Using the RAI 2.0 to Promote Continual Quality Improvement Across the Winnipeg LTC Region Joe Puchniak & Cynthia Sinclair 1 1
Winnipeg Health Region • One of 5 health regions in Manitoba • Largest with 28,000 staff • Operating budget of $2.1 billion • Administer and support 200 health service facilities and programs 2 2
WRHA PCH Program • 39 Personal Care Homes (nursing homes) in Winnipeg • Support >5,600 people • Variety of ownership models • Regional • Not for Profit • Corporate – For Profit • Operating budget approx. 348 million 3 3
RAI/MDS – Winnipeg • RAI/MDS = clinical decision support system for monitoring QI’s, outcome measures and population case-mix • Implemented across all 39 nursing home sites in Winnipeg since 2008 • Detailed picture of > 5600 residents living in the Winnipeg nursing homes, all data submitted to CIHI since 2009 • Potential to guide continual quality improvement and assist with evidence-informed decision making at all levels 4 4
RAI Assessments sent to CIHI(CCRS) from WRHA 5 5
International use of RAI/MDS Nordic Countries Europe Iceland, Norway, Sweden, Denmark, Finland Netherlands, North America Germany, Switzerland, Canada France, UK US Italy, Mexico Spain, Middle East Czech Republic Israel Russia South America Pacific Rim Chile, Argentina, Japan, South Korea, Taiwan, China, Hong Kong, Brazil, Peru Australia, New Zealand 6 6
RAI LTC Adoption in Canada RAI is a well researched tool used across Canada and the world 7 7
Multiple Possible Uses for RAI/MDS Data Collected Public Clinical Decision Making/ Accountability Operational Management Clinical & Utilization & Strategic Planning & Research Engagement e.g. Are we developing e.g. Are we getting the e.g. How do resident effective Care Plans? best outcomes for our populations at different What are the outcomes of health care dollars? facilities compare? How does care? Do our residents How effective are our our region compare with achieve their health goals? services? What are the other regions across Canada? What resources were used? priorities for quality improvement? MDS Assessment 8 8
WHAT IS THE PROBLEM/CHALLENGE? • RAI has not been used to inform decision making at nursing home sites and regional levels • Value of the RAI data not seen by staff & management • Reports not consistently being used to identify areas for improved resident care or to inform operational or policy changes 9 9
CAUSES OF THE PROBLEM • RAI generates lots of information – Sites overwhelmed • RAI not tied to standards or accreditation • No strategy or mandate to use the RAI data • Data does not equate to knowledge translation 10 10
GOAL OF THE PROJECT • To use the RAI data to identify areas for quality improvement and then use the RAI data to gauge the effectiveness of our intervention. 11 11
What Evidence did we use to Inform our Project? 1. Participatory Education and Leadership are key to effective and sustained knowledge translation (Stolee et. al, 2009; Barba & Fay, 2009; Marzlin, 2010; Morgan et al., 2007) 2. Antipsychotic Lit.: “In patient populations for whom the evidence of the efficacy of antipsychotic medications is limited and the risk of a fatal side effect is clear, prudence would suggest that the use of these drugs should be reduced sharply.” (Schneeweiss S, Avorn J., N Engl J Med, 2009 Jan 15; 360 (3):225-35) 3. RAI data 12 12
How Does our IP Affect the Problem? • Choosing one RAI quality indicator, high antipsychotic usage, to focus on –Provides for a focused approach –Allows for a quick measurable success –Prove success with one indicator and then move to the other quality indicators –Potential to link indicator with clinical initiative 13 13
How Does our IP Affect the Problem? • Choose one site: complete an intervention at the site • Intervention Objectives – Reduction of antipsychotic usage – Site and region to understand value of RAI data – Apply this understanding to work with other RAI QI’s 14 14
How we Reduced Antipsychotics? • To reduce antipsychotic usage = intensive implementation of P.I.E.C.E.S™ which is a dementia care model • P hysical, I ntellectual, E motional, C apabilities, E nvironment and S ocial • P.I.E.C.E.S promotes the use of medications as a last resort to manage challenging resident behaviors 15 15
Challenges and Change Management Strategies 1. Effectively communicate the project to all relevant stakeholders • Face to face meetings at various tables 2. Spread change throughout the region • Decision for pilot site 16 16
Challenges and Change Management Strategies 3. Effectively educate entire site • Intensive education – Classroom education for all staff – ‘Huddles’ – Posting RAI Data – Online learning module 17 17
Online Learning Module http://www.aissystems.com/wrhaeLearn/pieces 18 18
Challenges and Change Management Strategies 4. Management and MD “buy-in” and support • Management and MD meetings 5. Enthusiasm of staff • Kick off party, regular postings of data and progress, staff forums, regular unit feedback 6. Project Human Resources We are the resources No additional resources • 19 19
Project Results • Quantitative: - 10% reduction in antipsychotics overall at site - > 25% reduction in antipyschotic medication prevalence within cohort - No ↑ physical restraints or behaviors • Qualitative: - Improved teamwork - Growing leaders - Evidence based practice 20 20
Antipsychotics Middlechurch Pilot Site 21 21
Lessons Learned • RAI can identify areas for improvement and evaluate the effectiveness of clinical interventions. • ↓ antipsychotics = ↑quality of life while ↓cost • Participatory learning is an effective method for promoting best practice & sustaining knowledge transfer • Site management needs to play a visible and active role 22 22
Lessons Learned • P.I.E.C.E.S™ is effective • “Lead from where you stand” • Keep messaging simple and repeat often • Do fewer ‘projects’ - more targeted approach to assist PCHs with quality improvement 23 23
Spread and Sustainability • A regional guide as a blueprint • Online learning for P.I.E.C.E.S.™ • Benchmarking through Quality Team • Dedicated human resources - business plan in development 24 24
Conclusion • CIHI video presentation: The story of our project – the difference data can make http://www.cihi.ca/land/Article/Data+In+Action/cihi011336 25 25
Project Publicity/Media Stories: • CIHI Video – “ The Difference Data Makes”: http://www.cihi.ca/land/Article/Data+In+Action/cihi011336 • Wave Magazine Article – “Formula for Success”: http://www.aissystems.com/wrhaeLearn/pieces/www/swf/pdf/ EXTRA.fWAVE_JAN12_final2.pdf • CTV New Story – “Memories Before Medications”: http://winnipeg.ctv.ca/servlet/an/local/CTVNews/20120315/wp g_dementia_treatment_120315/20120315/? • CIHI Publication – “From Clinician to Cabinet”: http://www.cihi.ca/CIHI-ext- portal/pdf/internet/hsu_clinic_cab_pdf_en 26 26
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