Back in August 2015, the Safety Alert System (SAS) project team never imagined that they would have to launch the system at one of the Region’s busiest hospitals without their team lead.

But when the director responsible for the Safety Alert System (SAS) left the Region for another opportunity, that’s exactly what Tracey Matonovich and Tennille Corbett had to do.

“We were not expecting a leadership change,” says Corbett, co-lead of the SAS project team and Manager of Occupational Health and Safety. “However, I think it speaks to the work that the project team had been doing all along that we were able to carry on with it because we knew what we could provide to the Region.”

Tracey Matonovich agrees. “We knew that getting Royal University Hospital (RUH) online with thinking about the SAFER response* and 1600** tool for reporting was the next goal,” explains Matonovich, SAS co-lead and Manager of Patient Safety. “I think it was a benefit that we were actively engaged in implementing the manager training sessions (to prepare managers and staff for the incoming system) because even with the change to our project team, it enabled us to continue on and not lose focus.”

However, more change was to come, and the original team of five or six people put together to launch the system at RUH was quickly down to Corbett and Matonovich once it was up and running.

“We had an amazing team to help us get the system going at RUH,” says Matonovich. “But without those resources now, the impact has been that we haven’t been able to do some of the improvement work that the system needs.”

Most of the improvement work that needs to happen is with the system’s database.

“Once people started using the system to report, we were collecting a lot of data, which was great, but it was almost like turning on a fire hose,” says Corbett. “We are receiving all this information, but the challenge has been to disseminate it back out to the organization in an impactful and useful way. Right now, everyone is looking for ways to slice and dice that information for improvement work. It’s a manual and labour-intensive process, and it’s largely behind the scenes the work for Tracey and me, so we haven’t been able to move on it as quickly as the organization would like.”

It’s obvious that both Matonovich and Corbett have a passion for safety. For Corbett, coaching and facilitating leaders to investigate safety issues was already part of her team’s role in Occupational Health and Safety so the Safety Alert System work was just an extension of that.

Staff and actors simulate a safety concern and a call to the safety alert system.

A simulation of how an incident would be reported to the Safety Alert System was part of the celebration of SAS held in November 2015.

“Our team has always built a framework to provide services, assessments, consultations and training in workplace safety, and that’s our mandate,” says Corbett. “Plus, we had already been receiving incident reports through our Incident Report Line, which is still in use outside of the three acute care sites, so it was almost like expanding that model for the rest of the Region.”

Matonovich felt that her background with the Region’s Quality of Care work focused on concern management with patients and families, and management experience were a natural fit for Safety Alert System work.

“With what I knew of the Safety Alert System and stop-the-line principles, I saw the position as an opportunity to support not only patients and families to be safe but to support our Region as a whole to be safer.”

Clearly, for Corbett and Matonovich, safety isn’t divided into employee safety versus patient safety; they see it as two halves of a whole and the good news is that others are seeing it that way too.

“I think the Safety Alert System and the Safer Every Day 90-day initiative reinforced the knowledge and the priority of safety as everyone’s business,” says Matonovich.  “Because there has been great work in the last year, to reinforce the message that it’s not about staff safety or patient safety, it’s about safety. I think because we have continued to voice this from that same platform, it’s supporting the Region to move to that next level.”

Perhaps that is what continues to drive the two of them to see and create the opportunities for the system amidst the challenges.

“There’s a lot of time and investigation that’s involved in patient and employee safety incidents,” says Corbett. “There are opportunities to help train and coach our leaders through that process because it’s not exactly intuitive. We also need their voice and their guidance to help us solve some of the more systemic safety issues.”

“We know the appetite for information is there so if we can further improve the system to allow for its information to flow in a timelier and valuable way, it will really help us shape that leading practice piece,” says Matonovich.

What do Corbett and Matonovich envision as a perfect state for safety in our Region?

“It would be great if we all had the capacity to do that good, preventative leading work so that a safety incident doesn’t have to be taken care of as a side project because it didn’t happen in the first place,” says Corbett.

“Truthfully, it would be about further enhancement of strong collaboration amongst safety professionals and a sense of comfort and capacity for our leaders in dealing with safety investigations. It would be great for everyone to be a model for safety and for us to be able to say, this is the way our organization runs and safety is not only a priority, it is part of our organization’s foundation,” says Matonovich.

* SAFER represents a set of behavioural expectations and processes aimed at recognizing potentially harmful situations and fixing them in the moment before harm occurs. Described by the acronym SAFER, staff and physicians are expected to: “Stop the line” when the potential for harm is observed, Assess the situation to determine root cause and implement solutions to Fix the defect. If the potential defect can’t be fixed, staff and physicians should Escalate the problem. Organizational leaders are expected to support staff and work collaboratively to ensure that the risk has been adequately addressed so that it does not happen again. Reporting of near miss and actual safety events is supported and celebrated.
** Reporting of patient and staff safety events in the three acute sites currently is facilitated by calling into 1600.