NUR402 Test #2

Healthcare Categories 4 Levels

- Health Promotion - Disease and Injury Prevention (Protection) - Diagnosis and Treatment of Existing Health Problems (Primary, Secondary, Tertiary) - Rehabilitation

Human Resources

- Health care is labour intensive and expensive - Estimate...80% of operating cost is salary and benefits - List the duties, time and resources allocated to perform a catheterization for your client.

Budgets

- Help define services (costs) - Require forward thinking (planning) - Serve as benchmarks - Typically are monitored monthly - Foster collaboration between departments *Expenses* - the cost associated with the delivery of service *Expenditures* - resources used by an organization to deliver services --include labour, supplies, equipment, space, utilities, & miscellaneous items *Human Resources* - Salaries & benefits account for 80% health care budgets - Calculations are made according to amount of staff time required to complete a service *Staffing* - staffing models outline the number of staff required (based on the procedures or clients) most cost effective combination of staff important to consider *Supplies* - Zero-based budgeting is a process used to itemize expenses by detailing every supply item & quantity of items used - Budgets are completed at unit levels & final approval happens with senior administration - Budgets are monitored monthly - Flexible budgets allow for adjustments - Unit staff should be involved in discussion

Trends in Healthcare

- Need to work with interprofessional teams Future demands will include interdisciplinary education - To provide a seamless process with an integrated approach to health care delivery Focus on health care will be: - Outcome-focused - Evidence-based - Wellness-oriented - Population-based - Technology intensive - Cost aware

Community Health Centres

- Not Public Health - Not CCAC - 74 Community Health Care Centres in Ontario - Community governed not-for-profit primary health care organizations - Governed by a board of clients, community members, health providers and community leaders. - Enables health services to be more easily oriented towards what community members identify as their most important needs. - "Our goal is to work towards a complete state of well-being for individuals, families and entire communities"

3. Communicate effectively for patient safety

- Crucial to optimize positive patient outcomes - Focus is on "Process" - 2 main foci • *Preventing adverse events* • *Responding to adverse events* - Demonstrated competencies: 1. Effective verbal & non-verbal communication 2. Effective management in high risk situations 3. Written communication 4. Use of communication technologies

National Healthcare

- Designed to ensure Canadians have a reasonable access to medical treatment, hospital & physician services on a uniform prepaid basis (Health Canada, 2006) -1947: Saskatchewan initiates provincial universal public hospital insurance plan (known today as OHIP) - 1962: Saskatchewan introduced a universal, provincial medical insurance plan to provide doctors' services to all its residents - Tommy Douglas is the 'Father' of Medicare in Canada - Remaining provinces and territories also develop insurance plans

Provincial Public Health

- Ontario Public Health Association (OPHA) 1949 - Provide leadership on issues affecting the public's health - Currently 36 Health Units in Ontario Legislated by the Health Protection and Promotion Act Mandate: "To provide for the organization and delivery of public health programs and services, to prevent the spread of disease, to promote and protect the health of the people of Ontario." Education, community action, and advocacy Decision makers: board of health and a medical health officer, Members are municipal officials and community representatives

Patient Safety Incident

an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces "adverse event." (Example: e wrong unit of blood was infused and patient died from a haemolytic reaction.) No harm incident: A patient safety incident which reached a patient but no discernable harm resulted. (Example: e wrong unit of blood was infused, but was not incompatible.) Near miss: A patient safety incident that did not reach the patient. Replaces "close call." (Example: A unit of blood was being connected to the wrong patient's intravenous line, but this was detected before the infusion started.)

Collaborative Practice

an interdisciplinary process for communication and decision-making that enables the separate and shared knowledge and skill of the care providers to synergistically influence the client/patient care provided" Advantages - achieve optimal utilization of workforce - strengthen the provision of safe & high quality care - improves retention - enhances client & staff satisfaction Disadvantages - role confusion - providers perceive as excessive duplication of effort

Identify eHealth Ontario's purpose and initiatives.

eHealth Ontario is responsible for developing a single provincial eHealth strategy and aligning it with all publicly-funded eHealth initiatives through a single point of accountability. It is accountable to the government and to the people of Ontario. - The vision of eHealth Ontario is to achieve excellence in health care by harnessing the power of information. Its strategy is patient-focused and provides tangible clinical impact. It provides clinically relevant solutions for health care professionals, active engagement of communities and experts and collaboration and partnerships. - eHealth Ontario will ensure that its actions are transparent to the public and to all its stakeholders, that resources are used effectively and efficiently to realize performance improvements for Ontario's health care system. - The ultimate goal is to deliver a comprehensive, patient-focused, secure and private electronic system that will improve the way patients receive care.

Models of Care

based on the needs of clients & availability of competent staff skill levels - Total Patient Care Model - Functional Nursing/Team Nursing - Modular Nursing - Primary Nursing - Client Centred Collaborative Practice

Failure to Recognize

signs or cues of patient deterioration are evident several hours prior to a cardiac arrest, but may be subtle and not recognized by nurses or medical staff. - high frequency surveillance can increase the chance of noticing change - failure to recognize can be due to nurses inexperience or a high workload, one nurse having a lot of patients and by lack in ability to analyze, stems from perceived hierarchy in hospital

Case Management

strategy to improve patient care & reduce hospital costs through coordination of care Case Manager: - responsible for coordinating care & establishing goals from preadmission through discharge - evaluates the patient's outcomes daily & compares them to the predicted outcomes articulated in the clinical pathway - works with all the disciplines to facilitate care - Discharge Planner/CCAC

International Health Care

(WHO) World Health Organization - "to build a better, healthier future for people all over the world" - 7000 people working in 150 different country offices - Direct and coordinate international health within the United Nations' system. - Promoting health, preventing disease - Combat disease (smallpox eradicated in 1980) - Distribution of safe vaccinations and drugs - Health research in communicable disease - (SARS, TB, H1N1, Malaria) - Preparedness, surveillance and response.

5. Optimize human and environmental factors

*Human Factors* - Gender - Age - Personality - Risk tolerance - Work-life balance - Sleep deprivation *Environmental Factors* - Light and sound - Work interruptions - Technology

Organizational Structure

*Mission statement:* formal expression of the purpose or reason for existence of the organization *Philosophy:* value statement of principles & beliefs that direct the organization's behaviour *Vision:* provides a clear picture of what the future will look like, it defines the key results achieved & goals that are to be accomplished *Values:* may be formally stated & explicit, or may be implicit & part of the organizational culture

Changing Terminology

*Older Terminology* *Adverse Event (AE):* "An event that results in unintended harm to the patient, and is related to the care and/or services provided to the patient rather than to the patient's underlying medical condition. (The Safety Competencies, CPSI, 2009, p. 41) *Error:* New guidelines avoid using this term. Most incidents are 'a complex interplay of factors.' **note that you will still see these terms used frequently!

Guiding Principles of CPSI Disclosure Guidelines

*Patient-centered healthcare:* An environment of patient-centered healthcare fosters open, honest and ongoing communication between healthcare providers and patients. Healthcare services should be respectful, supportive and take into consideration the patient's expectations and needs at all times. *Patient autonomy:* Patients have the right to know what has happened to them in order to facilitate their active involvement and decision-making in their ongoing healthcare. *Healthcare that is safe:* Patients should have access to safe healthcare services of the highest possible quality. Lessons learned from patient safety incidents should be used to improve the practices, processes and systems of healthcare delivery. *Leadership support:* Leaders and decision makers in the healthcare environment must be visible champions of disclosure as part of patient-centered healthcare. Disclosure is the right thing to do: "Individuals involved at all levels of decision-making around disclosure must ask themselves what they would expect in a similar situation1." *Honesty and transparency:* When a harmful incident occurs, the patient should be told what happened. Disclosure acknowledges and informs the patient, which is critical in maintaining the patient's trust and confidence in the healthcare system.

External Level

*Physical/Structural* ■ Factors include health care delivery models, funding, and legislative, trade, economic and political frameworks (e.g. migration policies, health system reform) external to the organization *Cognitive/Psycho/Socio/Cultural Components* - Factors include consumer trends, changing care preferences, changing roles of the family, diversity of the population and providers, and changing demographics - all of which influence how organizations and individuals operate. *Professional/Occupational* Factors include policies and regulations at the provincial/territorial, national and international level which influence health and social policy and role socializations within and across disciplines and domains.

Organizational Level

*Physical/Structural* ■ Factors include the physical characteristics and the physical environment of the organization and also the organizational structures and processes created to respond to the physical demands of the work. Included among these factors are staffing practices, flexible and self-scheduling, access to functioning lifting equipment, occupational health and safety polices, and security personnel. *Cognitive/Psycho/Socio/Cultural Components* - Included among these factors are organizational stability, communication practices and structures, labour/management relations, and a culture of continuous learning and support. *Professional/Occupational* Factors are characteristic of the nature and role of the profession/occupation. Included among these factors are the scope of practice, level of autonomy and control over practice, and intradisciplinary relationships.

Discuss select identified safety issues that have ISMP developed best practices.

- Accidental daily dosing of oral methotrexate intended for weekly administration - Missing or inaccurate patient weights, and mix-ups between metric and non-metric units when measuring and documenting weight - Unintended intravenous administration of oral medications - Mix-ups between milliliters and non-metric units when measuring oral liquid medications - Inadvertent administration of neuromuscular blocking agents to patients not receiving proper ventilator assistance - Infusion-related errors when administering high-alert intravenous medications - Delay in administration or improper use of antidotes, reversal agents, and rescue agents - Accidental administration of an intravenous infusion of sterile water - Errors during sterile compounding of drugs, especially high-alert medications - Inappropriate use of fentaNYL patches to treat acute pain and/or patients who are opioid-naïve - Serious tissue injuries and amputations from injectable promethazine use - Lack of learning from external medication safety risks and errors

Functional Nursing/Team Nursing

- Divides work into functional units assigned to one team members each care provider is responsible for specific duties or tasks Advantages -Care can be delivered to large numbers of clients Disadvantages - Care seems fragmented to clients - Care delivered by several nurses - Continuity of care compromised

Health Outcomes for Canadians

- EMR use results in health system level benefits, such as reduced numbers of duplicate tests and adverse drug events. - Advanced use of EMRs can improve health outcomes and patient safety through preventive care and chronic disease management. - Telehealth saved more than 218 million kilometres in travel and $325 million in personal travel costs for patients and their families in 2016 alone. - 93 per cent of physicians who use an electronic medical record said EMRs allow them to provide improved patient care. - 63 per cent of patients who have used digital consumer health solutions said they avoided an in-person visit because they could request a prescription electronically. - 100 per cent of Canadians have at least one hospital clinical report, or their immunization record, available in electronic form, and their authorized clinicians can access this information outside of a hospital. - 100 per cent of diagnostic images taken in Canadian hospitals are filmless, and stored in a repository for access by authorized clinicians. - Drug dispensing profiles for 72 per cent of Canadians are now available for access by authorized clinicians. - 85 per cent of Canadian primary care doctors and 79 per cent of community specialists are using electronic medical records to record patient encounters. - Laboratory test results for 97 per cent of Canadians are available electronically for access by authorized clinicians.

Nursing Role

- Ensure the caliber of care is not compromised - Manage care costs as it relates to their own clinical practice - Accountable for distribution and consumptions of resources - Partner with management team to implement cost-effective practices

Healthcare Spending

- Canadian health care spending has increased three times amount since 1975 - In 2016, total health expenditure in Canada is expected to reach $228 billion, or $6,299 per person. - 11% of Canada's gross domestic product (GDP). - Federal government is funding a lower percentage than previously

Factors Affecting Health Care

- Capitation - New diseases - New technology - Aging population - Genetic engineering - Increasing cultural diversity - Information management - Globalization of the world economy - Payment of clinicians based on performance, using clinical guidelines

Regulatory Requirements

- Regulatory Requirements - Accreditation Canada (AC) assists health organizations across the country to examine & improve the quality of care & service they provide - new accreditation program in 2008 called Qmentum, which emphasizes health system performance, risk prevention planning, client safety, performance measurement, and governance

New Terminology

- *Patient Safety Incident*: An event or circumstance that could result in or did result in unnecessary harm to a patient. *Harm Incident*: A patient safety incident that did result in harm to the patient. Replaces 'Adverse Event' or 'Sentinel Event'. Near Harm Incident: A patient safety incident which reached the patient but no discernable harm resulted. Near Miss: A patient safety incident that did not reach the patient. Replaces 'Close Call'. Systems Approach: involves analysis of multiple factors Health Care Associated Harm: Iatrogenic*

CPSI (Canadian Patient Safety Institute) - Hand Hygiene Statistics

- 220,000 people are afflicted with healthcare-associated infections in Canada every year. - 8,000 to 12,000 of those individuals will die as a result of acquiring a healthcare-associated infection. One study found that: - 80% of hospital staff who dressed wounds infected with methicillin-resistant Staphylococcus aureus carried the organism on their hands for up to three hours. - 60% of hospital staff in contact with patients with Clostridium difficile infection were contaminated within half an hour without even touching the patient, merely from returning drug charts to the ends of beds! - 40% of all patient-nurse interactions resulted in the same species of Klebsiella pneumoniae being transmitted to healthcare workers' hands, even with contact as light as touching the patient's shoulder. - Meanwhile, simply washing with soap and water virtually eradicated these organisms.

1. Contribute to a culture of patient safety

- A commitment to applying core patient safety knowledge, skills and attitudes in everyday work - Two interdependent factors to achieve this: • *Organizational framework* that enables and supports a culture of safety • Appropriate *expertise, attitudes and values* of those who work in the system Institutions and individuals choose a Culture of safety

Services Not Covered By OHIP

- Ambulance services (45$ payment required) - Routine eye examinations for people aged 19-64 - Some Physiotherapy may be partially covered - Routine Dental Care (some emergency surgeries done in the hospital may be covered) - Podiatrists are only partially covered by OHIP. - Chiropractors - Necessary emergency medical care obtained outside of Canada is covered on a very limited basis

Population Health

- An approach to health care that focuses on health determinants - Aims to reduce inequities among different groups of population *Goal:* to improve the health of the entire population - Determinants of health (i.e. education level/ income level) contribute to health - Determinants of health determine ability to possess physical, social and personal resources to identify and achieve personal aspirations, satisfy needs and cope with the environment - Populations become healthier when we invest in preventing illness

4. Manage safety risks

- Anticipate, recognize and manage situations that place clients at risk - Non -technical/medical skills - Focus on system design Competencies: 1. Recognize routine situations that increase risk 2. Systematically identify, implement and evaluate safety solutions 3. Anticipate and manage high risk situations

Hierarchy

- Board of Trustees - Chief Executive officer - Vice Presidential Officer - Department Directors - Managers - Charge Nurses/Clinical Leaders/Nurse Educators - Staff Nurse

Health Care Professionals In Canada

- CIHI Nursing Workforce Infographic - Most of these registered professionals work in hospitals - Physicians make up the second largest group in the workforce - Nursing and physician workforce aging - Professions have subcultures that affect their working together (impact on care delivered to clients)

Provincial Health Care

- Canada's health care system is public but not nationalized - Each province/territory manages its own insurance system and has their own healthcare identification cards - Responsible for public health and long term care Inconsistency from province to province regarding 'extra' care not required from the Canada Health act (Rehabilitation, Dental Care, Mental Health, Outpatient Drugs, Vision Care, Long term care) - Substantial portion (30%) of such services being paid for through private insurance, or out of pocket - Primary Health Care is the foundation of the health care system: first point of contact people have with the health care system - Federal Government (2000) --Invested $800 million in Primary Health Care Transition Fund (support provinces/territories to improve and expand primary health care delivery in Canada) Health care services include: - Physicians and other health professionals services - Hospital Care (majority of health expenditures) - Funded from general tax revenues - No direct charges to the patient.

Public Health Activities

- Immunization - Alcohol Policy network - Injury Prevention Initiative - Nutrition Resource Centre - Youth Engagement Project - Heart Health Resource Centre - Chronic Disease Prevention Projects

Ontario Ministry of Health and Long Term Care

- In 2006, the MOHLTC divided the province into 14 regions or Local Health Integration Networks (LHINs) - Thought was... people living locally were better able to plan, fund and integrate health services in their own communities than people in Toronto - By April 1, 2007, LHINs took on full responsibility for health services in their communities.

Why is information Important to eHealth and nursing practice?

- Information is required to make good clinical decisions. - Information is a requisite in the development of nursing knowledge and research. - Information is required in the development of evidence-based practice.

Organization Practice Recommendations

- Organizations/nursing employers create and design environments and systems that promote safe and healthy workplaces, including such strategies as: ■ Creating a culture, climate and practices that support, promote and maintain staff health, wellbeing and safety. ■ Ensuring that the organization's annual budget includes adequate resources (human and fiscal) to implement and evaluate health and safety initiatives. ■ Establishing organizational practices that foster mutual responsibility and accountability by individual nurses and organizational leaders to ensure a safe work environment including protection from violence. - Organizations / nursing employers create work environments where human and fiscal resources match the demands of the work environment. - Organizations/nursing employers implement a comprehensive Occupational Health and Safety Management System, based on the applicable legislation, regulations and best practice guidelines. - Organizations/nursing employers are aware of the impact of organizational changes (such as restructuring and downsizing) on the health, safety and well-being of nurses and be responsible and accountable for implementing appropriate supportive measures. - Organizations/nursing employers form partnerships and work with researchers to conduct evaluations of specific interventions aimed at improving nurses' health and well-being. - Organizations/nursing employers implement and maintain education and training programs aimed at increasing awareness of health and safety issues for nurses. (e.g. safelift initiative, rights under OSHA, hazard awareness, etc.). - Organizations/nursing employers provide ongoing training programs and education programs to ensure staff possess the knowledge to recognize, evaluate and control or eliminate hazardous work situations. - Organizations/nursin

Strategic Planning

- Planning Goals & Objectives - Goals & objectives must be prioritized after identification (according to strategic importance/ required resources & time & effort involved) - Timelines for completion along with evaluative measures for each goal - Communication of all goals & objectives to all stakeholders is key (marketing)

6. Recognize, respond and disclose adverse events

- Recognize the occurrence of an AE or a Near Miss! - Respond effectively to reduce harm - Disclose event to all involved - Prevent reoccurrence - Most important is to eliminate the *culture of blame*

Professional Practice Models

- Shared governance: - Framework grounded in the decentralization of leadership that fosters autonomous decision making and professional nursing practice - Example: management relinquishes control over clinical practice issues - Nurses accept responsibility and accountability for their practice - Clinical practice council - Quality council - Education council - Research council - Management council - Coordinating council

CPSI (Canadian Patient Safety Institute)- Health Care Associate Infections

- are the most frequent adverse event in healthcare delivery worldwide. Hundreds of millions of patients are affected by healthcare-associated infections each year, leading to significant mortality and financial losses for health systems (World Health Organization HAI Fact Sheet, 2014). Each year, about 8,000 Canadians die from hospital-acquired infections; 220,000 others get infected. Treatment is more costly than prevention; estimated costs for 2004 were $82 million. Costs are estimated at $129 million for 2010. That's $12,216 per infected MRSA patient per year due to: - Prolonged hospitalization - Special control measures - Expensive treatments - Extensive surveillance You can successfully reduce healthcare-associated infections with these five evidence-based infection control strategies: - Establish an aggressive hand hygiene program - Clean and decontaminate the environment and equipment - Implement contact precautions for any patient infected or colonized with a superbug - Perform MRSA and VRE screening surveillance on admission and at other times - Regularly report superbug infection rates to frontline and hospital leaders

Failure to Escalate

- when abnormal findings are found there should be an escalation in care - ineffective communication is a primary barrier, they don't tell the physician out of fear a negative outcome from them

Focus of Quality Assurance (doing it right)

1. Assessing or measuring performance retrospectively; reviewing chart audits and incident reports 2. Determining whether performance conforms to standards 3. Improving Performance when standards are not met

Six Domains of Safety Competencies.

1. Contribute to a culture of patient safety 2. Work in teams for patient safety 3. Communicate effectively for patient safety 4. Manage safety risks 5. Optimize human and environmental factors 6. Recognize, respond and disclose adverse events

Focus of Continuous Quality Improvement (doing the right thing)

1. Meeting the needs of the customer proactively 2. Building quality performance into the work process 3. Assessing the work process to identify opportunities for improved performance 4. Employing a scientific approach and using data for assessment and problem solving 5. Improving health care performance and changing the health care system continuously as a management strategy, not just when standards are not met

Canada Health Act

1984: Canada Health Act, Federal Government combines both hospital and medical acts; to establish 5 basic principles for health care: - Universality available to all eligible residents of Canada - Comprehensive coverage for hospital and physician services - Accessible without financial and other barriers; available to all Canadians on the basis of need - Portable within the country and during travel abroad - Publicly Administered public authority administers and operates the plan on a non-profit basis

Integrated Healthcare Delivery Systems

A network of health care organizations that provides or arranges to provide a coordinated continuum of services to a defined population an is willing to be held clinically and fiscally accountable for the outcomes and the health status of the population served. Care provided on a continuum includes: - Prevention - Wellness - Health promotion - Acute, restorative and maintenance care Coordinated Services can be provided through a network of systems - Hospitals - Nursing homes - Schools - Public Health Departments - Social and Community - Health Organizations

TeamSTEPPS Pocket Guide: Step

A tool for monitoring situations in the delivery of healthcare *S*tatus of Patient __ Patient History __ Vital Signs __ Medications __ Physical Exam __ Plan of Care __ Psychosocial Issues *T*eam Members __ Fatigue __ Workload __ Task Performance __ Skill __ Stress *E*nvironment __ Facility Information __ Administrative Information __ Human Resources __ Triage Acuity __ Equipment *P*rogress Towards Goal __ Status of Team's Patient(s)? __ Established Goals of Team? __ Tasks/Actions of Team? __ Plan Still Appropriate?

Accreditation

Accreditation Canada (AC) national organization - Assists health service organizations across Canada to examine and improve quality of care they provide Qmentum (2009) new program: -health system performance - client safety - risk prevention planning - performance measurement - governance Accreditation (AC) has focused on patient safety: - Culture - Communication - Medication Use - Worklife/workforce - Infection Control Falls prevention Risk Assessment

Clinical Pathways

Advantages - Very instructive to new staff - Save time in the process of care - improve care & shorten length of stay - Allows for data collection of variances to the pathway Disadvantages - Some physicians perceive pathways to be cookbook medicine & are reluctant to participate in their development - Development requires a significant amount of work to gain consensus from the various disciplines on the expected plan of care - Pathways are less effective for patient populations that are nonstandard, since they are constantly being modified to reflect individual patient needs

Harm Incidents (Adverse Events)

Are occurring in health care at alarming rates and are resulting in increases in morbidity and mortality Canadian Patient Safety Institute established and funded by federal government focuses on: Education Research Interventions and Programs Tools and Resources

Clinical Practice

Benner's clinical or career laddering model acknowledges that practitioners can be expected to have acquired tasks, competencies, and outcomes that are based on five levels of experience. - Novice - task oriented, focused - Advanced beginner - somewhat independent - Competent - 2/3 years - Proficient - Expert - ++ experience

List of Acronyms

C-HOBIC - Canadian Health Outcomes for Better Information and Care CASN - Canadian Association of Schools of Nursing EHR - Electronic Health Record EMR - Electronic Medical Record ICNP - International Classifications of Nursing Practice ICTs - Information and Communication Technologies PHR - Personal Health Record SNOMED-CT - Systematized Nomenclature of Medicine - Clinical Terms

Describe the three CASN Informatics Competencies and assess yourself against the indicators for each competency.

CASN has identified three entry-to-practice nursing informatics competencies under the domains of: 1. Information and knowledge management - Uses relevant information and knowledge to support the delivery of evidence informed patient care. 2. Professional and regulatory accountability - Uses ICTs in accordance with professional and regulatory standards and workplace policies. 3. Use of ICTs - Uses information and communication technologies in the delivery of patient/ client care. These are encompassed in the Overarching Competency Uses information and communication technologies to support information synthesis in accordance with professional and regulatory standards in the delivery of patient/client care. C=Competent D=Developing T=To be developed

Describe CPSI Disclosure Guidelines

Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare providers, inter-professional teams, organizations, and regulators. These guidelines symbolize a commitment to patients' right to be informed if they are involved in a patient safety incident by promoting a clear and consistent approach to disclosure, emphasizing the importance of inter-professional teamwork, and supporting learning from patient safety incidents. Objective: 1. Facilitate patient/healthcare provider communications that respect and address the needs of patients and strengthen relationships. 2. Promote a clear and consistent approach to disclosure. 3. Promote interdisciplinary teamwork. 4. Support learning from patient safety incidents.

Research 2

Canadian Foundation for Healthcare Improvement (CFHI) 1997 Independent / nonprofit, Funded by federal government To improve health system performance by: maximizing value-for-money in healthcare spending improving patient and family experience of care optimizing patient outcomes To improve the health of Canadians by: addressing the determinants of health enhancing population health

Research 1

Canadian Institute of Health Information (CIHI)1994 Independent / nonprofit Provides essential data and analysis on Canada's health system and the health of Canadians Our vision: Better data. Better decisions. Healthier Canadians. Health care services Health spending Health human resources Population health

Private Health Insurance

Canadians can buy private insurance coverage or can participate in an employee benefit plan offered by the employer Dental plans Vision care Pharmaceuticals Paramedical (physiotherapy, chiropractic, speech, massage)

Professional and regulatory accountability Indicators

Complies with legal and regulatory requirements, ethical standards, and organizational policies and procedures (e.g. protection of health information, privacy, and security). Advocates for the use of current and innovative information and communication technologies that support the delivery of safe, quality care. Identifies and reports system process and functional issues (e.g. error messages, misdirections, device malfunctions, etc.) according to organizational policies and procedures. Maintains effective nursing practice and patient safety during any period of system unavailability by following organizational downtime and recovery policies and procedures. Demonstrates that professional judgement must prevail in the presence of technologies designed to support clinical assessments, interventions, and evaluation (e.g., monitoring devices, decision support tools, etc.). Recognizes the importance of nurses' involvement in the design, selection, implementation, and evaluation of applications and systems in health care.

Foundational Information and Communications Technologies (ICTs) Skills

Device Use Demonstrates basic skills with ICTs components (e.g., features of personal computers, hand held devices, tablets, workstations, modems, Bluetooth-enabled devices, keyboarding, use of peripheral devices including printers, USB flash drives, CD-ROMs, uploading and downloading data, Online Collaborative Learning, smart phones, mouse and touchpad interchangeably, etc.). Uses intranet and extranet networks to navigate systems (e.g., access to shared file servers, virtual private networks, World Wide Web, cloud computing, browsers). Application Use Uses electronic communication (e.g., email to create, send, respond, attach and receive attachments). Is familiar with the use of multimedia presentations (e.g., videos, podcasts, blogs, YouTube, etc.). Uses word processing, spreadsheets and presentation graphics (e.g., document, spreadsheet, slideshow creation, etc.). Navigates primary operating systems (e.g., Windows to manage files, determine active printers, access installed applications, create and delete files, etc.). Uses technology for self-directed learning. Is familiar with social networking applications (e.g.,Twitter, Facebook, LinkedIn, etc.).

Disease Management

Disease Management is a cost effect approach to improving service quality and integration and promoting consumer empowerment and quality of life

Describe the national efforts of Canada Health Infoway to use ICTs to improve access to care and health outcomes for Canadians.

Driving Access to Care "Improving access to care for Canadians, especially those who are most vulnerable and in greatest need, will improve health outcomes for all - Infoway is spearheading the replacement of fax- and paper-based systems with interoperable digital health solutions and driving change across Canada's health care systems by focusing on large, multi-jurisdicational or pan-Canadian projects. Infoway will provide safer access to medications through PrescribeITTM, Canada's e-prescribing solution. Infoway will also launch ACCESS Health, a new program to connect Canadians and their providers to the health ecosystem.

Describe research related to Failure to Rescue as a nurse-sensitive indicator. (Mushta, Rush, Andersen)

Failure to rescue as a nurse-sensitive indicator was found to be a "failing to rescue" pro-cess characterized by a cascade of events, including four key attributes: (1)errors of omission in care, (2) failure to recognize changes in patient condition,(3) failure to communicate changes ,and (4) failures in clinical decision making.

Identify how health care is organized and funded at all levels (organizational, municipal, provincial, national and international)

Federal government provides cash & tax transfers to provinces & territories in support of health through the Canada Health Transfer (CHT) program. $$$$ from the Federal Government to Provinces Support costs of publicly funded services, including health care Equalization payments to less prosperous provinces/territories Federal - Establishes and delivers national health care through the Canadian Health Care Act (CHA) - Provides financial assistance for provincial and territorial health care - Deliver health care to First Nations, Inuit people, military veterans, federal inmates and RCMP - Promotion of health and prevention of disease (public health programs and consumer safety) Provincial - Implementation of a provincial insurance plan following CHA principles - Allocation of hospitals and long term facilities - Determines employment of healthcare professionals for hospitals and long-term care facilities (determines the health care mix) - Distributes money to various health care services - Reimburses physicians and hospital expenses - Unique plan coverage ie. drug, coverage, ambulance services, home care etc.

Canada Health Act Imposes

Financial penalties that prevent physicians from charging more than provincial schedule of fees. Bans user fees and extra billing Establishes a billing agreement for services provided out-of province/ territory

Client Centered Collaborative Practice

Goal: to ensure delivery right care, by the right provider, in the right setting, requires a clear understanding of providers roles - Client-centred or Client-focused care - Focus on client needs rather than staff needs - Necessary care & services are decentralized & brought to clients - Staff close to patients in decentralized workstations - Care teams are established for a group of clients - Disciplines collaborate to ensure appropriate care is received Advantages - convenient for clients E- xpedites services to clients Disadvantages - Can be extremely costly$$$ to decentralize major services in an organization - Some perceive model as a way of reducing Registered staff (RN/RPN) & cutting costs in hospitals

2. Work in teams for patient safety

Goals for interdisciplinary teams: 1. *Participate effectively and appropriately* in an Interprofessional Team to optimize patient safety 2. Meaningfully1 *engage patients* as the *central participants* in the health care team 3. Appropriately *share authority, leadership and decision making* 4. Work effectively with other health care professionals to *manage conflict*

Explain the components of Analysis of Harm.

Harm may occur from one of or a combination of the following: - Natural progression of disease process - Inherent risks of treatments or procedures - System Failure - Provider performance

Use of ICTs (Information and Communication Technologies) Indicators

Identifies and demonstrates appropriate use of a variety of information and communication technologies (e.g., point of care systems, EHR, EMR, capillary blood glucose, hemodynamic monitoring, telehomecare, fetal heart monitoring devices, etc.) to deliver safe nursing care to diverse populations in a variety of settings. Uses decision support tools (e.g. clinical alerts and reminders, critical pathways, webbased clinical practice guidelines, etc.) to assist clinical judgment and safe patient care. Uses ICTs in a manner that supports (i.e. does not interfere with) the nurse-patient relationship. Describes the various components of health information systems (e.g., results reporting, computerized provider order entry, clinical documentation, electronic Medication Administration Records, etc.). Describes the various types of electronic records used across the continuum of care (e.g., EHR, EMR, PHR, etc.) and their clinical and administrative uses. Describes the benefits of informatics to improve health systems, and the quality of interprofessional patient care.

ISMP (Institute for Safe Medication Practices)

Independent, national, non-profit agency committed to Promoting medication safety in all health care settings in Canada.

Why is eHealth Important

Information, combined with nursing expertise and personal knowledge, allows a clinician to make sound clinical decisions (Thede, 2003) Information is pertinent to developing evidenced-based practice (Thede, 2003) Information is a requisite in the development of nursing knowledge and nursing research

TeamSTEPPS Strategies

Introduction Patient Assessment Situation Safety THE Background Actions Timing Ownership Next

Care Delivery Management Tools

Length of Stay (LOS) are opportunities to reduce costs 2 strategies to decrease LOS include: - Clinical pathways - Case Management - used to enhance outcomes & contain costs - outline expected clinical course & outcomes for a specific client type - Pathways by days-- each day expected outcomes are outlined - client progress is measured against the expected outcomes

Modular Nursing Care

Modular nursing is team nursing that divides a geographic space into modules of patients with each module having a team of staff led by an RN to care for them. - Units divided into two (or more) teams each led registered nurse (team leader) - Team leaders supervise & coordinate all of the care provided - Care is divided into tasks & assigned to care provider with the appropriate skill level (RN/RPN/PSW)

New Approaches to Health Care

Newer developments for approach to health care in Canada - Population Health - Integrated Health Care Delivery - Disease Management

Primary Nursing

Nurse is the primary provider of care (admission to discharge) Advantages - Clients & families develop a trusting relationship with the nurse - Nurse responsible for developing plan of care with client & family - Holistic approach to care, facilitates continuity of care - Authority for decision making is given to the nurse at the bedside Disadvantages - High cost $$$ - Knowledge required to match patients to appropriate staff. - Lack of geographical boundaries on unit (not grouped together) - Nurse-to-patient ratios must be realistic

Apply patient safety principles and CNO guidelines/professional standards to Transfer of Accountability.

Nurses are accountable for facilitating, advocating and promoting the best possible care for clients. Care transitions involve the process of communicating client-specific information from one caregiver to another, or from one team of caregivers to another, to ensure continuity of care and client safety. Transfer of accountability — or providing "report" or "handover" — is a crucial component of the care transition process. - care transition happens with change of location or health care providers. Also at end of shits or during breaks - When communicating to another care provider when transferring accountability, ask yourself: - What information does another care provider need to know to provide safe care? Is the information I am providing clear, client-focused and comprehensive? - Have I worked with the client and the health care team to develop a care plan that promotes client safety and continuity of care during the care transition? - How does our current practice contrast with best practice evidence, such as RNAO's Care Transitions best practice guideline?

Information and knowledge management Indicators

Performs search and critical appraisal of on-line literature and resources (e.g., scholarly articles, websites, and other appropriate resources) to support clinical judgement, and evidence-informed decision making. Analyses, interprets, and documents pertinent nursing data and patient data using standardized nursing and other clinical terminologies (e.g., ICNP, C-HOBIC, and SNOMEDCT, etc.) to support clinical decision making and nursing practice improvements. Assists patients and their families to access, review and evaluate information they retrieve using ICTs (i.e. current, credible, and relevant) and with leveraging ICTs to manage their health (e.g. social media sites, smart phone applications, online support groups, etc.). Describes the processes of data gathering, recording and retrieval, in hybrid or homogenous health records (electronic or paper), and identifies informational risks, gaps, and inconsistencies across the healthcare system. Articulates the significance of information standards (i.e. messaging standards and standardized clinical terminologies) necessary for interoperable electronic health records across the healthcare system. Articulates the importance of standardized nursing data to reflect nursing practice, to advance nursing knowledge, and to contribute to the value and understanding of nursing. Critically evaluates data and information from a variety of sources (including experts, clinical applications, databases, practice guidelines, relevant websites, etc.) to inform the delivery of nursing care.

Individual Level

Physical/Structural ■ At the individual level, the Physical Work Demand Factors include the requirements of the work which necessitate physical capabilities and effort on the part of the individual.vii Included among these factors are workload, changing schedules and shifts, heavy lifting, exposure to hazardous and infectious substances, and threats to personal safety. Cognitive/Psycho/Socio/Cultural Components - the Cognitive and Psycho-social Work Demand Factors include the requirements of the work which necessitate cognitive, psychological and social capabilities and effort (e.g. clinical knowledge, effective coping skills, communication skills) on the part of the individual.vii Included among these factors are clinical complexity, job security, team relationships, emotional demands, role clarity, and role strain. *Professional/Occupational* - Factors include the personal attributes and/or acquired skills and knowledge of the nurse which determine how she/he responds to the physical, cognitive and psycho-social demands of work.vii Included among these factors are commitment to patient/client care, the organization and the profession; personal values and ethics; reflective practice; resilience, adaptability and self confidence; and familywork/life balance.

Quality Assurance

Quality is ... - being better, doing things right the first time - health care professionals seeing themselves as having customers or clients - directing health professionals to give more than the basics - Every problem as an opportunity for improvement Customer is... (our client/patient) - anyone who receives the output of your efforts - can be internal, within the organization - can be external, outside the organization Emerged in health care in the 1950s as an inspection approach to ensure that minimum standards of care existed in health care institutions. Emphasis on "doing it right, Punitive & did little to sustain change or proactively identify problems before they occurred. "Doing the right thing..." Common terms used: Continuous Quality Improvement (CQI) Total Quality Management (TQM) Performance Improvement (PI)

CPSI (Canadian Patient Safety Institute)- Sepsis Introduction

Sepsis can be prevented in two ways: 1. Treating infections early and appropriately before they develop into sepsis. 2. Identifying, mitigating or preventing risk factors related either to the patient or as a result of care delivered to them Despite advances in understanding of the body and the disease the mortality rate continues to increase Examples of risk factors are: · Age (higher risk in infants and elderly persons than in other age groups). · Chronic diseases with/without severe organ dysfunction. · Immunodeficiency. · Immunosuppressive agents. · Inappropriate use of antibiotics. · The presence of implanted medical devices (intravascular or other). · Prematurity. · Infection is more likely to occur when the normal anatomy is altered by a process - benign or malignant - that either obstructs a normal passage (e.g. calculous cholecystitis, prostatitis) or breaks and enters a previously sterile system (e.g. skin breakdown by trauma, dermatological conditions). · Patients unable to communicate their symptoms often present later in their illness (i.e. often with sepsis).

CPSI (Canadian Patient Safety Institute)- Surgical Care Safety

Surgical care safety is one of four priority areas of focus for CPSI. The Canadian Adverse Events Study found a 7.5% incidence of adverse events in acute care hospitals. Surgery was identified as the service most responsible for the care 51.4% of the time in these adverse events. Improving safety in surgical care is multi-faceted and spans the period before surgery, during the surgical procedure, and during care following surgery. - Effective communication and teamwork are foundational to improving safety in surgical care. - A tool specific to surgical care that is intended to strengthen communication and teamwork is CPSI's Canadian Surgical Safety Checklist. Surgical teams can use the checklist to ensure that key care information is communicated throughout the patient's surgical journey and to enhance teamwork. Research has emphasized the impact of culture, communication, and teamwork on the effectiveness of the checklist. Several team training resources to improve patient safety are reviewed in CPSI's Canadian Framework for Communication and Teamwork. Other programs that have gained strength for surgical team training include the Comprehensive Unit-Based Safety Program (CUSP) and The Productive Operating Theatre. Implementing evidence-based guidelines is fundamental to improving safety in surgical care. Ensuring that surgical practices follow these guidelines reduces the likelihood that a surgical patient will experience a patient safety incident. There are three Safer Healthcare Now! Getting Started Kits directly applicable to surgical care. These include guidelines to prevent surgical site infections, reduce the likelihood of venous thromboembolism, and reduce medication incidents with a medication reconciliation process.

Total Patient Care Model

The nurse is responsible for the total care required for each client they are assigned for a worked shift Advantage - Client receives consistency in care for the shift Disadvantage - Nurse may not have same clients from day to day - This model uses high level of professional nursing hours - Costly $$$

Medicare

The provincial and territorial plans must insure all medically necessary services provided by: - hospitals - physicians - dentists, when the service must be performed in a hospital Medicare is a term that refers to Canada's publicly funded health care system. Instead of having a single national plan, we have 13 provincial and territorial health care insurance plans. Under this system, all Canadian residents have reasonable access to medically necessary hospital and physician services without paying out-of-pocket. Roles and responsibilities for health care services are shared between provincial and territorial governments and the federal government. The provincial and territorial governments are responsible for the management, organization and delivery of health care services for their residents.

Canadian Health Act

There are five main principles in the Canada Health Act: *Public Administration:* All administration of provincial health insurance must be carried out by a public authority on a non-profit basis. They also must be accountable to the province or territory, and their records and accounts are subject to audits. Comprehensiveness: All necessary health services, including hospitals, physicians and surgical dentists, must be insured. Universality: All insured residents are entitled to the same level of health care. Portability: A resident that moves to a different province or territory is still entitled to coverage from their home province during a minimum waiting period. This also applies to residents which leave the country. Accessibility: All insured persons have reasonable access to health care facilities. In addition, all physicians, hospitals, etc, must be provided reasonable compensation for the services they provide.

Changing to a Culture of Safety

To promote a culture in which we learn from our mistakes, organizations must re-evaluate just how their disciplinary system fits into the equation. Disciplining employees in response to honest mistakes does little to improve overall system safety. (David Marx, 2008)

Use the TeamSTEPPS Pocket Guide to practice effective communication and strategies for patient safety.

has five key principles. It is based on team structure and four teachable-learnable skills: Communication, Leadership, Situation Monitoring, and Mutual Support. - The arrows depict a two-way dynamic interplay between the four skills and the team-related outcomes. Interaction between the outcomes and skills is the basis of a team striving to deliver safe, quality care and support quality improvement. Encircling the four skills is the team structure of the patient care team, which represents not only the patient and direct caregivers, but also those who play a supportive role within the health care delivery system. Team Structure Identification of the components of a multi-team system that must work together effectively to ensure patient safety. Communication Structured process by which information is clearly and accurately exchanged among team members. Leadership Ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources. Situation Monitoring Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning. Mutual Support Ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload.

What is eHealth

late 1990s the term "eHealth" (also known as e-Health or electronic health) was beginning to be used in healthcare. Over the last decade the term eHealth has become a liberally applied neologism used to describe virtually anything that is "technology" in healthcare (Oh et al., 2005). Although there are differing views on what eHealth actually embodies (see Oh et al, 2005 for further discussion), it is generally agreed that eHealth is a representation of providing health services and information, enhanced by the Internet and related technologies (Eysenbach, 2001). eHealth has also been defined as a collection of interconnected technologies used to support healthcare that are client-centred and can be consumer-driven (Oh et al., 2005).

Ineffective Decision Making

nurses use many cognitive processes when scrutinizing clinical judgement. They use intuitive or rational decision making process. - Intuitive decision making involves passed experience in similar situations. Using own judgement to guide their decision. - The problem with this is that it blocks out other possibilities and makes assumptions that are not objective. This is called belief perseverance. - Intuitive is quick while rationale is slower - best clinical decisions are a mixture of both

Errors of Omission

occur when nursing care is omitted or forgotten, or a step in a process is either missed or absent and contributes to patient harm. - delays detection of deteriorating patient Three defining nurse-sensitive indicators • failure to recognize patient deterioration • failure to escalate rescue events when they are recognized • failure in the nurse's decision-making processes that intersects all aspects of care in failure to rescue events.

Care Delivery Models

organize the work of caring for patients

RNAO Healthy Practice Environment

presents the healthy workplace as a product of the interdependence among individual (micro level), organizational (meso level) and external (macro level) system determinants as shown above in the three outer circles - Assumptions of Model healthy work environments are essential for quality, safe patient/client care; ■ the model is applicable to all practice settings and all domains of nursing; ■ individual, organizational and external system level factors are the determinants of healthy work environments for nurses; ■ factors at all three levels impact the health and well-being of nurses, quality patient/client outcomes, organizational and system performance, and societal outcomes either individually or through synergistic interactions; ■ at each level, there are physical/structural policy components, cognitive/psycho/social/cultural components and professional/occupational components; and ■ the professional/occupational factors are unique to each profession, while the remaining factors are generic for all professions/occupations.

Local Health Integration Networks (LHINS)

previously known as CCAC, Community Care Access Centres *Main roles of the LHINs :* - Plan, fund and integrate health care services locally in communities - Each LHIN consulted the people in their communities - the general public, patients, advocates, health services. - Plan was tailored to local needs and priorities and met provincial strategic directions. *LHINs Funds:* - the health service providers - allocates local health dollars based on community priorities. - LHINs helps to integrate health services - better coordinated and more efficient. Helps people to: - Live independently at home (in home support/PSW...) - Apply for admission to a day program, supportive housing or assisted living program, certain chronic care/rehabilitation facilities - Apply for admission to long-term care home - Coordinate services for seniors, people with disabilities and people who need health care services to help them live independently - Determine eligibility for government-funded services and settings - Find out how services are delivered - Determine the availability of financial subsidies for particular service options Anyone can make a referral. The individual requiring service, family member, caregiver, friend, physician or other health care professional. Boundaries align with the LHINS Funded & legislated by the Ontario Ministry of Health and Long-Term Care. Now managed by the LHINs**** (2017)

Patients and CPSI

• Patients are involved in the analysis of harm incidents and the development of guidelines for disclosure. Patients want to know: - The facts about what happened. - The steps that were and will be taken to minimize harm. - That the HC org and/or provider is sorry for what happened. - What will happen to prevent similar events in the future.