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:

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:

“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:

*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 ( Follow him on Twitter @eddeestyle

Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.

Computerized provider order entry and clinical decision support are patient safety strategies with significant implementation challenges. This qualitative study aimed to characterize engagement with these two activities across multiple hospitals in the United Kingdom. Investigators conducted interviews, employed direct observation, and reviewed documents such as implementation plans.

PSI Caring Safely Research Grant

Congratulations to C-QuIPS staff and member, Trey Coffey, Kaveh Shojania, Joanne Goldman, Leahora Rotteau, Ross Baker, and Paula Rowland, and collaborators Marlys Christianson and Timothy Vogus, on their successful funding application from Physician Services Incorporated for their study “High Reliability Organizing in healthcare: Caring Safely at the Hospital for Sick Children”.

This qualitative study aims to gain in an in-depth understanding of whether and how Caring Safely at SickKids, an innovative and large scale hospital intervention focusing on high reliability organizing principles, informs patient safety culture and practices to prevent four types of hospital acquired harm: surgical site infections, central line associated bloodstream infections, pressure injuries and serious safety events. High reliability organizing is drawn from high-risk industries that have successfully avoided catastrophes despite their complexity. However, evidence around this organizational approach in healthcare is lacking. Using interviews, observations and documents, this study will explore how hospital leaders, healthcare providers and family advisors, are interpreting and practicing the principles of high reliability in the ‘Caring Safely’ initiative. The findings will provide valuable insights into the social processes and contextual factors that characterize organizational change for improving patient safety.