August 10, 2016


What is Poet?

PoET (Prevention of Error-Based Transfers) is an Ethics Quality Improvement Project that is founded upon our basic ethical obligation to provide treatment that patients want and can benefit from and not to provide treatment patients don’t want and can’t benefit from.

Currently error-based transfers result in many LTC residents in Ontario receiving treatment in hospital at end of life where it is unwanted and/or potentially harmful. For these individuals, we expect that fewer errors in decision making will lead to more appropriate end of life care provided without transfer to hospital. Additionally, we know that changes with the LTC population have the potential to greatly affect resource use, as we know that in Ontario healthcare spending increases towards end of life.
PoET is based in Ontario’s CWLHIN and prevents error-based transfers between Long Term Care (LTC) homes and William Osler Health System.


Here is the scope of the problem PoET addresses:

  • • Many Long Term Care home residents in Ontario are transferred and admitted to hospital multiple times prior to their death

  • •Many of these transfers are based on errors related to consent, capacity, and substitute decision making

  • •The Level of Care form - a form used in many Long Term Care homes in Ontario - drives these errors


PoET's goal is to improve patient care by preventing error-based transfers.

Because of these three factors residents may receive treatment they do not want and cannot benefit from, or they might not receive treatment they do want and can benefit from.

PoET's goal is to improve patient care by preventing error-based transfers to hospital emergency departments through the use of new, evidence-based PoET Project tools. PoET spreads a culture of decision-making that prevents ethical and legal errors and supports treatment for persons in the right place and at the right time.

Please contact us for help in launching the PoET project in your long term care home.


Here is how PoET developed:

PoET is rooted in strong evidence collected over 5 years. During these years it has also been gaining organizational and external support from Health Quality Ontario, public hospitals, and both public and private LTC Homes. In 2011, an assessment reported that some transfers from LTC to hospital emergency departments were error-based. Data from this report also showed that some LTC residents were transferred to hospital multiple times prior to death, and that some residents did not live very long after admission (almost 20% died within two weeks). We recognized the project’s potential to alleviate emergency department congestion and improve end-of-life care.

In 2012, our tests of change to reduce error-based transfers through consultation and education failed; however, we recognized the immense opportunities in removing the Level of Care (LOC) Form. We published our work in 2013, showing a 22% reduction in transfers, and continued working on this quality problem. In 2013, we discovered a palliative care gap that reflects a misunderstanding of what end of life services are available in LTC homes. In 2014, our first application to the IDEAS Advanced Learning Program failed, but we acted on suggestions from the IDEAS team, and were accepted on our second attempt. In 2015, we were awarded the IDEAS Alumni Award to spread this work. Since 2012, there has been a 56% decrease in the number of LTC residents who die in an Osler hospital and had been transferred there at least one other time in the two month period prior to death.

Our Change Concepts and Change Ideas

How we are changing what we think and what we do.

Through our experience working with hundreds of residents and LTC homes, we found that new ways of thinking and doing things were key to shifting understanding and improving resident care.

PoET seeks to realign decision making with Ontario’s Health Care Consent Act, which requires that the patient/resident be kept at the center of decision making. Maintaining this focus in LTC, and specifically, in relation to decision-making around transitions, will help to ensure that LTC residents (many of whom are frail elderly, some who are living with multiple comorbidities and/or diminished decision making capacity) receive wanted and beneficial treatment, and are not made to undergo unwanted and potentially harmful treatment. This work has the systems-level benefit of decreasing the number of non-beneficial and unwanted trips to the ED, while also enabling LTC residents to access the care that is available to them in their homes, but that might be denied to them because of errors in decision making prior to transfer.


Dr. Jill Oliver

Dr. Jill Oliver is a Health Care Ethicist whose expertise focuses on consent, capacity, substitute decision making, and end of life issues as they arise in long term care settings. Jill has a PhD in Philosophy from the University of Waterloo, an Academic Fellowship in Clinical and Organizational Ethics from the University of Toronto Joint Centre for Bioethics, and has also completed internships in Clinical Ethics at both Baycrest Centre for Geriatric Care, and William Osler Health System. Jill is currently leading the PoET Project, an Ethics Quality Improvement Project for William Osler Health System.

Dr. Paula Chidwick

Dr. Paula Chidwick is the Director Clinical & Corporate Ethics and Ethicist at William Osler Health System. She was the first full-time Ethicist to be hired at a community hospital. She has a Ph.D. in Philosophy specializing in Bioethics from the University of Guelph and a Fellowship in Clinical Ethics from the University of Toronto Joint Centre for Bioethics. Paula provides ethics services to health care organizations throughout Ontario. She publishes and lectures widely on a variety of topics including end-of-life, advance care planning, and diversity considerations in health care and ethical decision-making. She has served on the Canadian Bioethics Society Executive, Health Canada’s Scientific and Expert Advisory Panels, and for MOHLTC Critical Care Coaching Teams. She is currently a Subject Matter Expert for Critical Care Services Ontario and a founding member of the Clinical Ethics Summer Institute (CESI).

The PoET Project is pleased to acknowledge the cooperation and support provided by:

Please contact us for help in launching the PoET project in your long term care home.