2023-2025 Patient Safety Plan
At William Osler Health System (Osler), delivering safe, compassionate and high-quality care is at the centre of everything we do. Inspired by the valued feedback of staff, physicians, volunteers, patients, families and the community, Osler’s continuous quality improvement and patient safety journey represents our unwavering commitment to further improve the quality of care provided to our patients.
In keeping with our strategic direction, Quality Excellence and building on the successes achieved to date through our previous plan, Osler’s 2023-25 Patient Safety Plan aligns with evidence-based quality and safety standards and practices set by Accreditation Canada to enhance patient safety and minimize risk. It is guided by the results of our 2022 patient safety culture survey (PSCS) and sets the direction for achieving continuous improvements that contribute to the ongoing provision of safe and effective care.
This plan is supported and informed by Osler’s:
- Mission, Vision and Values
- 2019-24 Strategic Plan
- Annual Quality Improvement Plan
- Patient and Family Advisory Council
- Feedback from Osler patients and families
- Patient Declaration of Values
- Accreditation Canada’s 2022 PSCS results
- Review of current literature, an environmental scan and extensive stakeholder engagement
Patient, patient representative and family engagement is essential to safe care which includes an experience of physical, spiritual, emotional and cultural safety. The Patient Safety Plan is built upon foundational examples of patients, patient representatives and family engagement, including evidence of over forty patient safety initiatives informed by patient/family advisors, over twenty-five opportunities for patient family perspectives to influence the findings and recommendations during critical incident quality of care reviews and the voice of over 25,000 patients sharing feedback regarding their involvement in care and safety.
Oversight for the development and implementation of the Patient Safety Plan lies with Osler’s executive leadership team and Quality Governance Council. A dashboard of key performance and results is shared quarterly with the Quality Governance Council, the executive leadership team and the Board of Directors.
Steps we are taking to improve patient safety
1. Continue to foster a Just Culture
A Just Culture is a culture where organizations shift their focus from retrospective judgment of others and focus on actions that can be taken to correct system issues and prevent precursors that can lead to errors (Reason, 1997) by encouraging individuals to safely report risk and safety concerns. With leadership support, a lot of progress on this front has been accomplished to date, with the new plan further reinforcing a more focused approach.
Objective: To further enhance a culture where staff and physicians feel safe to report patient safety incidents and leaders respond to patient safety incidents in a fair and just manner by analyzing the systems and processes that contribute to the safety incidents and ensuring that the concerned staff and physicians feel respected and supported if things go wrong.
To achieve this objective we will:
- Develop tools and resources on Just Culture and ensure regular ongoing communication about the principles of Just Culture, including the resources available, through a defined communication plan.
- Provide Osler leaders and BPSO Champions with education opportunities as well as tools and resources to better understand Just Culture and to enable them to identify system factors and support staff and physicians in accordance with the principles of Just Culture.
- Provide Osler staff and physicians with education opportunities as well as tools and resources to better understand Just Culture and to build confidence in speaking up about safety concerns.
2. Improve reporting of patient safety incidents including Near Miss incidents
Incident reporting is the cornerstone of patient safety culture at Osler. Near Miss incidents are patient safety incidents that did not reach the patient and therefore did not cause any harm, but had the potential to cause harm. It is the responsibility of all staff and physicians who observe, are involved in, or made aware of an adverse event or Near Miss (including through patient and family reporting) to ensure it is reported in the hospital’s patient safety incident reporting system, Datix®. The previous Patient Safety Plan was instrumental in advancing significant improvements in reporting, with the new plan continuing to build on that work along with an enhanced focus on Near Miss incidents.
Objective: To develop an education plan and supporting resources to provide an environment that continues to support reporting of patient safety incidents including Near Miss incidents.
To achieve this objective we will:
- Continue to identify and address any barriers to the reporting of patient safety incidents including Near Miss incidents.
- Continue to provide Osler staff and physicians with education, training and appropriate tools and resources for the reporting of patient safety incidents including Near Miss incidents.
- Report the trends from Near Miss incidents and support teams in proactive development of safety initiatives based on these reports.
3. Ongoing patient and family engagement
Objective: Ongoing engagement of patients and families as partners in co-creating a culture of safety.
To achieve this objective we will:
- Engage patients and their families or caregivers in advanced education and knowledge of quality improvement.
- Inform patients and their families or caregivers regarding patient safety policies, education and initiatives.
- Gather, document and share patient or patient representative perspective to inform all critical quality of care reviews.
- Continue to capture patient perception of safety and involvement in care planning on the patient experience survey.
Role of patients, family members and caregivers
As a patient, a family member or a caregiver you have an important role to play in the implementation of the Patient Safety Plan by:
- Asking questions, staying informed and actively participating in care, treatment and planning.
- Acknowledging shared partnership and role in safety and sharing expectations and needs.
- Working closely with providers, especially during care transitions.
- Advocating for your own safety or the safety of your family at the point of care.
- Learning about and utilizing resources to self-manage a safe care experience.
- Reporting patient safety incidents, expecting an apology and supporting, and offering to co-create system solutions.
- Providing feedback to support organizational learning to make care safer for others.
- Sharing ideas for improving safety and listen to different perspectives.
