The focus of this module is to explore patient/family centered care and how it links to incident analysis and management to will help to make care safer. Guest speakers and patient representatives will highlight what the patient needs are at different points during the incident analysis and management process. During small group discussions, participants will tap in to their own experiences and apply the “Checklist for Effective Meetings with Patients/ Families”.

1. Incident Analysis Learning Program
Module One
Patient/Family Partnership
Thursday, November 8, 2012

2. Welcome
Sandi Kossey Ioana Popescu Carrie-Lynn Haines Tina Cullimore

3. The Virtual Classroom
Be prepared to use:
- Chat
- Pen
- Raise Hand
- Other
3
9-Nov-12 3

4. Where are you from?
Use to place your
name on the map
International:
(type here)

5. About You
0 Familiarity with incident analysis / management 10
0 Familiarity with the Canadian Incident Analysis Framework 10

6. Agenda
1. Invited guests will share how they were included in
the incident analysis & management process -
highlighting the overall outcome of their lived
experience.
2. Theory - practice leader/knowledge expert.
3. Facilitated discussion and virtual group exercise.

7. Learning Objectives
The knowledge elements include an understanding
of the following:
• What is patient engagement?
• What are the expectations of patients/families
following an unexpected situation?
• Why is patient/family involvement an important
part of incident analysis and making care safer?

8. Learning Objectives
The performance elements include the ability to:
• Use the checklist to plan a meeting with patients/
families .
• Describe ways in which patients/families can
partner in the incident analysis process in order to
build trusting relationships.

9. Sections of the Canadian Incident Analysis Framework
were written by a group of patients and families,
members of Patients for Patient Safety Canada (PFPSC).
These sections provide the basis for this module, thus,
the content is delivered from their perspective.
It is the voice of the patient/family.

10. Canadian Incident Analysis
Framework
Sections:
• Claire‟s story (John Lewis) (p. 5)
• 1.4 Incident analysis and
management from a patient/family
perspective (p. 14)
• Appendix F – Checklist for
Effective Meetings with
Patient(s)/Families (p. 87)
“Patients and families have important insights,
information and experiences to share. There are many
different ways that we can help. We are patients and
families. We are committed partners in the safety
and quality of our care.”

11. Patient / Family Partnerships in
Incidents and Incident Analysis
Patient / Family Partnerships in
Incident Analysis & Management
Raeline McGrath Sharon Nettleton

12. Patient/Family Partnership
The Lived Experience – Claire’s Story
Raeline McGrath

13. Claire’s Story
To nurses, doctors and health care professionals
who give their all each day to improve and save
lives, and who feel humbled and privileged to be
part of life and death, but most of all to Claire.

14. A lifetime of happiness -
that is our wish

15. Challenges
September 2006 - 12° October 2007 - 46°

16. The Big Day!
Feb 27, 2008 - PICU Day 1
• Transferred to the PICU after surgery
…peaceful, settled, chest sounds good, Dad
playing with and fixing Claire, child awoke…
• Successful posterior fossa decompression
• Intensivist and neurosurgeons are pleased
… Perfect!

17. “It Is Time”
March 14, 2008 - PICU Day 16
• Oscillator withdrawn and placed on conventional
mode of ventilation at 10:10.
• Claire died 50 minutes later at 11:00.
“Catastrophe”
…devastation - us and the PICU

18. Claire was gone… Now what?
• Devastation, desperation, a parent‟s guilt
• Return to nursing in the same division in which
Claire died – no book to guide me or the
organization
• After the dust settled
Confusion & questions
Instinct and intuition
Connecting the dots
…duty to Claire

19. Incident Analysis Process
• Preliminary file review – no findings
• Parents pose questions – internal case review completed
• External review - specialized area and parent an
employee
• Worst possible outcome
…the edge of the cliff

20. Preventable Death
…Claire’s picture is removed
from the „Memory Wall‟ in the
PICU
…shock, anger, overwhelming
for everyone

21. Important First Steps
• Apology and disclosure to family first – unexpected and
appreciated
• Disclosure – candor and openness from reviewers and
organization startling
• Disclosure to staff and physicians immediately following
• Action Plan developed to implement recommendations –
given to us
• Commitment made to family to keep them engaged in the
implementation process
… Silence from the PICU – devastating and
antagonizing

22. Process Challenges
Review shared with Family before staff from PICU
Review read to everyone – no hard copy sharing
pushback from PICU – indignation and denial
no blame translates into no accountability
…devastation, isolation, anger

23. Rewriting the Literature
• New CEO arrives
• A new attitude to disclosure, quality reviews, patient
safety – not fearing our motives
… relieved to move forward and to be included

24. What Works:
CONNECT AND COMMIT
• Families must be given the information necessary
to identify what happened, how it happened, and
what is being done to ensure that it doesn’t
happen again.
• Information to staff and families must be clear,
factual, and above all, shared.
• Honesty and openness are crucial.
• Uniqueness of situations - flexibility.

25. What Works:
CONNECT AND COMMIT
• Ongoing discussions with program staff and physicians.
• “Big Picture Thinking” - challenging the status quo.
• Working together with the family is much better than
working around them - inclusiveness.
• Use of outside consultants for support and to effect
change.

27. Follow-Up
Families must feel and observe a commitment and
acceptance of responsibility, accountability and of
steps being taken to prevent a reoccurrence.

29. Theory Burst – Patient/Family
Partnerships in Incident Analysis &
Management
Sharon Nettleton

30. Patient Engagement
• Thank you Raeline and so many other
patients/families for staying engaged and for your
work as partners in helping to make care safer.

31. Patient Engagement
• What is it?
• Why is it important?
• Why is it even more important when unexpected
things happen?

32. Engagement
What is it?
“ The feeling of being involved in a
particular activity.”
Macmillian Dictionary (English)

33. Patient Engagement
What it feels like
• I‟m able to share what I know, how I feel
• Someone is listening to me
• I‟m able to talk openly
• Someone understands me
• I‟m treated with respect
• Someone cares about me
• I‟m included in the team
• I feel safe
• I feel I have a partner(s) in my care

34. Patient Engagement
• An exchange of ideas, experiences and expertise
• Different perspectives / new thinking / other
possibilities, actions and solutions
• Innovations, improvements are possible

35. Patient Engagement
A relationship between
Person requiring health care
(patient, client and/or family or loved one)
AND
Person(s) who can provide health care services
(providers, clinicians, staff, administrators)

36. Patient Engagement
When patients or family feel
disengaged
• Left out, isolated, betrayed
• Unacknowledged, not listened to
• Not respected
• Unimportant
• Knowledge or expertise wasn‟t valued
• Not cared for
• Not safe

37. Patient/Family Centred Care
The provider or health organization perspective:
Dignity & respect
Access to information
Open communication
Involved in decision-making

38. Patient Patient/Family
Engagement Centred Care
What it feels like to the What it feels like to
the patient/family the provider
I feel heard I listen
I feel understood I try and understand
I feel cared for I show I care
I am helped I provide help
I feel safe I provide safe care

39. Patient Patient/Family
Engagement Centred Care
Partnerships or relationships between the patient/
family & care providers and principles of:
Involvement
Respect
Honesty
Trust
Safety

40. Patient Engagement &
Incidents
When unexpected things occur during our care,
these principles are even more important:
Involvement
Respect
Honesty
Trust
Safety
Healing/Learning/Improving

41. Words and Actions Matter
From OUR perspective…
• We often see you (care providers) for only minutes
at a time
• But we remember our encounters (what you say,
what you do, how you treat us, how you make us
feel) it has a lasting impact

42. When Unexpected Things
Occur
Being unprepared
Being (somewhat) prepared

43. When Something
Unexpected Occurs
First minutes, first words, first actions
really matter
Often set the stage for everything that happens
next
Ongoing connection

44. Framework

45. When Something
Unexpected Occurs
Normal Human Reactions
• Surprise, shock
• Guilt, feeling „let down‟
• Feeling frozen (not knowing what to say & how to act,
who to turn to, what happens next)
• Fear
• Avoidance
• Anger
• Name, blame, shame
• “Get past it”, “Move on”
• Grief

46. When Something
Unexpected Occurs
Reflective & Emerging Questions
• What happened?
• How/why did it happen?
• What (if anything) can be done to prevent this
from happening again?
• What happens next?
Learning, improving, rebuilding trust &
relationships, healing

47. When Something
Unexpected Occurs
1. Being (somewhat) prepared for the unexpected.
2. Knowing immediately what to do.
(Care & empathy for the patient/family AND the
providers directly involved).
3. Knowing where to access resources and people to
help.

48. Framework

49. Three Essential Questions
1. Who is going to look after the patient/family?
2. Who is going to look after the providers/staff
directly involved?
3. Who is going to coordinate/be accountable for the
management of the incident?
This is engagement!

50. Immediate Response
Engage with the Patient/Family
• Immediate Care for the people directly involved
(patient/family AND providers)
• Assign people to Stay Connected to those directly
involved (patient/family AND providers)

51. Framework

52. Preparing for Analysis
Engage with the Patient/Family
• Inquire and plan for patient/family involvement in the
analysis process
• Using the Checklist for Effective Meetings with
Patients/Families (Appendix F, p.87)

53. Framework

54. Analysis Process
Engage with the Patient/Family
• Involve the patient/family
• Begin with the patient/family perspective
• Include a patient/family advisor(s) on the review team

55. Framework

56. Follow Through and Close
the Loop
Engage with the Patient/Family
• Include (even begin) with the patient/family
• Include as part of the team to re-establish trust,
partnership/relationship
Demonstrates honesty, commitment, learning,
improvement and helps with healing

57. When Something
Unexpected Happens
Connect with the people involved
• Timely acknowledgement / empathy / apology
• Caring about the people & relationship(s)
• Includes patient/family
Commit to analysis
• Includes patient/family
Follow-Up
• Includes patient/family

58. Evaluating Patient Engagement
• How are „we‟ engaging patients/families when
incidents occur?
• Ask us (patients/families) what else could be
done.
• Engage patients/families as advisors in
helping to improve.

59. Evaluating the Incident
Management Process
What worked What needs
improvement
• Nurse‟s immediate response • Reaction of PICU
(regret, empathy, apology) • Removal of Claire‟s picture from
• Sharing of findings with family wall
• Verbal report to family • No paper copy to family
• Heartfelt apology, caring • Meeting with whole team
• Opportunity to continue
improvements
Observations
• Pushback from PICU
• Leadership change
• Communication & follow-up

60. Preparation Begins with
Discussions & Sharing of
Resources
Canadian Incident Analysis Framework
• Claire‟s Story (John Lewis)
• Patient/Family Perspective
• Checklist for Effective Meetings with Patients/Families
Other Resources
• “Claire‟s Story” (Raeline McGrath) Canadian Nurse Oct. 2009 Vol.
105, No. 8
• Beware the Grieving Warrier (Larry Hicock & John Lewis, 2004)
• After Harm (Nancy Berlinger, 2005)
• “Harm to Healing: Partnering with Patients Who Have Been Harmed”
(Trew, Nettleton, Flemons) www.patientsafetyinstitute.ca
• Canadian Disclosure Guidelines www.patientsafetyinstitute.ca
• Literature on Patient Engagement, Grief, Healing & Forgiveness
• Policies/Procedures/Practices within your own organization, other
organizations

61. A Safety Culture
In healthcare settings where there is a safety culture,
the people (providers, staff, administrators AND
patients/families) are engaged, encouraged and
supported to make care safer.

62. Patient/Family Partnerships in
Incident Analysis & Management –
A Provider’s Experience
Paula Beard

63. Partnering with Patients and
Families
• Involving patients/families in incident analysis
• Engaging with patients/families as members of
analysis teams
• Practical examples of ways to involve patients and
families in analysis

64. Applied Learning

65. Breakout Session
1. The technical host has
randomly assigned
half of the participants
to a breakout room
2. If prompted, click
YES to both popup
screens to join

66. Learning Objectives
Performance Element
Use the checklist to plan a meeting with
patients/families.

67. The checklist has been developed to help prepare
healthcare leaders and providers for meetings with
patients/families when a patient safety incident is being
discussed.
The most important attributes that leaders and providers
can bring to these meetings are compassion, a willingness
to listen and understand, and the ability to be supportive.

68. •
Virtual Group Exercise – Checklist
Review the “Checklist for Effective Meetings with Patient(s)/
Families” on page 87 of the Canadian Incident Analysis Framework.
* What are some of the barriers and enablers to meeting
with patients and families?
* What are some strategies to overcome the identified
barriers?

69. Learning Objectives
Performance Element
Describe ways in which patients/families
can partner in this process in order to build
trusting relationships.

70. Virtual Group Exercise – Gap Analysis
What would your preferred future state look like in relation to
key steps in the Canadian Incident Analysis Framework,
specifically:
* What are we doing well?
* What do we need to improve?
* What are our next steps?

71. Write a goal:
“Tomorrow I/we will….”

72. Next Steps
• Evaluation
• Follow up survey
Incident Analysis Learning Program
1. Patient/ family partnership – November 8, 2012
2. The essentials: principles, concepts and leading practices –
November 29, 2012
3. Incident analysis as part of the incident management continuum –
December 13, 2012
4. Comprehensive analysis – January 10, 2013
5. Concise analysis – January 31, 2013
6. Multi-incident analysis – February 21, 2013
7. Recommendations management – March 7, 2013
8. Follow-through and share what was learned – March 28, 2013

73. Additional CPSI Resources
• “Harm to Healing: Partnering with
Patients Who Have Been Harmed”
(Trew, Nettleton, Flemons, 2012)
• “Canadian Disclosure Guidelines:
Being Open with Patients and
Families” (2011)
• Learning Opportunities – information
about workshops, training, and
learning sessions
• Tools – a collection of documents,
templates, guidelines, and examples
www.patientsafetyinstitute.ca
www.patientsforpatientsafety.ca

74. Thank you!
Contact us at: analysis@cpsi-icsp.ca