodologies, participants will partner with HQO advisors to discover how these voices can join to improve the health system. Participants will learn tangible skills that they can bring into their work and leave feeling confident in their ability to partner with patients, their caregivers and other healthcare professionals from across the health system.


Target Audience

  • QI initiative leads who carry out the scale up plans
  • Front-line staff and health leaders who are looking for enhanced knowledge on how to bring the patient and family voice into QI work at their organization

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Embed patient engagement principles and leading practices in QI projects
  2. Discuss opportunities and challenges of bringing the patient/caregiver voice into QI

Speakers: Dr. Teodor Grantcharov/Dr. Vicky Stergiopoulos

Moderator: Kaveh Shojania

In this session, the speakers will share lessons learned from the design and implementation of local innovations to improve patient safety and the quality of care.

Dr. Vicky Stergiopoulos will present lessons learned from efforts to support transitions of care and service coordination for people who are homeless or frequent users of emergency departments. Barriers and facilitators to continuity of care for these populations will be discussed. As well, health and service use outcomes of brief inter-professional interventions implemented in a large urban centre to bridge hospital and community care will be described.

Dr. Teodor Grancharov will review the impact of objective and reliable assessment on quality of surgical education and safety. He will present lessons learned from the implementation of successful training strategies from other high-risk, high-performance, such as the “blackbox” used in the airline industry. As well, Dr. Grancharov will highlight the implementation of modern risk reduction strategies in surgery.


Target Audience

  • Clinicians and managers interested in the design and implementation of local innovations

Learning Objectives
By the end of this workshop, participants will be able to:

  1. Discuss two local innovations that have been implemented in the local context
  2. List the barriers and facilitators to implementing local innovations in the local context
  3. To apply strategies of implementation to their local contexts

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