Identifying and Reducing Risks Reporting for Learning and Improvement: The Manitoba and Saskatchewan Experience Paula Beard and Linda Smyrski Abstract Background Both Saskatchewan and Manitoba have embarked on major Both Saskatchewan and Manitoba have embarked on major provincial quality improvement endeavours that include a provincial quality improvement endeavours that include a mandatory reporting and learning process aimed at enhancing mandatory reporting and learning process aimed at enhancing patient safety by reducing the potential for recurrence of critical patient safety by reducing the potential for recurrence of critical incidents. This move from a voluntary, less comprehensive incidents. This move from a voluntary, less comprehensive process signals a commitment from policy makers that substantial process signals a commitment from policy makers that substan- improvements to safety will occur only when adverse events are tial improvements to safety will occur only when adverse events addressed systemically within the healthcare system. are addressed systemically within the healthcare system. Saskatchewan took the lead with the passage of legislative Saskatchewan took the lead with the passage of legislative requirements to report, investigate and share learnings arising requirements to report, investigate and share learnings arising from critical incidents as of September 15, 2004. Manitoba from critical incidents as of September 15, 2004. Manitoba is due is due to implement similar requirements in 2006. The focus to implement similar requirements in 2006. The focus of legisla- of legislation in both provinces is aimed at supporting a more tion in both provinces is aimed at reporting for learning in order secure environment for reporting and investigation and an to strive for further improvements in patient safety. environment of openness that promotes learning and sharing of important safety information. This article is the story of how By empowering staff and physicians to actively participate in two provinces are coordinating and striving for patient safety risk identification and mitigation, both provinces have become improvement. leaders in patient safety. Saskatchewan and Manitoba have taken an innovative and collaborative approach to strive for substantive Saskatchewan system changes, seeking out best practices in the areas of quality In late 1997–early 1998 it was clear to officials within and patient safety. Saskatchewan Health, Health Districts (now Regional Health H EALTHCARE Q UARTERLY V OL . 9, S PECIAL I SSUE • O C TOBER 2006 | 61 Reporting for Learning and Improvement: The Manitoba and Saskatchewan Experience Paula Beard and Linda Smyrski Authorities), Regulatory Authorities and other concerned and continues to be undertaken, resulting in the development individuals in the Saskatchewan healthcare system that they and implementation of many actions where risk to the safety could ill afford to lose the regionally learned lessons. Themes of individuals has been identified. A quality and risk manage- emerged in critical incidents throughout the province, and ment network was established and continues to provide valuable officials became concerned that without provincial coordina- support to the provincial patient safety agenda. These champions tion of information similar incidents would occur in each of the and other stakeholders were instrumental in the development of Districts. The process for collecting and analyzing the critical eight provincial policies. In response to the Thomas recommen- incident information varied across the system. dations, several policies were specifically designed to promote At this time Saskatchewan Health, in partnership with a openness in reporting critical incidents and learning from number of stakeholders, initiated several patient safety activi- mistakes, and to provide support for providers and patients in ties. Additionally, regional pockets of expertise were devel- dealing with critical incidents. oping. These activities came together over the next few years to become a robust and well-coordinated provincial undertaking Roadblocks as Catalysts for Change and to improve patient safety by sharing information and resulting Improvement lessons learned about critical incidents. Concurrent to Hoffman’s activities in the Regina Health An early theme provincially identified in Saskatchewan was District, the Assistant Deputy Minister of Saskatchewan Health the potential for critical incidents to occur as patients were and her staff were making plans to bring stakeholders together transferred from one region to another for continuing care. The for the inaugural meeting of the Provincial Critical Incident attempt to address issues related to these handoffs led to an Review Working Group. This group had originally assembled important effort coordinated by Saskatchewan Health with the representatives from various-sized regions, the Registrar with assistance of several stakeholders from Regions throughout the the College of Physicians and Surgeons, the Executive Director province. The Department convened the Interdistrict Transfer of the Saskatchewan Registered Nurses Association, and select Process Working Group to develop a process for the standard- staff from Saskatchewan Health. Initial efforts of this working ized movement of patients between health regions based on the group were focused on the development of a provincial policy available and required resources. The Saskatchewan Interdistrict to facilitate the sharing of local critical incidents, and the results Transfer Process was completed and approved for use in June of the accompanying reviews, at a provincial level. It quickly 2000. It provides clear guidance on the steps involved in moving became apparent that the Saskatchewan Evidence Act (Canada patients within (and when necessary outside) the province to 2006) would create a barrier to this type of sharing. Regions receive the appropriate services. were concerned that they would lose the protection provided to During the same period, the newly appointed Risk Manager their reviews by sharing the findings. By 2001 it was clear that for the Regina Health District, Carolyn Hoffman, attended the existing legislative protections would need to be extended an Institute for Healthcare Improvement (IHI) Conference at to the Minister so that maximum benefit could be attained which Patrice L. Spath spoke persuasively on the merits of root through sharing the reports. The focus then became the devel- cause analysis. The impact of Hoffman’s IHI experience was opment of appropriate language in the Regional Health Services significant and facilitated the introduction and implementation Act (Canada 2002) to enable the sharing of lessons learned. The of a Critical Incident Review Policy. The implementation of language contained in the Act, accompanying Regulations and this policy complemented the District’s work on updating and the Saskatchewan Critical Incident Guideline (Canada 2004) simplifying the occurrence reporting process. The District’s first was developed through broad and frequent consultation with critical incident review was facilitated by Hoffman in the mental stakeholders over the next three years, coming into effect on health setting in 1998. It immediately became clear that this was September 15, 2004. a tool to bring together the previously disparate risk manage- Subsequent to the release of the Thomas recommenda- ment activities of the District and move toward a culture of tions, a somewhat similar movement arose in Manitoba as patient safety. quality stakeholders voiced similar concerns. Consequently, and also in response to national and international recommen- Manitoba dations, amendments to provincial legislation were proposed. In Manitoba, the deaths of 12 children sparked the Sinclair The Regional Health Authorities Amendment and Manitoba inquest, which five years later resulted in the Thomas recom- Evidence Amendment Act received Royal Assent in June 2005. mendations to “identify institutional arrangements and proce- When proclaimed into force (at a date yet to be established), dures that would provide Manitobans with a stronger guarantee it will amend both the Regional Health Authorities Act and of competent, safe and ethical healthcare in the future” (Sinclair the Manitoba Evidence Act to require the disclosure, reporting 2000; Manitoba Health 2001). Collaborative work has been and investigation of critical incidents and to provide legislated 62 | H EALTHCARE Q UARTERLY V OL . 9, S PECIAL I SSUE • O CTOBER 2006 Paula Beard and Linda Smyrski Reporting for Learning and Improvement: The Manitoba and Saskatchewan Experience protection from use in legal proceedings for information gener- quent three years, the tool continued to be refined, and the ated in carrying out the required reporting and investigation Department ensured that all regions were exposed to it. The activities (Government of Manitoba 2005). introduction of the tool and reporting was simplified by the The legislation will protect the confidentiality of records and existence of Regional Quality of Care Coordinators (QCCs), information, including opinions and advice obtained, compiled who had a well-developed relationship with the Provincial or otherwise prepared for the purposes of investigating a critical Quality of Care Coordinators (PQCC) at Saskatchewan Health. incident – while protecting the rights of individuals affected by The QCCs quickly became the access points for moving critical