Quality Culture Trailblazer
Director of Quality and Risk Management
St. Joseph’s General Hospital
In 2010, St. Joseph’s General Hospital was facing many challenges, significant change, and among staff, morale was low. There was no formalized Quality Improvement program, and a poor culture of patient safety. As a result of these organizational issues, in October 2010 Accreditation Canada gave St Joseph’s the rating of “Non-Accreditation.”
In its own response to these issues, St. Joseph’s hired Leesa as an Accreditation Consultant. Leesa worked with staff, physicians, senior leadership, and the board of directors to teach principles of quality improvement, patient safety, and systems theory, with the goal of shifting the culture to one that focused on system changes and learning opportunity. As a result of her efforts and initiatives, the culture at St. Joseph’s has been dramatically and positively transformed.
To increase and encourage incident reporting, Leesa developed a “quick guide to adverse events reporting and follow up” and sat with staff on the units to walk them through the process. She worked with the software distributor to customize the program and make reporting incidents easier for staff and physicians to complete. Staff and physicians now readily complete incident reports, with the majority comprising of near misses and no-harm events.
Leesa also focused on timely, local data that was important to staff and physicians, rather than accountability data; she then ensured that the data was readily available to all staff. Her two-prong approach included the development of a patient flow scorecard, and a balanced scorecard that is now used across the organization.
With assistance from the BC Patient Safety & Quality Council, Leesa developed and co-facilitated quality improvement workshops for all middle management staff. Each participant has developed and implemented an improvement project, benefitting the hospital while providing hands-on skills training.
As the Director of Quality and Risk Management, a role she took on in 2012, Leesa models patient-centred care by meeting often with patients and their families to review a complaint or a critical incident. She is kind, caring and very considerate as she helps them understand the complexity of health care while at the same time understanding and helping them through the resolution process. She has made substantial changes to systems based on the outcome of these reviews.
Recognizing that pharmacists could have a greater impact if they were on the unit working in interdisciplinary teams, Leesa proposed the creation of a new role: the Clinical Pharmacist, who would conduct medication reviews for the frail elderly outside of the Pharmacy Department. The Clinical Pharmacist has dramatically reduced the number of inappropriate medication used by this population and reduced the number of medication errors by 15%.
Moreover, Leesa has worked with the Pharmacy Department to create a comprehensive antimicrobial stewardship program that monitors patients for treatment effectiveness and appropriateness. Patients are phoned within seven days of discharge to evaluate the treatment and to ascertain the patient was readmitted, or visited their physician. The program was considered a Leading Practice by Accreditation Canada and resulted in a cost savings of $75,000.
As a direct result of Leesa’s efforts, St Joseph’s General Hospital attained “Accreditation with Exemplary Standing” in 2014. Attaining the standards of excellence required for accreditation has become a part of daily work practices in an organizational culture where staff and clinicians are motivated to provide high quality care. This shift was driven by Leesa’s leadership, authenticity, creative thinking, and dedication to always putting quality first.
At a Glance
Medical Lead, Clinical Cardiology, St. Paul’s Hospital