Quality and safety work affecting physicians in the RQHR

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Quality and safety work affecting physicians in the RQHR


Antimicrobial Stewardship: what's happening

Lead Pharmacist (Casey Phillips) and Research Analyst (Jason Vanstone) have been busy working with various hospital departments for education and to develop strategies for Program implementation and data analysis

Final interview scheduled for our Lead Infections Disease Physician

Received funding for our Regina Summer Student Research Program project aimed at understanding knowledge and attitudes of Regina’s community pharmacists/physicians towards antimicrobial stewardship

What’s next?

  • Continue developing implementation strategies and data analysis to prepare for official launch
  • Communications
    • Branding the “RQHR Antimicrobial Stewardship Program” – website development (internal/external), logo development, community education/partners (public, academic, health professionals)
    • Structural components
    • Physical space for our team
    • Equipment/workstations
    • Meeting with the Ministry of Health/what is working as a Provincial approach?

What needs more work?

  • Connecting with Southern Regions and Saskatoon
  • Onboarding plan for our Lead Infections Disease Physician
  • Communication strategy: “Antimicrobial Resistance is a Problem”
    • Our program goal is to ensure that we are using antibiotics wisely
    • Education about the problem
    • Better resources
    • Provide patients with safer, higher quality care and improve outcomes
    • Getting patients the right antibiotic with they really need it
    • Collaboration, Education, Accountability

Stop the Line safety policy and procedure

The Safety Alert System Stop the Line Policy and Procedure is a province-wide initiative where all health regions have been mandated by the Ministry of Health to strive for zero harm to patients, staff, residents, practitioners and visitors to our facilities by the year 2020. The premise of this work is that SAFETY IS EVERYONE’S RESPONSIBILITY.

Our region will introduce the Stop the Line policy and procedure on May 1, 2016. Stop the Line represents an evolution of safety practices that already occur in many areas of this organization. It builds on and elevates these practices by providing clear expectations, principles and processes for taking action whenever we encounter a situation that is potentially unsafe. Through this policy, every individual in the workplace has a duty and responsibility to call out potentially harmful situations (or “stop the line”) as soon as possible and trigger a process to stop the harm before it occurs. We know that the people best suited to fix a problem are the ones closest to the problem. Stop the Line provides a way for the organization to help you protect your patients and colleagues.

Beginning in April, staff from Patient Safety and from Employee Health & Safety will lead education sessions to facilitate implementation of the Stop the Line policy and procedure. This is an opportunity for physicians to participate in and support the rollout of this important policy.

Checking in on Appropriateness in Practice: chart completion

The sixth plank in the Region’s Appropriateness Strategy is the effort to improve clinical practice. One of the areas of emphasis is improving inter-disciplinary communication. In that regard the Senior Medical Office reviews weekly chart completion and also the Medicine Service line audits documentation on the Medical Inpatient Units.

Two audits are presented a chart completion audit dated May 2nd 2016 and a ward documentation audit conducted on May 4th 2016.

Chart Completion Audit

3.5% of the medical staff account for 1340 incomplete records

The chart completion audit reveals that there are few physicians who are not discharging their professional responsibility as they are persistent in their tardiness to complete their records. Whatever the reason it is unacceptable practice.

As VP of Physician Services, I really need your help. Please note the worsening performance:

  • three Family Medicine physicians are responsible for 135 incomplete records;
  • 4 members of the Department of Medicine account for 155;
  • 10 Ob/Gyn account for 690: one of them responsible for 199
  • One Pediatrician with 36
  • One Psychiatrist responsible for 38; and
  • Seven surgeons account for 301.

23 (3.5%) of our medical staff membership physicians account for 1340 incomplete charts and some are incomplete since 2014! How can continuity of care to the patients when they returned to the community occur when the necessary information is not provided? How can HIMS staff get their important coding completed in a timely way?!!

Medical Inpatient Unit Audit

These are snapshot audits done on the first Wednesday of the month on each of the six medicine inpatient units. The results of the 4th of May Audit are as follows:


Here there is good news and bad news. There has been considerable improvement in the completion, documentation and timeliness of history and physical exams. There has also been significant improvement in the communication of the plan of care. The progress notes and daily physician visits are also showing improvement. The bad news is that there is a challenge with the completion of the Medicine Inpatient Pre-Printed Orders.

The Medicine PPO represents an evidence-based standard of care and indeed makes it easy for our physicians to do the right thing. The region has endeavoured to address the logistical issues of ensuring that the PPO is available yet some of our medical staff are refusing to use it.

The Senior Medical Office, and the PPO Committee, will be consulting with practitioners to assess the utility of the document and then making any required amendments. However the SMO is committed, in the interest of patient safety, to ensuring that a PPO will be used for all admissions to Medicine.

Submitted by: Dr David McCutcheon, VP Physician and Integrated Health Services

5E medication reconciliation process

    1. Policy

    All medications shall be prepared and administered by appropriate Health Care Professionals (HCP) in accordance with the Professional’s Scope of Practice as well as RQHR and Unit specific practices.

    • All medications shall be given according to a practitioner’s order, as per RQHR Policy #602 – Physician Orders. http://rhdintranet/hsl/public/RQHRpolproman/602pol.pdf
    • All patient allergies will be documented on the PIP section of the patient’s health care record and Medication Administration Record (MAR). Pharmacy will not enter orders into the Pharmacy Information System unless an allergy status is stated, thus ensuring no medications are dispensed to the patient that has an allergy to that medication.
    • In order to administer a medication in the RQHR IV Manual, the “REQUIREMENTS”and “MONITORING REQUIRED” sections within the monograph must be met. If unable to meet the monitoring requirements, the Most Responsible Physician must be contacted.

    2. Purpose

    • To ensure patient safety when administering medications.
    • To comply with Professional Practice Standards.

    3. Responsibilities

    • Health Care Professionals administering medications shall understand the indication, therapeutic effect, side effects and clinical/monitoring responsibilities.
    • The Health Care Professionals preparing, dispensing or administering the medication should clarify with the prescriber, if there is any indication that patient safety will be affected by administering the medication. https://www.e-therapeutics.ca/search
    • Unless prepared by Pharmacy, the medication must be prepared by the HCP administering the medication. The Health Care Professionals administering the medication must follow:

    4. Definitions

    • Patient refers to clients, residents, patients and families

    5. Revision History

    This is a new policy.