Canadian Incident Analysis Framework PDF

**DAY 2 - PATIENT AND FAMILY CENTERED CARE** **LEGAL, POLICY, AND ETHICAL FRAMEWORKS** **Canadian Incident Analysis Framework** **Target Audience:** The framework is designed to be used by those responsible for, or involved in analyzing, managing and/or learning from patient safety incidents in...

**DAY 2 - PATIENT AND FAMILY CENTERED CARE** **LEGAL, POLICY, AND ETHICAL FRAMEWORKS** **Canadian Incident Analysis Framework** **Target Audience:** The framework is designed to be used by those responsible for, or involved in analyzing, managing and/or learning from patient safety incidents in any health care setting. **Purpose** The purpose of the framework is to help individuals and health care organizations to determine: - What happened - How and why it happened - What can be done to reduce the risk of recurrence and make care safer - What was learned and how the learning can be shared **Overarching Goals** - To enhance the safety and quality of patient care - To promote a culture of safety within the organization - To promote patient and family-centred care - To encourage learning and dissemination of learning within and outside the organization - To increase the effectiveness of incident management - To improve the success of incident analysis as a tool in preventing and/or mitigating harm **Incident Analysis** In order to increase the effectiveness of analysis in improving care, incident analysis cannot be addressed in isolation from the multitude of activities that take place in the aftermath of an incident (incident management). **Canadian Incident Analysis Framework** **Before the Incident** - Pressure to act can mount quickly when a patient experiences an incident. - Organizations can best handle the situation if they develop a plan ahead of an incident occurring that describes the steps and responsibilities for various actions (who is doing what, how and when) and indicates the resources available (policies, procedures, checklists, skills) to manage the incident. - The incident management plan requires visible leadership support at all levels of the organization and is reinforced by a safe culture in place ahead of the incident. - Plans and procedures need to be tested, updated, and revised periodically to ensure they align with the evolving culture, structure, and processes of the organization. **Immediate Response** **Caring and Supporting** - A patient safety incident can be a very traumatic experience for the patients and providers involved. - Generally, the first action, after recognizing that an incident has occurred, is to **care for and support the patient and the family**, as well as ensuring the safety of other patients who may be at risk. **Report the Incident** - While each situation will be different and guided by individual organizational policies and practices, the next activity generally includes reporting the incident. - This typically involves completion of a paper or an electronic incident report form; however, incidents with a high potential for harm are often reported verbally as part of the immediate response. Reporting assists in understanding 'next steps' such as whether further investigation and analysis are needed, and/or whether additional resources and other actions, such as further notifications, are required. - The applicable manager or other recipient of the report will, at a minimum, review the facts of the incident and gather any additional information to ensure a preliminary understanding of what happened. - Any contributing factors identifiable at this point will also be documented. - Reporting is the trigger for a chain of internal notifications that, depending on the nature of the incident, will target individuals and/or units at different levels of the organization (for example, attending physician, CEO, risk management committee, medical managers, health record staff, unit or program managers, public relations). - External notifications may also be required to ensure alignment with regulations and to maintain the organization's reputation as per legislation, policy, protocols (for example, coroner, Ministry of Health) and current context (for example, media). - Timely and respectful internal and external communication results in increased trust of stakeholders, including the public. It is recommended that organizations develop internal guidelines for this purpose. ***IMPORTANT: Any items related to the event need to be secured for testing and for review by the analysis team.*** **Prepare for Analysis** - In order to determine appropriate follow-up to an incident, including the need for analysis, an initial investigation or fact-finding is needed. - The key outcome of this step will be a high-level timeline and documentation of facts related to the incident. - Once the initial investigation phase has been completed, a determination of next steps follows. **Select an Analysis Method** - Three types of incident analysis are described in this framework: ***concise***, ***comprehensive,*** and ***multi-incident***. - There is a range of criteria to determine the type of incident analysis the investigation will proceed with. - This decision is usually made jointly by the manager involved, together with the quality and safety leads, the clinical leads, and often senior leaders, and others as defined in organizational policies and procedures. - Each incident analysis method includes a systematic process to identify what, how and why it happened; what can be done to reduce the likelihood of recurrence and make care safer; and share learning. **Identify the Team and Team Approach** - Typically, a facilitator (with expertise in analysis) and a leader (with operational responsibility, who understands and supports analysis) share primary responsibility for conducting, coordinating, and reporting on each analysis in accordance with applicable organizational policies. - The success of the analysis depends on the involvement of those who provided care and of the patient/family. **Coordinate Meetings** - It is common for a facilitator to collaborate with the analysis team leader to conduct background work and collect the necessary information for the analysis (health record, timeline, relevant policies and procedures, evidence-based guidelines, and so on). - The full analysis team is convened at a mutually agreeable date and time. - It is recommended that all documentation provided to the team during meetings, including the sequence of events, be tracked, and returned to the facilitator at the end of the analysis. **Plan for and Conduct Interviews** - Interviews should be conducted as soon as reasonably possible after the incident because memories fade quickly and important details may be lost over time, and as individuals involved in the incident discuss their recollections with one another, versions may blur together and the opportunity to obtain unique perspectives and details may be missed. - It is recommended that individual interviews occur with all staff involved in the incident as well as individual or group interviews with the patient and family members as appropriate. - Sincerely thank people for helping to provide an understanding of the incident and ensure that their questions about the process are answered before drawing the interview to a close. **Analysis Process** **Comprehensive Analysis** - Usually used for complicated and complex incidents that resulted in catastrophic/major harm, or the significant risk thereof. - Multiple sources of information are consulted, including interviews with those directly or indirectly involved in the incident as well as experts, supplemented by a literature review. - A significant amount of time and resources (human and financial) can be invested to conduct the analysis. - The final report produced will include a detailed chronology of the facts, contributing factors and their influences, findings from the literature search/environmental scan, context analysis, recommended actions, and where applicable, implementation, evaluation, and dissemination plans. - Members of the senior leadership of the organization need to be kept apprised of progress and may be directly involved in the process. **Concise Analysis** - A succinct, yet systematic way to analyze incidents with no, low, or moderate severity of harm - Generally, the incident and analysis process are localized to the unit/program where care was delivered. - The sources of information used are available reports, supplemented with a small number of interviews and a targeted review of other sources of information. - The analysis is completed in a short interval of time by one or two individuals. - At the end of the analysis, a report is produced that contains the facts (including a brief timeline), contributing factors, a brief context analysis, and where applicable, recommended actions and a plan for evaluation and dissemination. **Multi-Incident Analysis** - A method for reviewing several incidents at once instead of one by one, by grouping them in themes (in terms of composition or origin) - Multi-incident analysis can be used for incidents that resulted in no, low, or medium severity of harm as well as near misses that took place at any location in the organization (possibly in a short interval of time). - Used to review a group of comprehensive and/or concise analyses - Can generate valuable organizational and/or system-wide learning that cannot be obtained through the other methods **Follow-Through** - Implement recommendations - Monitor and assess the effectiveness of the recommended actions **Close the Loop** - Share what was learned. - Learning from an incident, understanding, and articulating what can be done to prevent its recurrence and heal relationships are the ultimate goals of the patient safety incident management process. - Feedback loops must be created for each incident analysis to share the learning with the various individuals and groups who assisted with analysis and implementation activities. - Feed-forward communication loops where the learning is shared externally are important. Similar incidents may occur in any organization, system, or country. The learning from one organization should be transmitted to others to prevent further harm. - Informing the public about patient safety incidents also requires consideration and is a crucial process, in the event that the incident has been or will be publicly disclosed. **Three Broad Types of Ethical Theory** 1\. **Consequentialist theories** are primarily concerned with the ethical consequences of particular actions. 2\. **Non-consequentialist theories** tend to be broadly concerned with the intentions of the person making ethical decisions about particular actions. 3\. **Agent-centred theories** are more concerned with the overall ethical status of individuals, or agents, and are less concerned to identify the morality of particular actions. **The Utilitarian Approach** - Utilitarianism is one of the most common approaches to making ethical decisions, especially decisions with consequences that concern large groups of people, in part because it instructs us to weigh the different amounts of good and bad that will be produced by our action. - This conforms to our feeling that some good and some bad will necessarily be the result of our action and that the best action will be that which provides the most good or does the least harm, or, to put it another way, produces the greatest balance of good over harm. **The Egoistic Approach** - One variation of the utilitarian approach is known as ethical egoism, or the ethics of self-interest. - In this approach, an individual often uses utilitarian calculation to produce the greatest amount of good for him or herself. - Self-interest is a prerequisite to self-respect and to respect for others. **The Common Good Approach** - The perspective that our actions should contribute to ethical communal life - The best society should be guided by the "general will" of the people, which would then produce what is best for the people as a whole. - This approach to ethics underscores the networked aspects of society and emphasizes respect and compassion for others, especially those who are more vulnerable. **The Duty-Based Approach** - Doing what is right is not about the consequences of our actions (something over which we ultimately have no control) but about having the proper intention in performing the action. - The ethical action is one taken from duty, that is, it is done precisely because it is our obligation to perform the action. - Ethical obligations are the same for all rational creatures (they are universal), and knowledge of what these obligations entail is arrived at by discovering rules of behaviour that are not contradicted by reason. - "Categorical imperative." Act only according to that maxim by which you can at the same time will that it should become a universal law. **The Rights Approach** - This approach stipulates that the best ethical action is that which protects the ethical rights of those who are affected by the action. - It emphasizes the belief that all humans have a right to dignity. - "Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means to an end." **The Divine Command Approach** - As its name suggests, this approach sees what is right as the same as what God commands, and ethical standards are the creation of God's will. - *Following God's will* is seen as the very definition what is ethical. - Because God is seen as omnipotent and possessed of free will, God could change what is now considered ethical, and God is not bound by any standard of right or wrong short of logical contradiction. **The Virtue Approach** - - **Frameworks for Ethical Decision-Making** Based upon the three broad types of ***theory***, it makes sense to suggest three broad ***frameworks*** to guide ethical decision making: 1\. The Consequentialist Framework 2\. The Duty Framework 3\. The Virtue Framework NOTE: While each of the three frameworks is useful for making ethical decisions, none is perfect---otherwise the perfect theory would have driven the other imperfect theories from the field long ago. **The Consequentialist Framework** - In the Consequentialist framework, we focus on the future effects of the possible courses of action, considering the people who will be directly or indirectly affected. - We ask about what outcomes are desirable in a given situation and consider ethical conduct to be whatever will achieve the best consequences. - The person using the Consequences framework desires to produce the most good. **Advantages and Disadvantages** - - - - **The Duty Framework (Deontological)** - - - - **Following Moral Rules Regardless of Outcome** - This framework also focuses on following moral rules or duty regardless of outcome, so it allows for the possibility that one might have acted ethically, even if there is a bad result. - Therefore, this framework works best in situations where there is a sense of obligation or in those in which we need to consider why duty or obligation mandates or forbids certain courses of action. **Limitations** - First, it can appear cold and impersonal, in that it might require actions which are known to produce harms, even though they are strictly in keeping with a particular moral rule. - It also does not provide a way to determine which duty we should follow if we are presented with a situation in which two or more duties conflict. - It can also be rigid in applying the notion of duty to everyone regardless of personal situation. **The Virtue Framework** - In the Virtue framework, we try to identify the character traits (either positive or negative) that might motivate us in a given situation. - We are concerned with what kind of person we should be and what our actions indicate about our character. - We define ethical behaviour as whatever a virtuous person would do in the situation, and we seek to develop similar virtues. **Benefits** - Obviously, this framework is useful in situations that ask what sort of person one should be. - As a way of making sense of the world, it allows for a wide range of behaviours to be called ethical, as there might be many different types of good character and many paths to developing it. - Consequently, it takes into account all parts of human experience and their role in ethical deliberation, as it believes that all of one's experiences, emotions, and thoughts can influence the development of one's character. **Limitations** - Although this framework takes into account a variety of human experience, it also makes it more difficult to resolve disputes, as there can often be more disagreement about virtuous traits than ethical actions. - Also, because the framework looks at character, it is not particularly good at helping someone to decide what actions to take in a given situation or determine the rules that would guide one's actions. - Also, because it emphasizes the importance of role models and education to ethical behaviour, it can sometimes merely reinforce current cultural norms as the standard of ethical behaviour. **A Convincing Argument** The Argument for a Canadian Quality and Patient Safety Framework for Health Services: - Unintended harm occurs in a Canadian hospital or home care setting every 1 minute and 18 seconds. - Every 13 minutes and 14 seconds, someone dies. - Patient safety incidents are the third leading cause of death in Canada. **Who is Included in the Framework** - Public - Board Members - Health Leadership - Health Teams (including patients and families) - Policy Makers **Five Goals of The Framework** 1\. **People-Centred Care:** People using health services are equal partners in planning, developing, and monitoring care to make sure it meets their needs and to achieve the best outcomes. 2\. **Safe Care:** Health services are safe and free from preventable harm. 3\. **Accessible Care:** People have timely and equitable access to quality health services. 4\. **Appropriate Care:** Care is evidence-based and people-centred. 5\. **Integrated Care:** Health services are continuous and well-coordinated, promoting smooth transitions. **The Focus of Collaboration** - There are "five customized guides, one for each key stakeholder group in our health system. - Each Action Guide emphasizes the importance of each stakeholder's role "to improve quality and patient safety". **Some Context...** - Almost a decade ago, the first hospitals in Ontario began to re-examine the rules which govern the presence of family and friends at the patient\'s bedside as they receive care. - The traditional model of a firmly established set of 'visiting hours' is giving way to two new models: - **A Family Presence Policy** -- which ensures the ability of defined family members to stay with their loved one at any time of the day (or night). - **Open (or Unrestricted) Visiting** -- which eliminates visiting hours and allows anyone to visit at any time. **How Policies Develop and Change** With advocacy from the Institute for Patient and Family-Centred Care (IPFCC) and the Canadian Foundation for health care Improvement (CFHI), many hospitals are currently reviewing, or have recently reviewed and changed their policies, and are shifting from traditional policies of set visiting hours to more open policies. **Family Presence Principles** - To encourage and support this trend, the Ontario Hospital Association (OHA) has developed a set of family presence principles. - The principles uphold the ideal that patients are encouraged to welcome defined family to their side while in the hospital, regardless of the time of day. - The principles ensure allowance for locally-developed nuances that are sensitive to the needs of departments. **Here are some examples:** - mental health, intensive care units - building conditions such as ward rooms, isolation units - circumstances such as public health alerts **This Information is Based on...** - The core concepts of family presence policies identified from exemplar policies at leading hospitals across the province of Ontario; - Guidance from member hospitals with significant experience transitioning to more progressive policies and who have directly engaged their patients and families to develop their policies; and - Guidance literature and best practices identified by the Institute for Patient- and Family-Centred Care (IPFCC) and its patient advisors, and/or the Canadian Foundation for health care Improvement (CFHI) and the Better Together Campaign. **Principles** 1\. Patients should be assured that their family will be welcomed at their side regardless of the time of day. 2\. Policies should adopt the broadest possible definition of 'family'. Patients define their 'family' and how they will be involved as partners in care. 3\. Family presence must be balanced with other factors affecting patient care. The presence of family at the bedside must be understood as balanced with other needs for patient care. 4\. Developing a family presence policy or changing an existing family presence policy and/or visitor policy, should always be done in consultation with patients, families, and hospital staff. **Practice Considerations** To meaningfully put these principles of family presence into practice in a complex hospital environment, a significant number of considerations are advisable in developing a hospital policy. As a starting point for an organizations review of their policy, nine major areas for consideration are included below: 1. Family presence is subject to patient preference, with family and care team input. At all times, the wishes of the patient are paramount". 2. It is still appropriate to differentiate between "family" and "visitors". 3. The elimination of visiting hours should not be understood as an obligation for family members to be present around the clock. 4. Family members who are defined by the patient as partners in care should be given a way of identifying themselves to staff. 5. As family presence is balanced with other factors, a mechanism for addressing any concerns should be identified for patients, families and staff. 6. Certain additional steps may still be required to enter a hospital building after hours. 7. Certain additional requirements are appropriate with respect to children: a. Young children must be accompanied by a non-patient responsible adult. b. Children should be prepared by their family or other non-patient, responsible adult for the experience of being in a hospital and be able to generally abide by the expectations of all family regarding their presence in hospital. For example, noise level, privacy of other patients, allowing staff to fulfil their duties, and so on. 8. Public Health restrictions may limit family presence. 9. Organizations may consider linking their family presence policy to other related policies, including, but not limited to: patient concerns management, Patient Bill of Rights, hand hygiene, and pet visitation. **Kingdon's Theory and the Critical Questions** **Accessibility Policy** - Health Quality Ontario is committed to ensuring equal access and participation for people with disabilities. - Committed to treating people with disabilities in a way that maintains their dignity and independence. - Do so by removing and preventing barriers to accessibility and by meeting our accessibility requirements under the Accessibility for Ontarians with Disabilities Act (AODA), 2005 and applicable regulations. - - Customer service - General requirements - Information and communications - Employment **Ethical Support Frameworks Adopted in Canadian Hospitals** **Resources in Hospitals** - - - education, - case consultations, - policy development, and - research. **Documents by Clinical Ethics Centres in Hospitals** - Ethical Decision-Making Framework - Advance Care Planning - Capacity Assessment - Informed Consent to Treatment - Power of Attorney for Personal Care - Substitute Decision Making - Centre for Clinical Ethics Brochure **St. Michael's Hospital Centre for Clinical Ethics** Follows the ethical framework called... **YODA** - - Identify the problem. - Acknowledge feelings. - Gather the facts. - - What are the Goals of Care? - Consider alternatives. - Examine Values. - Evaluate alternatives. - - Articulate the decision. - Implement the Plan. - Concluding Review. **Professional Code of Ethics: Definition** "A societal code that governs the conduct of a subset of the population who engage in a particular set of tasks that are not commonly engaged in by the wider public." **How the Professional Code of Ethics Works** A professional code serves 4 functions: 1\. Guidance to individual professionals 2\. Guidance to ethics committees 3\. Informs clients of what to expect from professionals 4\. Informs other professionals of what to expect from their peers **CMA Code of Ethics and Professionalism** - See website. **Code of Ethics for Doctors** - - - - - **Virtues Exemplified by the Ethical Physician** Trust is the cornerstone of the patient-physician relationship and of medical professionalism. Physicians enhance trustworthiness in the profession by striving to uphold the following interdependent virtues: - - - - - **Code of Ethics for Nurses** - - - - - **Primary Values in Nursing** - Providing safe, compassionate, competent, and ethical care - Promoting health and well-being - Promoting and respecting informed decision-making - Honouring dignity - Maintaining privacy and confidentiality - Promoting justice - Being accountable **Code of Ethics for Dentists** - The CDA Principles of Ethics define the fundamental commitments that guide a dentist's ethical practice and to which the dental profession aspires. - It forms the foundation of a dentist's professional responsibilities to his or her patient, to society, to the profession, and to him or herself. **The Importance of Trust** Trust is the foundational to the dentist-patient relationship and the contract between the dental profession and society. - **Honesty** -- Be truthful; behave in a trustworthy manner by furthering the patient's well-being and acting with moral concern to achieve a good outcome. - **Competence** -- Be competent; provide treatment in accordance with your level of clinical expertise, within currently accepted professional standards and evidence-based practice and keep your knowledge and skills of dentistry contemporary. - **Fairness** -- Be fair; treat all individuals, patients, and colleagues fairly, and practice in a just and equitable manner. - **Accountability** -- Be accountable; take responsibility for your actions, decisions, judgment and professional competence and act, first and foremost, for the benefit of, and in service to, the health of patients and the community. **Ethical Principles that Govern Pharmacists** - **Beneficence (to benefit):** Forms and guides our commitment to serve and protect the best interests of our patients establishes the fact that our primary role and function as health care professionals is to benefit our patients. - **Non maleficence (do no harm and prevent harm from occurring):** Guides our commitment to serve and protect the best interests of our patients addresses the reality that as we strive to benefit our patients, we must be diligent in our efforts to do no harm and whenever possible, prevent harm from occurring. - **Respect for Persons/Justice:** Guides our understanding of how we ought to treat our patients. Respect for persons acknowledges that all persons, as a result of their intrinsic humanity, are worthy of our respect, compassion and consideration. We demonstrate this when we respect our patients' vulnerability, autonomy and right to be self-governing decision-makers in their own health care. The principle of "Justice" requires that we fulfill our ethical obligation to treat all patients fairly and equitably. - **Accountability (Fidelity):** Ties us to our professional promise to be responsible fiduciaries of the public trust ensuring that we keep our promise to our patients and society to always and invariably act in their best interests and not our own. It is this principle that holds us accountable, not just for our own actions and behaviours, but for those of our colleagues as well. **What do Patients Value in Patient-Centred Care?** - Strong communication skills are desired in health care professionals, as this was seen as being important for facilitating shared decision-making and positive patient-provider relationships. - Patients expressed that they preferred to have some degree of control over decisions about their health and their treatment plans. - Patients consistently reported that they wished to be treated as individuals with unique preferences and needs, rather than simply as a patient with a disease. **What do Patients Value in Medical-Home Delivery Model?** - Team-based primary care is desirable due to perceived benefits of better collaboration among care providers and greater continuity of and access to care. - Nurse practitioners can take a greater role in delivering care, either as primary-care providers or as someone patients can easily contact to ask questions without needing to make an appointment. - Electronic health records and other technology are important for enhancing care for both the provider and the patient to support "coordination and continuity of care". - Patients value technology that they can use to schedule appointments online and discuss health issues that do not necessitate appointments to support managing their own care. - Patient access to medical records is desirable as it can improve communication and patient education.