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Safety first

Every day, CHEO leadership puts safety first

 Three women gathered around a boardroom table, paying attention to the phone. They are taking part in CHEO’s daily brief, a daily teleconference where CHEO leadership meets to talk about safety.

CHEO begins each day with the “daily brief.” Seven days a week, 365 days a year, leaders from across the organization — from every department and location — come together for 15 minutes to inform one another of the status of their unit and the challenges they expect to face in the coming 24 hours.

The daily brief is an integral practice of safe, reliable organizations that are part of Solutions for Patient Safety — a network of over 135 North American pediatric hospitals and facilities who share best practices with one another. 

The daily brief helps CHEO leadership understand, virtually in real time, the remarkably complex needs of the organization. Why, for instance, a repair in Medical Imaging might not get dealt with immediately since Facilities Management staff are required for a more pressing need in the Emergency Department. Why administrative offices are too warm because cooling must be temporarily redirected to patient occupied spaces. Why there may be a temporary shortage of some materials because CHEO’s supplier in Puerto Rico has been damaged by hurricanes. And so on…

“I was the first to admit that I was not a fan when this idea was first proposed,” says Mari Teitelbaum, Chief Innovation Officer. “I was worried that we would be adding yet another meeting but in fact I am now the daily brief’s biggest fan. Those 15 minutes are often the best 15 minutes of the day.”

For instance, the daily brief has made everyone aware of the constant challenge of staffing a busy pediatric organization. In a restaurant, when a staff person calls in sick and cannot be replaced, customer service suffers but that’s all. At CHEO, when a nurse is sick, they must be replaced by a properly qualified colleague or there is a risk to patient safety — a nurse from Emergency may not have the right qualifications to be called in to replace a nurse from Mental Health. In peak cold and flu season, staff sick calls increase and each needs to be replaced by precisely the right person.

“The daily brief keeps us better able to stay ahead of our needs,” says Dr. Ken Farion, Medical Director, Strategy, Quality and Systems Improvement. “We can better anticipate where there may be staff or equipment shortages and plan ahead, even if it’s just 24 hours in advance.”
Adding the daily brief is one of several CHEO initiatives that puts safety first, not only for children, youth and families but also for staff and medical staff.
It may be brief… but it’s mighty.  

It’s been one Epic year at CHEO

A head and shoulders picture of four women standing in front of a poster which says, “you — staff, nurses and physicians — will make Epic everything it can be for the children, youth and families we serve. Thank you for being innovators. Thank you for being leaders.”

The introduction of Epic, the most powerful electronic health record in the world, has been gradual. Way back in 1994 CHEO became the first Canadian hospital to partner with Epic, using it for patient registration and scheduling. Then, five years ago in October 2013, Epic became part of CHEO’s electronic medical records, rolling out in waves to all of the Ambulatory Care clinics. Learning from this experience, on October 18, 2017, CHEO expanded Epic to include inpatient units, the Emergency Department and Pharmacy.

“Always looking to improve care and put safety first, we all agreed to work towards consolidating all of a child’s medical information in one virtual place, making it available to every clinician in our organization exactly when it is needed,” says Tammy DeGiovanni, Director of Ambulatory Care and Chief Nursing Information Officer. “We rallied around the idea of one patient, one chart.”

Epic makes a child or youth’s health information available enterprise-wide in real-time. If a family visits the orthopedic clinic Tuesday morning and then the plastic surgery clinic Wednesday afternoon, all of the information from Tuesday will be ready for the plastic surgeon on Wednesday. Before Epic, this information would have been in one paper chart which might have languished on someone’s desk or been updated days after a clinic visit. Now, updates occur in real-time. 

Families appreciate the convenience — they don’t have to tell their story over and over again because there it is… in Epic. Clinicians appreciate the comprehensiveness — all the important information they need is there… in Epic. 

DeGiovanni cites three big changes since Epic was expanded one year ago:

Information in a child or youth’s chart is integrated throughout the system in real-time. For instance, when a child is admitted, their allergies are instantly transmitted to Dietary Services to restrict their diet and ensure their safety — that they are not accidentally given food that contains the allergen. When a child is discharged from the hospital or makes a visit to the Emergency Department, a summary is automatically forwarded to the child’s physician. These summaries are sometimes sent even before the child has left the hospital. When a child or youth is seen overnight in the Emergency Department, a summary of the visit including recommendations for follow-up will be waiting for their family physician in the morning. 

Medication orders are accurate and much faster. When a physician orders a medication in Epic, the order is instantly transmitted to Pharmacy where it is verified — ensuring there are no potential interactions with other medications, there are no allergies, and the dosage is correct. In adults, medication can usually be standardized (“take two tablets every six hours”) but with tiny children, the dosage must be carefully adjusted for each child to match their weight. With Epic, ordered and verified medications are delivered within an hour. This process used to take four hours.

Epic has enabled barcode medication administration (BCMA). Every medication is scanned prior to being given to a child or youth, ensuring that it is the right medication in the right dose at the right time for the right child. BCMA puts the safety of children and youth as our first priority. It reduces human error and ensures that medications are exactly what was ordered.

The expansion of Epic to inpatient units, Emergency and Pharmacy one year ago has brought CHEO very close to the promise of one patient, one chart. Four months ago, in June 2018, Epic expanded again, this time to include Surgery and parts of Development and Rehabilitation. In 2019 Epic will expand to include Anesthesiology in February 2019, Ophthalmology in June 2019, and Dentistry shortly after that. 

Moving CHEO from paper health records to Epic has been the biggest transformational initiative in the organization’s history. There have been countless hours of renovating, training, programming, testing and practicing. The result is safer, more reliable and continuously improving care for children and youth.

Solutions for Patient Safety is a big part of Safety First at CHEO

 Ten smiling members of CHEO’s Solutions for Patient Safety team — nine women and one man — posed in a hallway in the Pediatric Intensive Care Unit.

CHEO is improving our care by improving safety for every patient, every day. We are in our third year as a member of Solutions for Patient Safety (SPS).

SPS is a network of over 130 children’s hospitals across the United States and Canada who work together — sharing information, best practices and research — to eliminate preventable harm to children and youth.

Despite our efforts, we sometimes cause harm to young people in our care. That sounds ominous but what does it mean? Just that health care can occasionally be so complex that children and youth acquire conditions that they would not have otherwise, except for coming in to our care.

For instance, some children in the Pediatric Intensive Care Unit require a “central line” — a catheter in a large vein near the heart. Medications and fluids administered by a central line are very fast acting. But, all catheters can introduce bacteria into the bloodstream and bacterial infections from central lines can be more serious than infections from an IV in the forearm or foot.

This is an example of the complexity of health care: a patient requires a central line despite the risks associated with it. CHEO’s goal is to ensure that no children or youth ever acquire a central line associated blood stream infection (CLABSI) because of something that we did, or did not do.

Membership and adherence to SPS protocols has reduced CLABSI rates in member hospitals by 21.1% since 2015. This is a big project involving lots of staff and physicians but is well worth it as we anticipate that CHEO will see similar results — good science gets good results.


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