Health & Community Leaders Talk: Peter Pisters
Safer, Smarter Care for a Healthier Ontario
Peter Pisters, President and CEO of University Health Network, shares the value of research evidence in improving patient safety, generating smarter care and a healthier Ontario.
Almost every person who works in health care has seen or heard about a terrifying event where a patient was hurt or was almost hurt because something went wrong. Nobody who works in health care wants errors to happen. Trust has been placed in us and we do everything we can to live up to that trust.
Notwithstanding the noble intentions of health care workers, preventable harm does happen and these events occur far more often than industry insiders or the general public understand. Indeed, by our estimates – and there isn’t reliable data in Canada so we must extrapolate from U.S. data – more than 30,000 Canadians die each year as a result of preventable harm in health care settings.
The causes are many and familiar – wrong medication or medication given in the wrong dose, an infection acquired in the hospital because proper protocols for handwashing or sterilization of equipment are not followed, complications which arise from a fall that could have been prevented, foreign objects accidentally being left inside patients during surgery. The list of types of preventable harm is a very long one and, in complex, dynamic environments that have high reliance on technology and where patients move from one setting to another being handed off to different care teams, the opportunities for errors grow.
I’m proud to be the leader of Canada’s most research-intensive hospital, where we apply research findings into improving clinical care and outcomes. I see wonderful care and a commitment from everyone to heal and help our patients. I also see the enormous possibilities of using our clinical teams and researchers to help us understand how errors occur and how we can make our hospital a much safer place to receive care. Our efforts, in partnership with the Hospital for Sick Children, are going forward under a shared program that we call Caring Safely. Many other organizations including Sinai Health System, Women’s College Hospital, Health Quality Ontario, the Canadian Medical Protective Association, the Ontario Hospital Association and others have all expressed great interest in our efforts to drive preventable harm to zero. Through smarter, safer care, University Health Network, along with its partners, will help to build a healthier Ontario.
For critical insights on improving safety, we are looking to other industries that have made extraordinary safety improvements over the past 30 years. These industries include aviation, nuclear power, and chemical manufacturing — industries that have a relative complexity of the work environment similar to healthcare and where reliability and resilience have been hard wired into the workforce. Collectively, these industries have adopted practices known as high reliability. In high reliability industries safety is a core value and employees are supported and trained to spot problems before they happen and take immediate action. The lessons learned from success in other industries are applicable to healthcare.
I believe that safety is an implicit expectation that Ontarians have of our hospitals. For those who would like to read more about High Reliability Organizations I recommend two books – Why Hospitals Should Fly by J.D. Nance and Managing the Unexpected by Karl Weick and Karen Sutcliffe of the University of Michigan. The first is written in novel form and imagines what it would be like to work in a hospital that has adopted the principles of reliability and resilience. The second book is a seminal academic work that outlines the principles that define high reliability organizations.
At UHN, we started this journey with an organization-wide survey from the Agency for Healthcare Research and Quality (AHRQ) that has given us rich data about attitudes to safety on our units, in our clinics and throughout the organization. The response was overwhelming with two of our sites achieving 100% participation, and a third at 98%. This extraordinary response to administrative efforts to measure our safety culture clearly demonstrates the deep interest that the UHN community has in our safety transformation and our shared commitment to safety for each other and for the patients we serve. One major benefit of the AHRQ safety survey is that it is used throughout North America, enabling us to benchmark ourselves with over 700 hospitals.
You can learn more about the work Canada is doing to address patient safety here.
Toronto Rehabilitation Institute has been using the AHRQ safety culture survey for many years and has used their data to identify issues that can then be worked on by the manager and the team on the unit. They have seen changes to their safety culture year over year and all of UHN will learn from their experience with the survey and with the ways they have worked with their staff to make Toronto Rehab a safer organization.
The Institute of Medicine once noted that “errors… are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals”. By decreasing incidents of preventable harm and increasing a focus on patient safety we can create a healthier and smarter environment for everyone that comes through our doors.
UHN is a proud member of CAHO, which supports the health research enterprise that makes Ontario Healthier, Wealthier and Smarter. We’re determined to also make it safer, and I thank CAHO for allowing me to write about the start of this journey and welcome your thoughts and questions.
Read more Health and Community Leaders Talk posts here, and share your own insights about the value of health research on Twitter with our hashtag, #onHWS.
To learn more about how health research makes Ontario healthier, wealthier, and smarter, check out our website and our other blog posts and videos.