Regional Workshop Vancouver, BC June 5, 2014
Breakfast Sessions • Introduction to the CLeAR Initiative – for new team members and those wanting a refresher • Networking For Team Sponsors • Networking For Medical Directors
Optional Session Introduction to the CLeAR Initiative Ben Ridout
Medication-Related Initiatives Commonalities • Purpose: Patients/Residents – Quality of life, safety, overall management, not just meds
• Purpose: Medication Use – Appropriate, effective, reduce adverse drug events
• Core Function: assessment, care planning, monitoring and review
Medication-Related Initiatives • BC Patient Safety & Quality Council – Clinical Care Management • Medication Reconciliation • 48/6-Hospital Care for Seniors
– CLeAR-Call for Less Antipsychotics in Res Care
• Shared Care Committee – Doctors of BC / Ministry of Health Collaborative • Polypharmacy in Elderly • Transitions in Care
What is CLeAR? Call for Less Antipsychotics in Residential Care • Voluntary quality improvement initiative designed to support teams in addressing behavioural and psychological symptoms of dementia (BPSD)
CLeAR Goals • Improve dignity for seniors through best practice care for BPSD, leading to a reduction in antipsychotic use • Enhance linkages of existing initiatives that align with and support the work of this initiative • Build improvement capability and capacity in residential care.
How CLeAR works? • Provides teams with tools, resources and ideas to reduce non-evidence based antipsychotic use • Teams receive enhanced support to achieve goals Change is possible. Initiatives in UK, Manitoba and facilities in BC have successfully reduced use of antipsychotics
Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act
Plan
Study
Do
The Improvement Guide, 2nd ed.
Available Resources • • • • • • •
Website / CLwK Driver Diagram Measurement Guide Templates Other teams Faculty Improvement Advisor
Networking Session for Team Sponsors Leanne Couves
Discussion • What are you doing now to support your Improvement teams? • What is working and why? • What are you learning? • New Ideas: Executive Review of Improvement Projects
Executive Review of Improvement Projects: A Primer for CEOs and other Senior Leaders James Reinertsen Michael Pugh Tom Nolan
Background
It has been said that currency of leadership is attention. If that is true, then leaders who wish to transform their organizations should channel their attention to the key leverage points for the quality transformation, and use their chosen leverage points well. Improvement projects are important processes in the overall transformation of institutions. Well-chosen projects, with high aims for improvement, capable project leadership and teamwork, and good organizational support, can raise the standard of care in the project area or department, promote spread throughout the organization, and demonstrate the values and behaviors that will drive the transformation. If a project produces real results—i.e. sustained improvement of a breadth and depth that makes both patients and caregivers notice—it sends a signal that will be heard throughout the organization that quality improvement is not just a sidebar activity. If, on the other hand, projects produce superficial results, or tepid results are over-praised, or those working in projects cannot connect them to overall organizational strategies, this also sends a signal—one that will hinder, rather than accelerate the transformation. For these reasons, projects are key leverage points—high visibility moments—in the long-term transformation process. Executive review of projects can be a critical factor in whether the projects will help, or hurt, the transformation. The first step is for executives to make the decision to channel attention to project reviews, and to budget the time in their own schedules for this activity. The next step is to learn how to do a good project review—the principal focus of this brief practical guide. It’s not enough to give projects your time. You must also know how to use that time well—so that your reviews help, rather than hurt. Purpose of Senior Leader Project Review The purpose of reviews of projects by CEOs and other executives should be clear: 1. To learn whether the project is on track, or is likely to fail 2. If the project is not achieving the intended results, to understand why: a. Lack of organizational will? b. Absence of strong enough ideas for improvement? c. Failure to execute changes? 3. To provide guidance, support, and stimulus to the project team on will, ideas, and execution 4. To decide whether the project should be stopped.
Networking Session for Medical Directors Chris Rauscher
Shared Vision and Introductions Chris Rauscher
Your Faculty Region Fraser Health
Interior Health
Faculty Member Ann Marie Leijen Gina Gaspard Louise Joycey Carol Ward Cindy Reiger Dena Kanigan Elizabeth Antifeau Janice Vance Sandra Psiurski Trevor Janz
Region Island Health Northern Health
Vancouver Coastal
Public Members
Faculty Member Kathleen McFadden Wendy Carmichael Chris Hunter Ian Schokking Andrea Felzmann Barbara Radons Elisabeth Drance Faria Ali Betty Murray Johanna Trimble
How Faculty Can Help • Provision of evidence-based change ideas based upon their clinical experience – Guidance on application of those changes
• Help the central CLeAR team • Some capacity to do site visits with the improvement advisors • Input on CLwK – Discussion forum and resources
Your CLeAR Team Ben Ridout, Improvement Advisor
Corrina Hayden, Project Coordinator
Katie Procter, Improvement Advisor
Leanne Couves, Initiative Director
Mary Lou Lester, Improvement Advisor
Eric Young, Health Data Analyst
Dr. Chris Rauscher, Clinical Lead
Kevin Smith, Digital Media and Communications Specialist
Dr. Keith White, Clinical Lead
Christina Krause, Executive Director, BCPSQC
How CLeAR Team Can Help • Provision of evidence-based change ideas and guidance on application of those changes • Provision and education on methods and tools for improvement and measurement • Advice and feedback on your progress • Direction and co-ordination for the initiative on a provincial basis • Communication strategies and mechanisms to keep organizations connected throughout
Participating Teams Across the Province
Improve dignity for seniors who live in residential care with cognitive impairment through a focused collaborative and support for best practice care for BPSD, leading to a reduction in the use of antipsychotics in this population; Enhance linkages of existing initiatives that align with and support the work of this initiative; and Build improvement capability and capacity in residential care.
CLeAR’s Aim Achieve a reduction of 50% in the inappropriate use of antipsychotics in participating facilities across the province through evidence-based management of the behavioural and psychological symptoms of dementia (BPSD) for seniors living in residential care by December 31, 2014.
Enablers Expect • Good ideas • Methods to apply them • Help from experts • Support from each other • To make a difference!
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Expected • To participate • To learn through action • To measure and report progress • To share “Everyone Teach, Everyone Learn” • To make a difference!
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC
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Aim of Regional Workshop • By the end of this sessions, participants will:
Celebrate your hard work and success to date Introduce your new team members to the CLeAR approach Hear new ideas from CLeAR faculty and other teams Share and learn how to build upon successes, and overcome the barriers – Build upon the improvement skills that you are developing, assess your progress, look at pivotal change ideas – – – –
• Including the Driver Diagram and BPSD algorithm
– Build your local community for ongoing sharing, learning and sustainability of this important work
• PLAN YOUR NEXT STEPS
Principles for the Day • • • •
Everybody teaches, everybody learns Share generously (transparency) Steal shamelessly Acknowledge graciously
• When we cooperate, everybody wins. » W. Edwards Deming
Agenda 0920 0950 1015 1045 1100 1115 1215 1315 1330 1415 1500 1515 1545 1615 1630
Faculty Presentations Team Presentations ----BREAK and Storyboard Networking An Overview of CLeAR Progress, Results and Opportunities Reducing Antipsychotics: An Overview of Driver Diagram Table Discussions: Exploring Driver Diagram and Changes in Detail ---LUNCH and CLwK sign up! Reports from Table Discussions Overcoming Barriers to Improvement Model for Improvement: Putting Ideas into Action ---BREAK and Storyboard Viewing More on Measurement for Improvement Improvement Team Meetings and Reports Action Period Activities and Support Infrastructure Close Session
Worksheet for the Morning
Used to document and take notes on specific ideas you might want to try.
Worksheets for the Afternoon Improvement Charter
Used to document your project plans to Dec 2014 – goals, measures, initial ideas and team
PDSA Cycle
Used to document your learning cycles – PDSAs.
Your Objectives • What questions would you like to have answered by the end of today? One Question per Post it
Faculty Presentation Johanna Trimble Jane Devji
CLeAR Regional Workshop Lower Mainland June 5, 2014 Johanna Trimble Public Member: Call for Less Antipsychotics in Residential Care (CLeAR) Faculty. Shared Care Polypharmacy Initiative Polypharmacy Reduction Initiative, Fraser Health Authority
Fervid’s “family care team” Johanna, Dale, Fervid and Kathie
Fervid experienced a precipitous mental decline after entering the Care Centre -- we suspected new medications
“Assume that any new symptom you develop upon starting a new drug may be caused by the drug. If you have a new symptom, psychiatric or otherwise, report it to your doctor” www.worstpills.org
Delirium • A temporary, reversible change in consciousness, attention, thinking, memory • acute condition • unpredictable course • subtle symptoms may be unrecognized or confused with dementia
“Ask about changes in your loved one even if no one asks.” http://thisisnotmymom.ca
Fervid’s drug interaction: Seratonin Syndrome
(citalopram, an SSRI antidepressant & tramadol, a pain drug) Seratonin Syndrome Symptoms 1. Cognitive/behavioral: confusion, agitation, lethargy, and coma. 2. Autonomic instability: rapid heart rate, sweating, rise in temperature. 3. Neuromuscular: twitching a muscle or group of muscles, coordination problems.
Some of these - noticed by the family - are also symptoms of UTI for which many courses of antibiotics were given, resulting in c. difficile
Medication Review: The family insisted on a meeting and drugs were de-prescribed. Fervid returned to normal cognitively.
Fervid over-medicated
Fervid back to normal
But…Fervid had lost too much function to return to independent living
We learned a lot from Fervid in her remaining time with us (4 yrs)
“I’ll always take care of you. It sustains me as much as it sustains you. I expect to be a support person all my life, which may not be long, but it’s here to stay.”
The meaning for all of us and our society…
Fervid died blessing us. If she had died 4 years earlier of a drug interaction, she would have died not even recognizing us. Include families and patients when planning care. Let’s give care which will allow our elders quality of life and a chance for a meaningful leave-taking for themselves and their loved-ones.
Death is not a medical issue, it is a human issue.
This work matters.
SCC Polypharmacy Initiative “It’s (about) quality of life…for my residents. I've seen dramatic differences in the quality of their life when the burden of their medication is reduced...”
Fraser Health: Polypharmacy Reduction in Residential Care
Resources:
http://www.rxfiles.ca/rxfiles/Modules/ltc/ltc.aspx
Resources:
https://www.agingbraincare.org/tools
Dedicated to Fervid Trimble 1917 - 2008
A picnic in the garden with Fervid
Contact information:
[email protected]
Delta View’s Journey from Drugs to Hugs
Presented By Jane Devji, CEO
Removal of Restraints
Our restraint free journey began in 1988 I attended a workshop where the presenter taped three of my fingers on my non dominant hand together to demonstrate to me what a restraint would feel like This experience inspired me to remove all Physical Restraints from the residents in our facility. Our next step was, reducing Chemical Restraints from our facility by eliminating the use of PRN antipsychotic medications for behaviours.
Creative Solutions:
By removing restraints, residents were now more active and able to move freely. We had to be creative about engaging residents with dementia. Introduced — foot soaks and massages. Walking program — we walked with the resident outdoors 3-4 times a day. Incorporated daily activities such as car washing and gardening to give the residents a sense of purpose. Introduced music therapy, where residents actively participated. Incorporated Pet Therapy into daily living.
Creative Solutions continued We
began researching facility designs which would better support residents with dementia (researched
models from California, Ohio, Arizona)
We
were inspired by the Corrine Dolan Center in Cleveland, Ohio which we based our designs on. We designed our building to feature two 40 bed units with indoor/outdoor walking loops and expansive gardens around the facility. (Delta View
Habilitation Centre was created on 4 acres of land)
Outdoor Gardens
Delta View Habilitation Centre (DVH) DVH
Opened in July 1991 with a two day conference on Dementia The conference featured four speakers including Dr. Lynn Beattie, who was the Head of the UBC Alzheimer’s Clinic, as well as Moyra Jones who was well known for creating the Gentle Care Philosophy. Success of our event was reported in The Vancouver Sun, The Province and CTV News This Media Coverage highlighted DVH to be a provider of exceptional Dementia Care
Stakeholder Support Our Success relied on attaining trust, belief and support from: Families Residents Physicians Staff Surrounding Community
Family Support
To be successful, you must establish and maintain a therapeutic partnership with your families Ensure there is open communication and transparency with families at all times
the first 72 hours are critical in establishing a solid foundation We suggest you make proactive phone calls in both the morning, and evening to update and reassure the family on how their loved one is doing.
Discuss and identify what the Resident Needs and Goals are.
Example:
Want the resident to start walking within a month Review the need for Current Medications
We created Family Support Group: “Friends of Delta View” We trained staff to be responsive to family needs We involve family members in Care Conferences, within six weeks of Admission, and Quarterly thereafter.
Your Resident…
We need to know Everything about our Residents Obtaining Resident’s detailed “Life Story” helped us get to know the Resident on a personal level and understand his or her needs. We created “My Day” for each resident with family assistance
Resident’s 24 hour day recorded hourly, which outlines Resident‘s preferences
Example: “I like to wake up at 7am and have my coffee and newspaper waiting for me when I have breakfast”
Physician Partnership
We had a good relationship with our physicians, who believed in our philosophy and supported us in reviewing and reducing unnecessary medications.
Staff Support
We needed staff who were caring, creative and flexible. Staff needed to be resident centered, period. We required nurses, who were willing to try something different and assist the residents in reducing antipsychotic medication and manage withdrawal symptoms We developed flexible routines accommodating the Resident needs and preferences, that still met licensing requirements. Dr. Lynn Beattie was available on call to assist staff. Moyra Jones provided Education to all Staff and Families on All Models of Gentle Care
Our Criteria for Admission
Exhibit inappropriate behaviours High Elopement Risks Obsessive Pacing Extreme Paranoia Excessive Behaviours Overly Sedated/Medicated
Our first Days... •
• •
• •
Initially, I was the only nurse on duty, admitting 15 Residents and communicating with their respective families I learned a lot about the residents from the Families By communicating regularly with the families I established unique and strong partnerships Families were part of the solution on our Journey Families supported our philosophy of first trying alternate non-pharmacological options before resorting to medications.
Created a Family Information Package
No Physical Restraints Reduction in Chemical Restraints What to expect on Admission and first three weeks Behaviours and how to avoid getting into behaviours Importance of Hydration and Nutrition Use of Finger Foods Regular Toileting and meeting Elimination Needs Visiting Tips Creating Comfort Tips for Behaviours or Anticipated Behaviours Creating Moments of Joy and Memorable Moments Binder for Families to View when Visiting Visiting other Residents and Encouraging them in their visit, rather than shooing them away
Tips on Therapeutic Relationships
Prior to admission provide families with an understanding of our philosophy, always remember the grieving that takes place at the time of placement.
Keep admission day simple and low key. Enjoy a cup of tea with the new resident and family members.
Always phone the family the morning after admission to tell them how the first night went.
Keep them informed! Encourage phone calls. Initiate phone calls to an ailing care giver.
Set up a buddy system with another appropriate family member.
Encourage flexible visiting times and help them understand what is too little or too much for their loved one – (Depending on adjustment of resident).
Make a point of talking to every family member when they visit.
Provide an area for families to visit comfortably.
Help families feel comfortable on the unit and help them adapt to the behavior of other residents.
Always make time for a family member.
Remember a complaining family is a hurting family.
Encourage participation in family group (Friends of Delta View)
Involve family members in care planning.
Provide reassurance – re: appropriate clothing to bring in, lost articles, belongings sometimes shared with other residents.
Encourage participation in education sessions.
Help family understand that this is their unit and encourage participation in projects.
Share with families “special moments” that you have had or witnessed regarding their loved one, including photographs
Involve family members in special occasions.
Resident Life Stories and “KFC”
“Resident’s Life Story” includes:
Early history Personal Interests Preferences Things or Activities that provide comfort Important Family Members Important Dates in the Person’s Life Hobbies and Interests Favorite Music and Foods
KFC KNOW Me! Who am I?—what are my likes and dislikes? What is my past history? What makes me happy? Understand my dementia and avoid blaming me for my behavior Collaborate and Communicate with my Interdisciplinary Team so you can provide me with the best care Include my family and friends in discovering who I am Know my strengths, and promote my sense of well being. What are my triggers? (know MY supportive interventions) Use behavior pattern record (ABC) to create and update my care plan so it is always current Recognize that all behaviors have meaning (verbal and nonverbal) Anticipate My Needs and Redirect Me Ask: Am I… Thirsty? Hungry? In pain? Constipated? Needing to go to the bathroom? Possibly suffering from delirium and/or an infection [i.e. UTI]? Finding it too noisy? Assess my environmental triggers Needing more sleep? Tired? Bored? Sad? Lonely? Invasion of Personal Space Feeling Anxious and Scared? Feeling Depressed? Experiencing Mental or Medical Illness?
FOCUS on Me and not on the Task! Provide Person Centered Gentle Care! Understand Me. Am I experiencing loss of power and control? Make eye contact with me & approach me from the front Speak directly to me. Speak calmly, slowly and clearly Position yourself at the same level as me Maintain PRIVACY, RESPECT & DIGNITY. I can only process one thing at a time Break tasks into steps Offer me choices I am unable to express feelings, needs and sensations Understand that I have experienced many losses, including power and control of my personhood Understand that I can’t change, but you can change CALM & Safe Environment! Speak to me in a calm manner using a normal tone Always maintain positive & effective teamwork when working with me Understand my emotions and help redirect me with positive approaches If I am anxious, provide reassurance and validate my feelings Provide personal space as needed Never argue or insist: “If you don’t insist, I won’t resist!”
Our Results...
We were successful in reducing all medications except for Lithium
We reduced the use of “Haldol”
We became known as the Pioneers in Reducing Medications We reviewed and began reducing some medications within 24hours of Admission
Unchartered Territory at the time
We did not use PRN antipsychotic medication We withheld medication, if the resident was too drowsy By End of 2-3 weeks, we started seeing the Real Person
Residents were adequately hydrated and nourished. Residents seemed happy and their moods were elevated. Residents wanted to walk outdoors. Residents appeared more comfortable in view of the Regular Toileting routines and numerous spa baths per week. Residents benefitted from HUGS-HUGS-HUGS!
Results...
As a result we got funded by the Ministry for 25 Special Care beds which were admitted into our “Special Care Unit.” Delta View was recognized across Canada as well as Internationally (Spain, Switzerland, Italy, United States) for its philosophy on “Hugs not Drugs”
Remember its all about “Hugs not Drugs”
www.youtube.com/watch?v=hN8CKwdosjE
All it will take you is “one hug”
Rapid Fire Presentations Teams
• Windermere Care Lodge • Cedarview Lodge • Delta View Life Enrichment Centres
WINDERMERE’S ACTION AND IMPROVEMENT TEAM
" Together, We Want To Make a Difference"
A Word From our Administrator Ross Sugimoto How does a 214 bed complex care facility balance the physical, social, psychological and safety needs of all its residents and families in an environment where antipsychotics have historically had a significant impact? Windermere Care Centre is looking to challenge its multi-disciplinary team to identify where antipsychotic use is inappropriate and assess how pharmacological and non-pharmacological approaches and interventions can be combined to create positive outcomes. We expect this journey to be challenging, educational, inspirational and rewarding. We also anticipate that together we are able to improve the care we provide and make a positive impact on the lives of our residents and their families.
" Together, We Want To Make a Difference"
RESULTS Percent of Residents on an Antipsychotic 40% 35% 30% 25% 20% 15% 10% 5% 0%
" Together, We Want To Make a Difference"
CHANGES TESTED • We Track changes ……. Weekly • IDT review with the health care team
Monthly • Medication review with the pharmacy and the physicians Annually • Care conferences with the residents, family and Health care team Admissions, Significant changes, and residents returning from acute care • Reviewed as needed
Recreation Department
is using the Montessori Based programming to reduce anxiety and engage the residents in their choice of activity " Together, We Want To Make a Difference"
LESSONS LEARNED • Hospital admissions result in residents retuning back with new antipsychotic drugs. • New admissions come in with antipsychotic drugs, both regular and PRN and as they are new to the facility, we are unsure about continuing these meds. • Team engagement and support is crucial in achieving set goals and persistence certainly pays. Chug along!! • Celebrate success, even if it is small! • We have introduced and are using the Montessori based recreation program for the resident to allow for more one to one programming. " Together, We Want To Make a Difference"
Cedarview Lodge CLeAR Action and Improvement Team Optimizing the Quality of Life for our Residents
What We Wish for Our Facility/Residents Maximize our residents quality of life by: • •
•
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Providing person-centered care by learning about what is important to the resident and their family Identifying non-pharmacological alternative approaches in resolving behavioural concerns such as pain management as the first-line approach to care planning Working as an Interdisciplinary team in planning and assessing the residents care needs
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Team Goals and Objectives • Improve care for residents who have BPSD by reducing the number of residents who are on antipsychotics • Create opportunities for existing initiatives to work together • Build new skills and knowledge for improvement in residential care
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Approach and Strategy • Identified interested team members (champions) • Implemented monthly team meetings • Provided each unit with a CLeAR binder with tools designed to document and monitor residents in program
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Approach and strategy • Used LEAN methodology to map CLeAR process with team which resulted in: - Establishing CLeAR objectives - Creating roles and responsibilities for team members and staff
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Results
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Delta View’s CLeAR Initiative Team
Eliminating inappropriately prescribed anti-psychotics
Aim/Goals • • • •
Aim: Get back to our roots! Continue to gain staff buy in Educate that all behaviours have meaning Goals/Objectives: Decrease use by 50% July 2014 and 75% by Dec 2014
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Changes Tested • Hold Safety Huddle on BPSD algoarithm in each home (discuss one resident on antipsychotic and review tool) • Build standardized BPSD guideline and algoarithm tools into assessment/review process • Introduce Shared Care Polypharmacy Initiative Clinical Algorithm and Antipsychotics Drug Advisory Sheet 85
• Hand outs with information on Seroquel handed out to nurses at meeting • Creating a no-blame culture and more focus on the system by increasing use of learning boards • Safety huddle on effective communication held - personal goals for all 8 homes discussed in groups • More group work and activities to initiate discussion 86
Lessons Learned • Decreasing one Resident at one time works well as there is more time for 1:1 • Support required from all disciplines to decrease anti-psychotics • All anti-psychotics are restarted (if they are restarted) within 7-10 days of being discontinued • Most support required within 14 day withdrawal period (engage family) 87
Next Steps • Continue to educate staff and families on anti-psychotics and their effects • Implement an informed consent form prior to initiating use of anti-psychotics (under review) • Continue with aromatherapy, music and other non-pharm methods to address behaviours • All behaviours have meaning 88
Break and Storyboard Networking All
Questions to Run On • What are 1 or 2 ideas that stood out for you? Examples you could use and adapt? • What continues to be challenging?
Used to document and take notes on specific ideas you might want to try.
Overview of CLeAR Progress, Results and Opportunities Leanne Couves
Your Progress • Table Discussion: What progress has your team made?
Activities Teams are : • • • • •
Getting organized Engaging staff Trying and testing ideas – PDSA Cycles Starting to show positive results Sharing documents and questions through webinars
Some Ideas Being Tried 1. Appropriate Antipsychotic Use Facility
Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Facility 7 Facility 8 Facility 9 Facility 10 Facility 11 Facility 12 Facility 13 Facility 14 Facility 15 Facility 16 Facility 17 Facility 18 Facility 19 Facility 20 Facility 21 Facility 22 Facility 23 Facility 24 Facility 25 Facility 26 Facility 27 Facility 28 Facility 29 Facility 30 Facility 31 Facility 32 Facility 33 Facility 34 Facility 35 Facility 36 Facility 37 Facility 38 Facility 39 Facility 40 Facility 41 Facility 42 Facility 43 Facility 44 Facility 45 Facility 46 Facility 47
2. Best Practice Management with BPSD
1. Appropriate (B) Improve (C) Communication Antipsychotic Use medication needs with care team assessment
(A) Use BPSD Algorithm & Guidelines
(B) Nonpharmacological interventions
3. Culture: Enhance Teamwork/Communication
(C) Use alt. comm. (D) Involve family (A) Environment of respectful comm. and care delivery and caregivers and teamwork strategies
(B) Sharing and comm. between team members
(C) Administrative Leadership Walkarounds
4. Residental Care Planning (A) Expand "care team" definition
(B) Implement (C) Individualized Team Comm. Tools Care Plans
Source: Saskatoon Health Region
Additional Context • • • •
Reporting bias New admissions are often on anti-psychotics Teams are working hard to reduce dosage Residents successfully taken off AP die or are transferred
Additional Measures • Process Measures: – # of residents on a reduced dose – % of residents on a reduced dose – # care reviews conducted using BPSD Algorithm – # reviews with family &/or caregiver involvement – # BPSD related incidents – Other measures?
• Balancing Measures: – Number of new admissions – Number ER visits for assessment/treatment of BPSD – Number of Falls – Family/staff satisfaction – Other measures?
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Real-Time Assessment 1
Non-Starter Team formed. Aim determined. Team attended Learning Session 1.
2
Activity but No Testing Team engaged in data collection and developing changes. No tests of change or evidence of testing within last month.
3
Modest Improvement Testing has begun. There is anecdotal evidence of improvement.
4
Improvement Implementation has begun. Improvements have reached 50% of at least one goal.
5
Significant Improvement 100% of at least one goal is reached.
6
Outstanding Sustainable Results Targets exceeded. Changes spread to larger system.
Challenges & Opportunities • What challenges has your team faced?
Challenges & Opportunities • Connect the aims/goals from the charter to the measures and begin getting data to share your progress, successes and improvement journey • Sharing between teams – Webinars – CLwK
Reducing Antipsychotics: An Overview of Driver Diagram Chris Rauscher
Driver Diagrams • Shows theory for improvement – the logic • Organize theories, concepts and ideas • Focuses improvement team on the why’s, what’s and how’s and back again! • Basis for choosing what idea to test
How Do Driver Diagrams Work? • Primary Drivers:
– These are key areas that research shows we need to address in order to reach our goal.
• Secondary Drivers:
– These are the actions we can take to successfully implement primary drivers.
• Change Ideas:
– One more step. These are suggestions that can help us implement secondary drivers.
Secondary Drivers / Change Concepts Primary Drivers
Specific Ideas to Test Join gym Ride bike to work
Move More
Take yoga class Drink less grape juice
Reduce weight
Eat Less
Aim / Outcome(s) HOW
Improve Health
WHY
HOW
WHY
HOW
WHY
Source: L. Couves, Improvement Associates
Worksheet – Example
Table Discussions: Explore Change Ideas in Detail All
Topics/Questions for Groups
LUNCH Meet back at 1:15
CLwK – Register Now!
BPSD Algorithm Website www.bcbpsd.ca
Reports from Table Discussions
Overcoming Barriers to Improvement Leanne Couves
Purpose • Identify barriers to implementation of improvement strategies • Develop practical strategies and specific ideas on how to overcome those barriers to improvement • Choose ideas to build into plans • Have a resource that you can refer back to when need arises
Paired Discussion • What barriers have your team successfully addressed in the last 3 months? • What barriers continue to be a challenge?
Barriers to Improvement • Not enough testing of changes • Not learning from PDSA Cycles • Measures not helping to answer the question “How will we know a change is an improvement?”
Common Barriers to Improvement • Lack of Buy-in / Resistance to Change / Engaging Staff • Working with Physicians, Medical Directors • Lack of Time, Staff & Other Resources • Lack of Senior Leadership Support • Lack of Effective Communication • Lack of Effective Measurement / Data / Feedback • Others?
Some General Approaches • • • • • • •
Understand why Uncover causes Start small Use trial and learn Engage others Use power of Collaborative Think abundance
Everybody Teaches, Everybody Learns • Identify yourself based on experience in improvement work • = New (attending CLeAR workshop for first time, new to leading improvement) • = Experienced (attended Kick off Session, have experience leading improvement)
• Self-sort – find equal mix of new and experienced group members • Stand by one flipchart
Walkabout Exercise
• At each flipchart
Barrier • Solutions that we know work • New ideas that might work • Questions? • ?’s, √’s and X’s
• Rotate clockwise until your group has written on each flipchart
Random Word Provocation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Spectator Individualist Crown Pitfall Accordion Ocean Plow Deck Wall Alligator Lock Trapeze Prank Lake Priest
16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
Summer Landlord Kernel Dog Bait Elephant Earthquake Raft Script Thorn Senate Error Equality Towel Blood
31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45.
Touchdown Station Shoe Navy Fire Flood Uprising Cactus Camp Prisoner Typewriter Variation Cigarette Chalk Vest
46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.
Detour Knife Tiger Eye Delusion Tree Whisky Ink Snake Conductor Hockey Consumer Parrot Partner Blowtorch
Debrief • At your first flipchart – What are 2-3 key strategies (circle or highlight) for this barrier?
Next Steps • CLeAR Team (us) – Take photos of each flipchart and post to CLWK • Teams (you) - Choose one or two strategies and build into your plans
Model for Improvement Leanne Couves
Change and Improvement Every system is perfectly designed to produce the results it gets. Performance is not simply a matter of effort; it is a matter of design. Donald Berwick, MD former CEO, Institute for Healthcare Improvement
All improvements require change but not all changes are improvements. Associates in Process Improvement 9-Jun-14
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Operational Definition of Improvement 1 4
on measures (balancing) that matter to the organization
Improvement is the result of some design or redesign of the system.
2
Cycle time
result is positive, relevant
before
after
and lasting impact
3
Reference: The Improvement Guide, 2nd ed. Langley, Moen, Nolan, Nolan, Norman & Provost, p. 16
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Model for Improvement What are we trying to accomplish?
Improvement Charter
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act
Study
Plan
Do
Develop, Test and Implement Changes Source: Associates in Process Improvement
Your Charter • • • • • •
What are your goals? Specific objectives? What resident population will your team focus on? Do you have any constraints? How will your team measure progress towards your aim? Objectives? What data do we have?
•
Which ideas from Driver Diagram stood out for your team? Where could your team start?
• • •
Who will work on the project? How will the team work together? How often will you meet?
•
Components of an AIM Statement Direction
Focuses the team on improvement
Process
Keeps the team on topic
Measure
Defines what success looks like
Timeline
Ensures an urgency to continue
Bold Aim, Firm Deadlines “Some is not a number. Soon is not a time” Donald Berwick, MD Former CEO, Institute for Healthcare Improvement
How Will We Know a Change Is an Improvement? • Choose 2-6 measures that are useful and manageable • Include a balanced set of measures to avoid sub-optimization • Purpose is for learning - not judgment or research – Relevant and timely
What Changes Can We Make That Will Result in Improvement? • • • • • • •
Driver Diagram!! Asking staff and others for ideas Critical thinking Creative thinking Hunches Best practices Insight from research and benchmarking 9-Jun-14
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How will we manage the work? • Designate roles and responsibilities – Team Sponsor (e.g. Director of Care) – Day to day leadership – Technical support
• Make milestones and deadlines explicit • Agree to principles for working together
9-Jun-14
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Discussion: Your Charter • Why document? • How will you use on an ongoing basis?
Ideas for Improvement Where do ideas for change come from? They must be developed. Some ideas may be successful, some will not. Testing is required. Which ideas should be implemented? Only the ideas where there is a high degree of belief that the changes when implemented will result in improvement. The illustration that follows shows how degree of belief is increased through the three phases of developing, testing, and implementing a change. - Ron Moen, as written in the Canadian ICU Improvement Guide
Develop, Test, Implement a Change Driver Diagram & Process Map
Why Test? • Increase belief that a change will result in improvement • Document how much improvement can be expected • Learn how to adapt changes to local conditions • Evaluate costs and effects of the change • Minimize resistance upon implementation
Three Principles for Testing a Change 1. Test on a small scale 2. Collect data over time 3. Build knowledge sequentially and include a wide range of conditions in the sequence of tests
Principle 1: Test On a Small Scale DEGREE OF BELIEF IN SUCCESS OF THE CHANGE CONSEQUENCE OF FAILED TEST
LOW
HIGH
MINOR
Medium-scale tests
One cycle to implementation
MAJOR
Very small-scale tests
Small-to-medium scale test
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Designing a Small Scale Test Simulate the change Have an expert review the change Test the idea with volunteers Use 1:1:1 rule – one clinician in one location with one client • Use manual “pencil and paper” data collection • Conduct the test over a short time period– what COULD we do by next Tuesday? • • • •
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Driver: Prevent falls
Change Concept: Use three questions when exiting a resident’s room 1. Do you need to use the toilet? 2. Do you have any pain or discomfort? 3. Do you need anything before I leave?
Act: •Adopt, adapt or abandon based on what was learned. •Build knowledge into next PDSA Cycle
Plan: •State objectives. •Make predictions •Make conditions explicit. •Develop plan (5 W’s, How)
Study:
Do:
•Complete analysis & synthesis •Compare data to predictions •Record under what conditions results could be different. •Summarize what was learned.
•Carry out the test •Document problems, surprises, and observations. •Begin analysis.
6/9/2014
1st PDSA Cycle – Scale it Down: Specific Change: Exit questions Objective: Test exit questions, to understand how it impacts risk of falling with high risk patients Prediction/Theory: Exit questions will allow staff to address potentially risky behaviors before they happen. Three questions are easy to remember and not threatening to residents. Conditions: high risk residents, exp. RN Plan: Nurse A will ask three questions of Mrs. Smith on Tuesday, Nov 20th. Ask Nurse A if questions useful for preventing falls and easy to remember.
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Principle 2: Collect Data Over Time Before & After Tests 9
8 8
63% Improvement
7
Cycle Time
6
5
4
3 3
Make Change 2
1
0 Week 4
Week 11
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Do you think this change resulted in an improvement? Case 2 10
8
Cycle Time
6
4
Make Change 2
0 1
2
3
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9
10
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14
Week
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Do you think this change resulted in an improvement? Case 3 10
8
Cycle Time
6
4
Make Change 2
0 1
2
3
4
5
6
7
8
9
10
11
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14
Weeek
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Case 4 10
8
Cycle Time
6
4
Make Change 2
0 1
2
3
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5
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9
10
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14
9
10
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14
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10
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14
Week
Case 5 10
8
Cycle Time
6
4
Make Change 2
0 1
2
3
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8
CaseWeek 6 10
8
Cycle Time
6
4
Make Change 2
0
9-Jun-14
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2
3
4
5
6
7
8 Week
149
Annotated Run Chart - Example
Source: A Saskatchewan Falls Collaborative Team 9-Jun-14
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Expand Conditions “It is not enough to determine that a change resulted in improvement during a particular test…you will need to predict whether a change will be an improvement under different conditions in the future” Langley, et al. The Improvement Guide
Principle 3: Build Knowledge Sequentially and Include a Wide Range of Conditions in the Sequence of Tests Breakthrough Results
Wide-scale tests of change
Test new conditions
Follow-up tests
Very small-scale test
Theories, Hunches, Best Practices, Change Concepts
p. 146
Examples of PDSA Cycle “Ramps” PDSA #1.4: Adjust when Vitamin D administered, expand to all clients at Lodge X. PDSA #1.3: Adjust Vitamin D ordering processes in pharmacy PDSA #1.2: Expand to all clients on Mrs. J floor PDSA #1.1: Use 1:1:1 rule (Mrs. J at Lodge X on Tuesday)
Concept #1: Start vitamin D
PDSA #2.3: Update falls diary format and try on all clients for 2 weeks PDSA #2.2: Try revised falls diary with 1 high risk client next week
PDSA #2.1: Design a “falls diary” prototype and ask 3 front-line staff how to improve it.
Concept #2: Track falls in a falls diary
“Failed” Tests • Expected and important • Reasons for “failed” tests – – – – –
Change not executed well Support processes inadequate Hypothesis/hunch/theory not useful for conditions Change executed but did not result in local improvement Local improvement did not impact safety or specific aims in the Charter
• Collect data during the Do Phase of the Cycle to help distinguish between these different reasons.
Your Next PDSA Cycle • Pick one idea that you’d like to try • How could you try it on a small scale within the next week? • Document your PLAN (Do, Study, Act happen at your facility)
Break Popcorn and Chips!
Measurement for Improvement Ben Ridout
Why Measure? What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?
Act
Plan
Study
Do
Source: Associates in Process Improvement
Why Measure? In quality improvement, data shows you where you are starting from and how close you are to reaching your aim Data helps you: • Know how you’re doing • Share your progress • Learn what is and isn’t working • See the impact of changes
Data Collection 1. Data for your project measures (listed on improvement charter) 2. Data for your PDSA cycles Let’s start with PDSA cycles…
Data Collected for PDSA Cycles • Need to measure each of the ideas being tested • Easy to collect, designed to give the team immediate feedback on the change being tested – Specific to the change • May only be collected once or twice
PDSA Example • Change idea: Enhanced education about dementia and BPSD for all staff • Test: running a couple of 20 minute education sessions for staff taught by Chris • A few things to decide: – – – – –
What to measure How frequently How many to measure How to collect and display Who will collect the data
PDSA Example 1. Ask participants if they learned new information (Outcome) – – – – –
What to measure - did participants learn something new How frequently – each education session How many to measure - all How to collect – Raise of hands Who will collect the data - Chris
2. Number of people who attend (Process) – – – – –
What to measure - Number of people How frequently – each education session How many to measure - all How to collect – Count at the end of session Who will collect the data - Chris
Data Collection 1. Data for your project measures (listed on improvement charter) 2. Data for your PDSA cycles
Remember: Data Over Time Purpose of data over time is to determine if what we are trying to improve is getting better. Need to know: - where we started (baseline) - how we change over time (e.g. each week) - when we have reached our target
Types of Measures 1. Outcome Measures 2. Process Measures 3. Balancing Measures
1) Outcome measures Based on your aim statement, what ultimately will be better? • Currently 4 outcome measures submitted to CLeAR • These measures help to: – Track achievement of the overall CLeAR aim – Track how teams are progressing with improvement – Help us provide targeted support
Additional CLeAR Measures Teams should be tracking additional measures These measures can be used by teams: – to reflect facility-specific goals – to track progress – to learn what is and isn’t working – to share with others (e.g. staff, families, etc) • These measures can be shared (optional) as part of your Monthly Report
2) Process measures What are you doing differently? Is it actually happening? • Will vary by team; based on facility-specific changes • Some examples: • • • •
% of residents on a reduced dose # care reviews conducted using BPSD Algorithm # reviews with family &/or caregiver involvement # BPSD related incidents
Process Measures to Test 1. Number of residents on reduced dose over time 2. % of residents on a reduced dose Developed based on feedback from teams – Reduction, not discontinuation, may be appropriate – Concern about new admits and deaths
Sample Tracking Tools
Process Measures to Test If you’re interested in testing these measures let us know and we can share resources with you! Sample tracking tools: • Medication tracking tool examples available on: – CLwK in Measurement folder – Appendix C of Measurement Guide
3) Balancing Measures Are there any unintended consequences of your changes that should be tracked? • Some examples of balancing measures: – Number of new admissions – Number ER visits for assessment/treatment of BPSD – Fall rates – Family satisfaction surveys, etc.
Measurement for Improvement Chose 2-6 useful measures Using small samples Collected frequently Plotted over time Reviewed by those involved in improvement Used for learning (not punitive)
Measurement for Improvement Integrate into daily routine Don’t wait for a perfect electronic system – use manual system or simple Excel sheet Design and test data collection forms Use qualitative data Continually improve your data collection system
Actions • Identify measures related to your aim (or look to what others might be doing to learn) • Try an example of a data collection tool template • Trial a small change using a PDSA template and review with your Team • Apply what you’ve learned today – start your data collection!
Measurement Resource
Team Meetings and Reports All
Have You Completed Your… Improvement Charter
Driver Diagram Worksheet
Is our charter still relevant? How can we update it with new knowledge?
What new ideas did we learn about today? What changes could we try?
Next PDSA Cycle
What change will we test by next Tuesday? What changes are ready for implementation?
Report Out • What changes are you planning test? • How will you measure your progress?
Action Period Activities & Support Ben Ridout
Focus for Next 3 Months • “All Teach, All Learn” – 4 Regional Workshops – CLwK – Increased Faculty guidance and support
• MD Engagement – Webinar – Networking session at Regional Workshops
• Continued Coaching on changes, improvement science – Webinars – Monthly report feedback – Site visits
• Measurement Support – Sharing of tools and resources – Development of additional measures
CLwK – Ask for Help
CLeAR Webinars
Mark Your Calendars! • Tentatively scheduled for second Tuesday of the month – What time works best for you?
• Themes for each webinar • Small group discussions • July 8 – Culture – Guest Speaker-Ann Marie Leijen, plus team presentation
Follow-up Webinar Mark Your Calendars!
June 12th (Thursday) – 11:00am to 12:00pm • Purpose: – Answer follow-up questions – Share new insights after reflection – Share any activities since the workshop – Make faculty available to provide feedback
Next Steps • Post your storyboards on CLwK • Update improvement charter • Test the change you identified today with PDSA worksheet • Try the driver diagram worksheet • Test the new process measures • Submit your monthly data and team report
Monthly Reporting Purpose Action Teams: • Opportunity to reflect on changes tried and progress • Receive individualized feedback from Improvement Advisor • Keep a record for team sponsor or Accreditation CLeAR Team and Faculty: • Understand progress and challenges • Learn about / share ideas that are working • Design resources to support team needs • Celebrate successes 188
Questions?
Summary and Closing Comments Chris Rauscher
Thank You • Participating Teams • Faculty • CLeAR Team
Partners
• Evaluations: We appreciate your feedback! • Post your storyboard to CLwK
Principles Going Forward • • • •
Everybody teaches, everybody learns Share generously (transparency) Steal shamelessly Acknowledge graciously
When we cooperate, everybody wins. » W. Edwards Deming
