Regional Workshop Vancouver, BC June 5, 2014 Breakfast Sessions - - PowerPoint PPT Presentation

Vancouver, BC June 5, 2014

Regional Workshop

Breakfast Sessions

• Introduction to the CLeAR Initiative – for new

team members and those wanting a refresher

• Networking For Team Sponsors
• Networking For Medical Directors

Ben Ridout

Optional Session Introduction to the CLeAR Initiative

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)

• 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.

CLeAR Goals

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

The Improvement Guide, 2nd ed.

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

Available Resources

• Website / CLwK
• Driver Diagram
• Measurement Guide
• Templates
• Other teams
• Faculty
• Improvement Advisor

Leanne Couves

Networking Session for Team Sponsors

Discussion

• What are you doing now to support your

Improvement teams?

• What is working and why?
• What are you learning?
• New Ideas: Executive Review
• f Improvement Projects

• institutions. Well-chosen projects, with high aims for improvement, capable project

• rganization that quality improvement is not just a sidebar activity. If, on the other hand,

• activity. The next step is to learn how to do a good project review—the principal focus
• f this brief practical guide. It’s not enough to give projects your time. You must also

• 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

• 4. To decide whether the project should be stopped.

Chris Rauscher

Networking Session for Medical Directors

Chris Rauscher

Shared Vision and Introductions

Your Faculty

Region Faculty Member Region Faculty Member

Fraser Health

Ann Marie Leijen

Island Health

Kathleen McFadden Gina Gaspard Wendy Carmichael Louise Joycey

Northern Health

Chris Hunter

Interior Health

Carol Ward Ian Schokking Cindy Reiger

Vancouver Coastal

Andrea Felzmann Dena Kanigan Barbara Radons Elizabeth Antifeau Elisabeth Drance Janice Vance Faria Ali Sandra Psiurski

Public Members

Betty Murray Trevor Janz 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 Katie Procter, Improvement Advisor Mary Lou Lester, Improvement Advisor

• Dr. Chris Rauscher, Clinical Lead
• Dr. Keith White, Clinical Lead

Corrina Hayden, Project Coordinator Leanne Couves, Initiative Director Eric Young, Health Data Analyst Kevin Smith, Digital Media and Communications Specialist 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
• rganizations 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.

Expect

• Good ideas
• Methods to apply them
• Help from experts
• Support from each other
• To make a difference!

Expected

• To participate
• To learn through action
• To measure and report

progress

• To share “Everyone Teach,

Everyone Learn”

• To make a difference!

Enablers

9-Jun-14 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 22

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

• vercome 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 Faculty Presentations 0950 Team Presentations 1015

• ---BREAK and Storyboard Networking

1045 An Overview of CLeAR Progress, Results and Opportunities 1100 Reducing Antipsychotics: An Overview of Driver Diagram 1115 Table Discussions: Exploring Driver Diagram and Changes in Detail 1215

• --LUNCH and CLwK sign up!

1315 Reports from Table Discussions 1330 Overcoming Barriers to Improvement 1415 Model for Improvement: Putting Ideas into Action 1500

• --BREAK and Storyboard Viewing

1515 More on Measurement for Improvement 1545 Improvement Team Meetings and Reports 1615 Action Period Activities and Support Infrastructure 1630 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 PDSA Cycle

Used to document your project plans to Dec 2014 – goals, measures, initial ideas and team 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

Johanna Trimble Jane Devji

Faculty Presentation

CLeAR Regional Workshop Lower Mainland

Johanna Trimble

Public Member: Call for Less Antipsychotics in Residential Care (CLeAR) Faculty. Shared Care Polypharmacy Initiative Polypharmacy Reduction Initiative, Fraser Health Authority

June 5, 2014

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.”

Fervid died blessing us. If she had died 4 years earlier

• f 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.

The meaning for all of us and our society…

Death is not a medical issue, it is a human issue.

This work matters.

“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...”

SCC Polypharmacy Initiative

Fraser Health: Polypharmacy Reduction in Residential Care

Resources:

http://www.rxfiles.ca/rxfiles/Modules/ltc/ltc.aspx

Resources:

https://www.agingbraincare.org/tools

A picnic in the garden with Fervid Dedicated to Fervid Trimble 1917 - 2008

Contact information:

isyourmomondrugs@gmail.com

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

• f 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

• utdoors 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

• f 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

• r 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 anti- psychotic 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 T

eam 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 non-

verbal)

• 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”

 Unchartered Territory at the time

 We became known as the Pioneers in Reducing Medications  We reviewed and began reducing some medications within 24hours of

Admission

 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”

Teams

Rapid Fire Presentations

• 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

• utcomes.

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

" Together, We Want To Make a Difference"

0% 5% 10% 15% 20% 25% 30% 35% 40%

Percent of Residents on an Antipsychotic

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:

• 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

9-Jun-14 78

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

9-Jun-14 79

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

9-Jun-14 80

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

9-Jun-14 81

Results

9-Jun-14 82

Delta View’s CLeAR Initiative Team

Eliminating inappropriately prescribed anti-psychotics

84

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

85

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 Anti- psychotics Drug Advisory Sheet

• 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

87

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)

88

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
• ther non-pharm methods to address

behaviours

• All behaviours have meaning

All

Break and Storyboard Networking

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.

Leanne Couves

Overview of CLeAR Progress, Results and Opportunities

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

• comm. between

• 1. Appropriate Antipsychotic Use
• 2. Best Practice Management with BPSD
• 3. Culture: Enhance Teamwork/Communication
• 4. Residental Care Planning

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?

97

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

Chris Rauscher

Reducing Antipsychotics: An Overview of Driver Diagram

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.

Reduce weight

Improve Health

Move More Eat Less

Take yoga class Ride bike to work Drink less grape juice

HOW

Aim / Outcome(s) Primary Drivers Secondary Drivers / Change Concepts Specific Ideas to Test

Join gym

HOW HOW WHY WHY WHY

Source: L. Couves, Improvement Associates

Worksheet – Example

All

Table Discussions: Explore Change Ideas in Detail

Topics/Questions for Groups

LUNCH

Meet back at 1:15

CLwK – Register Now!

BPSD Algorithm Website

www.bcbpsd.ca

Reports from Table Discussions

Leanne Couves

Overcoming Barriers to Improvement

Purpose

• Identify barriers to implementation of

improvement strategies

• Develop practical strategies and specific ideas
• n 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

Barrier

• Solutions that

we know work

• New ideas that

might work

Walkabout Exercise

• At each flipchart
• Questions?
• ?’s, √’s and X’s
• Rotate clockwise until

your group has written

• n each flipchart

Random Word Provocation

1. Spectator 2. Individualist 3. Crown 4. Pitfall 5. Accordion 6. Ocean 7. Plow 8. Deck 9. Wall 10. Alligator 11. Lock 12. Trapeze 13. Prank 14. Lake 15. Priest

• 31. Touchdown
• 32. Station
• 33. Shoe
• 34. Navy
• 35. Fire
• 36. Flood
• 37. Uprising
• 38. Cactus
• 39. Camp
• 40. Prisoner
• 41. Typewriter
• 42. Variation
• 43. Cigarette
• 44. Chalk
• 45. Vest

16. Summer 17. Landlord 18. Kernel 19. Dog 20. Bait 21. Elephant 22. Earthquake 23. Raft 24. Script 25. Thorn 26. Senate 27. Error 28. Equality 29. Towel 30. Blood 46. Detour 47. Knife 48. Tiger 49. Eye 50. Delusion 51. Tree 52. Whisky 53. Ink 54. Snake 55. Conductor 56. Hockey 57. Consumer 58. Parrot 59. Partner 60. 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

Leanne Couves

Model for Improvement

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-14 129

Operational Definition of Improvement

before after

1

Improvement is the result of some design

• r redesign of the

system. and lasting impact

3

result is positive, relevant

2

• n measures (balancing) that matter to

the organization

4

Cycle time

Reference: The Improvement Guide, 2nd ed. Langley, Moen, Nolan, Nolan, Norman & Provost, p. 16

9-Jun-14 130

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

Source: Associates in Process Improvement

Improvement Charter Develop, Test and Implement Changes

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?

Direction Process Measure Timeline Focuses the team on improvement Keeps the team on topic Defines what success looks like Ensures an urgency to continue

Components of an AIM Statement

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-14 136

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-14 137

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

Small-to-medium scale test Very small-scale tests

MAJOR

One cycle to implementation Medium-scale tests

MINOR HIGH LOW

CONSEQUENCE OF FAILED TEST DEGREE OF BELIEF IN SUCCESS OF THE CHANGE

9-Jun-14 143

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?

6/9/2014 Webinar 5: Making Improvements 144

6/9/2014 Webinar 5: Making Improvements 145

Plan:

• State objectives.
• Make predictions
• Make conditions explicit.
• Develop plan (5 W’s, How)

Do:

• Carry out the test
• Document problems, surprises,

and observations.

• Begin analysis.

Study:

• Complete analysis & synthesis
• Compare data to predictions
• Record under what conditions

results could be different.

• Summarize what was

learned.

Act:

• Adopt, adapt or abandon

based on what was learned.

• Build knowledge into next

PDSA Cycle

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? 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.

Principle 2: Collect Data Over Time

Before & After Tests

1 2 3 4 5 6 7 8 9 Week 4 Week 11 Cycle Time

Make Change

63% Improvement

3 8

9-Jun-14 146

Case 2

2 4 6 8 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Week Cycle Time

Make Change

9-Jun-14 147

Do you think this change resulted in an improvement?

Case 3

2 4 6 8 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Weeek Cycle Time

Make Change

9-Jun-14 148

Do you think this change resulted in an improvement?

Case 4

9-Jun-14 149

Case 5

Case 6

Annotated Run Chart - Example

9-Jun-14 150

Source: A Saskatchewan Falls Collaborative Team

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

Theories, Hunches, Best Practices, Change Concepts

Very small-scale test Follow-up tests Test new conditions Wide-scale tests of change

• p. 146

Breakthrough Results

Examples of PDSA Cycle “Ramps”

Concept #1: Start vitamin D Concept #2: Track falls in a falls diary

PDSA #1.1: Use 1:1:1 rule (Mrs. J at Lodge X on Tuesday) PDSA #2.1: Design a “falls diary” prototype and ask 3 front-line staff how to improve it. PDSA #1.2: Expand to all clients on

• Mrs. J floor

PDSA #1.3: Adjust Vitamin D

• rdering processes in pharmacy

PDSA #1.4: Adjust when Vitamin D administered, expand to all clients at Lodge X. PDSA #2.2: Try revised falls diary with 1 high risk client next week PDSA #2.3: Update falls diary format and try on all clients for 2 weeks

“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!

Ben Ridout

Measurement 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

Why Measure?

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

All

Team Meetings and Reports

Have You Completed Your…

Improvement Charter Driver Diagram Worksheet

Is our charter still relevant? How can we update it with new knowledge? What change will we test by next Tuesday? What changes are ready for implementation? What new ideas did we learn about today? What changes could we try?

Next PDSA Cycle

Report Out

• What changes are you planning test?
• How will you measure your progress?

Ben Ridout

Action Period Activities & Support

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?

Chris Rauscher

Summary and Closing Comments

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