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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:

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.

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

City Wide Quality and Safety Rounds: Thursday, Sep 8th @ 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.


  • To share current and emerging knowledge to advance the work of Toronto’s quality and safety community
  • To highlight quality improvement and patient safety work that is having an impact at a local level and is relevant to other hospitals, city-wide.
  • To create a forum that will connect individuals working in quality improvement and patient safety and to generate discussions and networking opportunities

Speaker(s): Shoshana Hahn-Goldberg, Karen Okrainec, Jennifer Goodwin, Jullian Chen, Patrick O’Brien

Title: Implementing Patient-Oriented Discharge Summaries (PODS)

Location: 525 University Ave., Room 630

OTN Webcast Link:

From January through March 2015, eight hospital departments across Toronto came together to implement Patient-Oriented Discharge Summaries (PODS), a tool developed through a codesign process involving patients, caregivers and providers. This presentation presents data on how the hospitals came together and the impact of PODs. Two early adopter hospitals (St. Michael’s Hospital / Hospital for Sick Children) will present their experience as well as the impact of implementing PODs within their environments.

Shoshana Hahn-Goldberg, PhD is a health policy and management post-doctoral fellow at OpenLab, an innovation centre at the University Health Network. She has a PhD in Industrial Engineering from the University of Toronto. She is co-lead of the Patient Oriented Discharge Summaries (PODS) initiative.

Karen Okrainec, MD MSc, Clinician Scientist, General Internal Medicine, University Health Network. Karen Okrainec is a general internist with experience in health disparities, patient experience and health outcomes/ health services research.

Jennifer Goodwin RN, APHON has been a nurse on the Blood and Marrow floor at the Hospital for Sick Children since 2005. She is currently a Clinical Support Nurse In Charge. She had the opportunity to work on developing the PODS on 8B at HSC.

Jullian Chan RN, graduated from Ryerson University with a Bachelor of Science in Nursing in 2010. She has been working in the cardiology department for over 5 years as a bedside nurse and a clinical support nurse.

Patrick O’Brien, MA is a Quality Improvement Specialist at St. Michael’s Hospital. Over the last two years he has supported the implementation of various discharge summary projects (including the Standardized Discharge Summary and Patient Oriented Discharge Summary) at both Toronto Central LHIN and St. Michael’s.

City Wide Quality and Safety Rounds: Wednesday, Sept 6, 2017 @ 12-1PM

Topic: Technology and Compassionate Care – Making the Connections to our Work in Quality

Speaker: Dr. Brian Hodges, MD PhD, FRCCPC

Host Site: Health Quality Ontario (Attend in person: Toronto Rehabilitation Institute – UHN University Centre Site Lecture Theater – Basement Level 550 University Avenue Toronto, ON M5G 2A2)

Sites participating via OTN: C-QuIPS/Sickkids: 525 University Avenue, Rm 630

OTN Webcast Link:

Dr. Brian Hodges, MD PhD, FRCCPC is a practicing psychiatrist and teacher whose research focuses on assessment, competence, compassion and the future of the health profession. He is a professor in the Faculty of Medicine and at the Ontario Institute for Studies in Education at the University of Toronto; the Richard and Elizabeth Currie Chair in Health Professions Education Research at the Wilson Centre and Executive-Vice President Education at the University Health Network.

Invited Speaker Rounds: Tuesday, May 19th @ 12-1PM

Speaker: Martin Marshall
Title: Researcher-in-residence model: practical examples, theoretical and conceptual underpinning, benefits and challenges
Description: Most people involved in improving care for patients would like to think that their decisions are influenced by the best possible research evidence. Most academics would like to think that their research has an impact on patient care. But too often neither of these aspirations are a reality. Academic research is often difficult to access, hard to use and sometimes fails to address the questions of greatest importance to practitioners. One of the reasons for this is the traditional separation of researchers working in the ivory towers of academic institutions, and clinicians and managers working in the swampy lowlands of front line health services.

The Researcher-in-Residence model being developed by UCL Partners and others in the UK, is designed to address this challenge. Experienced researchers work as members of operational teams, sharing responsibility to address practical problems by negotiating their scientific expertise alongside the expertise of front line practitioners. The nature, origins and development of this model will be described in this seminar, with practical examples of its use in the UK. The presentation will be followed by an opportunity to critique the model, explore its merits and challenges, and examine its applicability within the Canadian health system.

Martin Marshall is Professor of Healthcare Improvement at UCL and leads Improvement Science London, an initiative to promote and embed the science of improvement across both the health service and academic sectors. Previously he was Director of R&D at the Health Foundation, Deputy Chief Medical Officer and Director General in the Department of Health, and a clinical academic at the University of Manchester. He has been a GP for 24 years, now serving an inner city community in Newham, East London. He is a fellow of the RCGP, RCP and FPHM, and was a non-executive director of the Care Quality Commission until 2012. He has over 190 publications in the field of quality of care and in 2005 he was awarded a CBE in the Queen’s Birthday Honours for Services to Health Care.

Invited Speaker Rounds: Thursday, May 19th @ 12-1PM

Speaker: Dr. Noah Ivers
Title: The science and practice of Audit and Feedback: data-driven quality improvement
Description: All too frequently, when quality improvement interventions are tested in trials, the effects are less than expected. This talk will review the empirical evidence for audit and feedback as an intervention to improve quality of care and summarize best practices in the design of such interventions. It will also explore how those leading quality improvement initiatives can simultaneously contribute to the underlying science regarding how the effectiveness of such interventions can be optimized.

Noah Ivers is a scientist at Women’s College Research Institute (WCRI) and adjunct scientist at the Institute for Clinical Evaluative Studies. He is also a family physician at Women’s College Hospital (WCH) and an Assistant Professor in the Department of Family and Community Medicine and at the Institute for Health Policy, Management and Evaluation at the University of Toronto.

Noah’s focus is on developing approaches for evaluating physician performance to improve the quality of care that patients receive in primary care settings. His research is based on the principle that when healthcare providers have a solid understanding of how they rank among their peers in treating specific diseases and conditions, it can help drive change and improve health outcomes for all.

Noah’s research draws on a foundation in clinical epidemiology and health services research. He focuses on the use of data to drive decision making in healthcare, as well as the design of systems that improve interactions between doctors and patients. Always with a strong evidence-based approach, Noah is advancing the global research agenda in quality improvement and patient-centred care.

Noah received the Rising Star Award from the Canadian Institutes of Health Research-Institute of Health Sciences and Policy Research (CIHR-IHSPR) in 2013. He has also received New Investigator Awards from CIHR and from the Department of Family and Community Medicine at the University of Toronto.

City Wide Quality and Safety Rounds: Thursday, May 11, 2017 @ 12-1PM

Topic: FIXING IT FOR GOOD: How human factors informed design can create a safer, more resilient health system

Speaker(s): Joseph A. Cafazzo, PhD PEng and Anjum Chagpar, MHSc PEng

Host Site: University Health Network: Toronto General Hospital, Peter Munk Building, 11th floor, Rm 190

Sites participating via OTN: C-QuIPS/Sickkids: 525 University Avenue, Rm 630; St Michael’s – Li Ka Shing Knowledge Institute, Rm 211; Sunnybrook: Bayview Campus – McLaughlin Auditorium, EG-61

OTN Webcast Link:

The rate of preventable adverse events has been stubbornly unchanged after many years of concerted effort to reduce harm in healthcare settings. Safety research and practice in healthcare continues to focus on measurement and cause of adverse events. Far less time has been focused on creating resilient solutions to the problem. This gap is likely why we’ve seen little progress in our safety efforts. There is however precedence in other industries on how to design safety critical systems that are resilient to human error, or that eliminate risk altogether. This presentation will describe how the healthcare settings must change in fundamental practice and governance to truly address the continued safety chasm.

The objectives of the session are:

I. To describe well established human-factors informed design methods that create more resilient mitigations to reduce and even eliminate harm.

II. To describe how safety practitioners can use these methods right now, and see results sooner, by diverting their time toward designing more resilient corrective actions, and focusing less on measurement and cause analysis.

III. To discuss how fundamental change is needed in healthcare practice and governance to reflect other safety critical industries.

Dr. Joseph Cafazzo co-founded Healthcare Human Factors @ UHN in 1994, growing to become largest group of its kind devoted to the application of human factors engineering to problems of healthcare delivery and patient safety. He is Associate Professor, University of Toronto, where he teaches and conducts research in the areas of human factors, clinical engineering, and health informatics. He is a recipient of the Career Scientist award by the Ontario Ministry of Health and Long Term Care and is Clinical Lead, Design and Engineering, of the Techna Institute at the University Health Network.

Anjum Chagpar is the cofounder and Managing Director of Healthcare Human Factors. Over the last 15 years, she has adapted and expanded the focus of her team to address broader patient safety challenges through the fusion of design disciplines with human factors engineering. Anjum holds degrees in Systems Design Engineering and Clinical Engineering from the Universities of Waterloo and Toronto respectively.

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