Registed Nurses' Association of Ontario

Promoting a culture of safety: Leading organizational quality improvement initiatives through the Canadian Incident Analysis framework

Lorraine Schubert
Centre for Addictions and Mental Health (CAMH)

In June of 2015, CAMH’s Chief of Nursing and Professional Practice released a bulletin across the organization to provide an update on how CAMH is enhancing patient care and staff safety. Dr. Rani Srivastava stated: “our goal is an ambitious one: to eliminate violence in the workplace and maintain safety for both staff and patients, while we provide high-quality care that promotes recovery”. Indeed ambitious, it is an important component of the Strategic Plan for Professional Practice. To build a SAFE and WELL CAMH we need to “understand the critical factors in the interaction of patients, staff and the care environment”. To enhance safety and minimize risks, CAMH has embarked on a journey of continuously improving knowledge and procedures to ‘prevent’, ‘respond’, and ‘improve’. In my role as a Senior Manager of Operations and Practice, After Hours I was in a very unique position to actively influence continuous improvement efforts across the organization and the RNAO Advanced Practice Fellowship gave me the opportunity and resources to actively support this critical strategic direction.

As a fellow, I began by expanding my knowledge base through an extensive literature review on Safe Cultures and Safety Practices in the health care environment in general and in the mental health care environment in particular. I was then able to review CAMH’s policies, procedures and practices through a lens focused on current Best Practices. This concentrated study supported my subsequent efforts to engage clinicians in reflective practice efforts to mitigate risks across the organization during my work as Senior Manager of Operations and Practice, After Hours. Through this knowledge exchange I was building not only my own repertoire of skills but also resiliency throughout CAMH – a truly enriching experience.

Early in my fellowship I acquired certification as a Patient Safety Trainer. The course offered by the Patient Safety Institute included both a comprehensive curriculum in safety practices across the health care sector and tools to engage stakeholders. Utilizing a number of different teaching/learning methodologies and technology, I was able to dedicate time in the application of principles learned in my efforts to continuously enrich my skills and disseminate them across the organization. Also offered by the Patient Safety institute in partnership with the Institute for Safe Medications Practices Canada, I completed the Incident Analysis Framework train-the-trainer program. I had now acquired the knowledge and tools necessary to actively engage in critical incident reviews. Initially, my learning curve was very steep but well supported by my mentor and a specialist in quality and risk. Under their expert supervision, I was able to build my capacity and gradually become more self-sufficient. Working with teams across the organization for the purpose of conducting incident reviews was yet again another very enriching experience in knowledge acquisition and building a community of practice network.

More recently, I have the opportunity to co-lead a quality improvement initiative developed by my mentor, Ann Pottinger and being piloted on the high-risk acute care adult unit. The project entitled Improving Safety/Care Planning in Response to Patient Post-Restraint Debriefs, aims to engage clinicians in the practice of offering debriefing opportunities to patients after a restraint event in order to understand the triggers and contributing factors from the patient’s perspective and inform safety planning to prevent future incidents of aggression or violence. In this groundbreaking original project I will have the privilege to educate and support staff in their efforts to engage patients and provide exemplary patient-centered care.

The RNAO Advanced Clinical Practice Fellowship has given me the valuable commodity of dedicated time to garner valuable insights into the continuous quality improvement work in mental health care and beyond. Furthermore, the required engagement of a mentoring team was a critical component necessary to achieve the deliverables for this project. I am very grateful to my mentoring team and most particularly to Ann Pottinger for her unwavering support, expertise and kindness during my steep learning curve. The relationships that I have build through this fellowship experience will serve to support my continued work in the provision of safe patient care across the organization and the engagement of clinicians in this critical strategic direction.

The RNAO Advanced Clinical Practice Fellowship has provided me with an exceptional career booster and framework to develop both professionally and personally while specializing in the area of continuous quality improvements and safety specialist. I am deeply grateful for this opportunity to advance nursing practice and would highly recommend the program to nurses across service sectors.


  • Certification as a Patient Safety Trainer
  • Certification as a trainer in the Canadian Incident Analysis Framework
  • Draft paper on Safe Culture in Mental Health for eventual publication
  • Participated and Lead teams of clinicians in critical incident reviews
  • Co-leading a pilot project on a high-risk adult acute care unit
  • Engaged clinicians in reflective practice across the organization
  • Just-in-time education related to risk mitigation and safety practices
  • Built an internal and external community of practice related to patient safety

The continuous quality improvement skills that I have acquired through this fellowship will be sustained and further developed through a dedicated appointment in the Quality and Risk department on a part-time basis. I will have the opportunity to continue this critical work under the guidance and mentorship of Ann Pottinger, Director of Quality and Risk and her team.

  • I will continue to support the quality improvement pilot project on the high-risk acute adult unit and I will contribute to the application process to present results at relevant conferences. I also hope to co-author an article for publication on this project.
  • I plan to continue refining the draft article on Safe Cultures for publication.
  • I will continue to lead teams in incident reviews utilizing the Canadian Incident Analysis Framework.
  • I will continue to look for opportunities to engage clinicians in reflective practice and just-in-time learning across the organization during my work as a Senior Manager of Operations and Practice, After Hours.
  • I will look for opportunities to expand my knowledge and repertoire of skills through courses and workshops. This will also give me the opportunity to build on my network.