PSLS = Improved Patient Safety

Sep 14, 2016 | Spotlight

As an administrative assistant to eight patient care managers who each have diverse portfolios, my curiosity was sparked by the Patient Safety and Learning System, as PSLS kept coming up in meeting minutes, regardless of it being  a meeting for the Renal Department or the Eating Disorders Program or the Alder Unit. It was something that seemed to be reoccurring across all types of care.

So what is the purpose of PSLS and how does it promote a just and safe reporting culture at Providence Health Care? I was determined to better understand how a seemingly mundane computer system was able to improve the safety of the growing number of patients at Providence Health Care.

And I had the privilege to learn about the ins and outs at the Alder Unit located at Langara St. Vincent’s Hospital.

A culture of care             

I quickly realized that patient safety is not just something discussed in staff orientation or monthly meetings - it is the culture of our care.

“At the Alder Unit, PSLS reporting and closing the loop is viewed as an integral part of sustaining a culture of patient safety and excellence in care,” says Sarah Carreire, leader, Patient Safety Learning System. “PSLS is part of a full circle – the Alder team live and breathe patient safety and are encouraged and supported to use best practices. In turn, because the team feels safe and respected when reporting events, a true partnership is formed between them, the patients and families.”

In order to truly appreciate PSLS, I went on to pick the brains of Patty Yoon, patient care manager, Tertiary Mental Health, and Malcolm Jenkins, previous Unit Supervisor, Alder Unit, for some specific patient stories, and how they tie into the PSLS.

When I sat down with Malcolm, he quickly recalled a patient whom he had received a more-than-normal amount of PSLS reports on. Despite Patty, Malcolm and the rest of the Alder team following standard procedures, the meetings on how to prevent future falls and aggression related to this patient proved ineffective.

This prompted the Alder team to start to view each individual report as part of a bigger picture, and that was when they put together that the patient’scommunication difficulties was due to his chronic, persistent psychotic disorder, which had induced a severe anoxic brain injury.

From analyzing the PSLS reports from a patient-centered care perspective, the team identified that the patient became agitated each time the seatbelt was placed on him in his wheelchair; it was a symbol of his independence being stripped away. A conversation about patient safety and quality of life arose and, through involvement with the patient’s family, the team’s final decision was to not use the seatbelt in order to provide the patient with the independence he deserves. After this decision was made, the reports of agitation and falls both decreased.

A balancing act

From this experience, the Alder team saw the success of identifying a PSLS report as an individuals, and linking that individual into a story, proactively involving the patient and the patient’s family into the conversation of what is the unique care needed, and transparently weighing out the pros and cons of  risk which, in this case, prompted a conversation around the patient’s falls and agitation when the seatbelt was used versus when it is not used.

“Risk is a complex process that changes across time, people and environment. The Alder team is a great example of taking something like patient falls and applying a flexible and adaptive approach in their assessment and management of care,” Carriere comments. “This encourages a resilient culture of patient safety, in addition to ensuring families that their loved one is safe in our care. Management and senior leadership further foster this culture by empowering frontline staff to work with uncertainties, such as risk-taking with high falls’ risk patients, and promoting communication (e.g., creating awareness among the staff team about the status of the patient and their choice), decision-making, leadership, and above all, teamwork.”

The Alder team demonstrated how, if they treat each PSLS report as part of a patient’s larger story, the patient is communicating with us, often times without having to say a word. The team, under the leadership of Patty and Malcolm, showed me that there is a daily balance between providing a patient with safety and autonomy and at Alder, this balance is viewed as a dynamic, flexible decision-making process that involves the team, the patient, and the family.

“Change is growth and, with each incident, the Alder team is able to use their experience and wisdom to decide what is the best practice, which may change from case to case depending on many factors,” summarizes Sarah.

Pursuing excellence via PSLS

Thanks to my conversations with Sarah, Patty and Malcolm, the next time I hear PSLS in a meeting, I will no longer think of it as just a mundane reporting tool.

Instead, I will think of it as a reporting tool and more importantly, a learning tool. I  am now confident that thanks to a combination of expertise, offered by people like Sarah, Patty and Malcolm , and asking questions like “how did it happen?”, “how can we prevent it from happening again?”, “what changes do we need to make?” and, most importantly, “what can we learn from this?” we will not only continue to be  leaders in patient safety, but that our continuous growth and desire to learn will be what keeps us at the forefront of delivering exceptional care.

At the suggestion of Sarah, the interest of Chantal and the willingness of Patty and Malcolm, we were able to come up with this story, highlighting what we hope is the first of many “patient safety success stories.” Way to go, Alder, and if your area has a story to share, please be in touch! Stay tuned to this space for our next installment in this safety success series.

Quality & Safety

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Comments

I visited alder briefly and wad very impressed with Patti and Malcolm. I am pleased with your onfo
A very well written document and what a great story! Jo-Ann

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