Quality Improvement and Patient Safety Forum – Oct 16, 2018

Thank you to those who attended the quality improvement and patient safety forum on October 16th 2018. This interactive day in Toronto focused on:

  • Building Skills: Develop and enhance skills to apply quality improvement and patient safety work.
  • Networking: Connect with a network of practitioners, leaders and scholars with advanced expertise in quality improvement and patient safety.
  • Innovation: Share knowledge and your experiences with success and failure in quality improvement and patient safety

This year, we were thrilled to have Jeffrey Braithwaite from the Australian Institute of Health Innovation and Brian Hodges from the University Health Network deliver the keynote speeches. For more information please visit: https://events.hqontario.ca/ehome/index.php?eventid=347105.

Click here to view the Poster Abstracts selected for the Open  Competition for the QIPS Forum 2018!

Please note: The Speaker Presentations that were made available to the audience are below.

AM Workshops:

Session: Joy in Work: Implications for Quality Care
Session: Morbidity and Mortality Rounds – How to Implement and Improve M&Ms for Patient Safety
Session: Quality for Leaders – How Do You Make Quality Part of Your Strategy?
Session: Tackling Health Inequities: Applying Population-Based Approaches to Quality Improvement Programs

Morning Plenary Session : Adapting the Role of Health Care Professionals for the Future

PM Workshops:

Session: What’s Needed to Lead Systems Change?
Session: Measurement and Monitoring of Safety Conceptual Model in the Canadian Healthcare System
Session: Embracing the Plan-Do-Study-Act (PDSA) Method in Practice, Not Just in Name Only
Session: Nurturing Improvement within your Team

Afternoon Plenary Session:Finally, connecting the dots and making it work

Sharing ideas on Risk, Human Performance, Teams and Leaders: November 5th and 6th

Please join us for Risky Business: Embracing Uncertainty this coming November. This will be a different conference on risk management in healthcare, and promises to challenge how we think, what we know and above all, to inspire change. The Hospital for Sick Children in Toronto has supported and sponsored Risky Business conferences for the past decade as part of their commitment to safety and quality, and are very pleased to once again be involved with the next Risky Business conference in Toronto.
More information can be found here :



C-QuIPS Rounds : Monday, June 18th at 9:30am

The keynote speaker this year for the Department of Medicine’s Annual Day (June 18, 2018) is Dr Sanjay Saint from the University of Michigan. His particular interest lies in the intersection between patient safety and infection control. For instance, he has led numerous studies and projects related to catheter-associated urinary tract infections (CAUTI), including a major publication in NEJM study a couple of years ago: Saint S, et al A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. N Engl J Med. 2016 (attached)

The title of the talk is: Enhancing Patient Safety by Preventing Hospital Infection: In Search of the ‘Aha’ Moment…….


1. To discuss intersectional innovations – “aha” moments – and distinguish from directional innovations

2. To discuss issues related to hospital infections, in general, and catheter-associated UTI and hand hygiene, in particular

3. To describe how several diverse disciplines – psychology, sociology, mindfulness – can help clinicians have “aha’ moments

Time: 9:30am at the C-QuIPS offices, 525 University avenue, Suite 630, Toronto, M5G 2L3.


C-QuIPS offices, 525 University Avenue, Suite 630

City Wide Quality and Safety Rounds: Wednesday, Feb 28th @ 12-1PM

Topic: Using Simulation to Inform Quality and Patient Safety Improvement Strategies

Speakers: Dr. Jordan Tarshis MD, FRCPC ( Director, Sunnybrook Canadian Simulation Centre), Agnes Ryzynski (Manager, Simulation & Curriculum Development, Sunnybrook Canadian Simulation Centre), Emily Louca ( Education Manager, The Hospital for Sick Children) and Dr. Douglas Campbell ( Medical Director, Allan Waters Family Simulation Centre)

Host Site: St Michael’s Hospital, Cardinal Carter 16-101.

Sites participating via OTN: CQUIPS and Sickkids: 525 University Avenue, Rm 630 St Michael’s Hospital: Cardinal Carter 16-101

OTN Webcast Link: http://webcast.otn.ca/mywebcast/?id=79621149

The use of simulation in health care has long been a tool for training clinicians across all disciplines. However, simulation also provides a powerful method for identifying system and process issues that can lead to unintended consequences for our patients and clinical teams. Across the Toronto Central LHIN many hospitals are embracing the use of simulation to unearth pitfalls and gaps in the systems and processes in which clinicians work in and then developing improvement initiatives to ultimately improve patient safety and quality of care.

Sunnybrook Health Sciences Centre, St. Michael’s Hospital and the Hospital for SickKids have all focused on this use of simulation. During this session each hospital will share their experience with utilizing simulation as a tool to inform quality and patient safety improvement strategies.


  1. To learn about the use of simulation beyond the purposes of training
  2. To understand how simulation is being used to inform quality and patient safety improvement strategies
  3. To create a dialogue on how other organizations can utilize low-technology simulation to improve quality of care and patient safety


City Wide Quality and Safety Rounds: Thursday, Dec 8th @ 12-1PM

Topic: Beyond the Checklist: Working to Advance a Culture of Safety in the OR

Speaker: Dr. Carol-Anne Moulton, MBBS, PhD, FRACS

Host Site: Toronto General Hospital, 11th Floor Peter Munk Building, Rm 190

Sites participating via OTN: CQUIPS and Sickkids: 525 University Avenue, Rm 630 St Michael’s Hospital: Li Ka Shing Knowledge Institute, Rm 211

OTN Webcast Link: http://webcast.otn.ca/mywebcast?id=62737255

“Slowing down when you should” has been described as the transition from automatic to effortful functioning in professional practice. The ability to “slow down” is an important factor in expert judgment. Building on previous work that studied slowing down as an individual cognitive and social phenomenon, this talk will describe recent work that has extended the framework to explore team slowing down moments in the operating room. Two examples of team slowing down moments are the surgical safety checklist, and, as this talk will describe in more detail, intraoperative handoff. Making team slowing down moments explicit provides opportunities for both team and self-reflection. This has implications for continuing improvements in practice in order to advance a culture of safety in the OR.

Dr. Carol-Anne Moulton is an Associate Professor in the Department of Surgery, University of Toronto and Staff Surgeon with the Division of General Surgery, University Health Network. She is currently the Medical Director of the Operating Room in Toronto General Hospital and a Scientist in the Wilson Centre. Dr. Moulton’s research program focuses on understanding the complexity of surgical judgment, the development of surgical expertise, and underlying causes of surgeon error.

C-QuIPS Quality and Safety Rounds

Date: Tuesday, November 28th 2017
Time: 12:00 PM – 1:00 PM
Speaker: Dr. Pat Croskerry, MD, FRCP ( Edin), PhD
Location: 525 University Avenue, Rm 630

City Wide Quality and Safety Rounds: Thursday, Nov 10th @ 12-1PM

Centre for Quality Improvement and Patient Safety in partnership with the Toronto Academic Health Science Network (TASHN) hospitals, are pleased to present monthly City-Wide Quality & Safety Rounds. The rounds will be hosted by different hospitals on a rotating basis, and broadcast through Ontario Telemedicine Network to all TASHN hospitals.

Title: Improving Care for Patients with Delirium

Location: Sunnybrook Bayview Campus McLaughlin Auditorium, EG-61

OTN Webcast Link: http://webcast.otn.ca/mywebcast?id=61171936

*Please note: C-QuIPS Sickkids site (525 Univsersity Rm 630) has booked space for members in Downtown Toronto. Please join us here to view and participate in the live webcast Q&A*

Session I. Understanding versus Managing: The Power of Person-Centred Language with Responsive Behaviours

Care providers often use the terms “difficult” and “challenging” when describing a client presenting with the symptoms of disturbed perception, thought, mood or psychomotor behaviour (“responsive behaviours”). Language such as this is stigmatizing and contributes to a culture of labelling and blame.

A TAHSN Senior Friendly Community of Practice working group was formed to develop a shared person-centred approach for behaviour description that is specific, objective, and free of bias. This approach provides a foundation for written and verbal communication regarding responsive behaviours that can be used in hospitals and academic institutions across the continuum of care.

Mary-Lynn Peters, Nurse Practitioner, Trillium Health Partners

Deborah Brown, Nurse Practitioner, Senior Friendly Strategy, Sunnybrook Health Sciences Centre

Session II. Better with Time: A Team Based Approach to Spread the Improvement Work on Delirium Accuracy

Sunnybrook Health Sciences Centre uses the CAM (Confusion Assessment Method) tool to screen for delirium. Audits identified that compliance with the tool is 100%, however accuracy was low. The presentation will outline how General Internal Medicine through the Senior Friendly Hospital Action Program improved CAM accuracy using a team based approach.

Florence Wong, Advanced Practice Nurse, General Internal Medicine Unit & Level 1 ICU

Sarah Evans, Registered Nurse, General Internal Medicine Unit

Tanya Abji, Occupational Therapist, General Internal Medicine Program

Tina Sahota, Physiotherapist, General Medicine/Community Program

All Presenters are from Sunnybrook Health Sciences Centre

C-QuIPS Quality and Safety Rounds: Wednesday, Nov 8, 2017 @ 12-1PM

Topic: Morbidity & Mortality Rounds – Making Them Effective

Speaker: Dr. Edmund Kwok, MD FRCPC, MHA, MSc

Location:  525 University Avenue, Rm 630

Despite a century of holding regular M&M reviews, the medical community has been struggling with making them effective and impactful in addressing quality and patient safety issues. This session with examine where we’ve been going wrong, and how we can incorporate latest evidence to evolve M&M practices for the next century.

Dr. Ed Kwok received his medical degree at Queen’s University, and completed a 5-year Royal College residency training in Emergency Medicine at the University of Ottawa. During his fellowship year he also obtained a Masters in Health Administration (MHA) at the Telfer School of Management. His special interests and research focus include ED flow, Quality Improvement and Patient Safety. He is currently the Director of Quality in the Department of Emergency Medicine at the University of Ottawa. He blogs at CanadiEM (http://canadiEM.org/). Follow him on Twitter @eddeestyle