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How to Get There: A Regional Approach to Senior Friendly Hospitals
Kathleen Graham RN MN CHEVP Patient Care & CNO
Queensway Carleton HospitalOttawa
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Ottawa RGAP developed “Vision for Care” Strategic Plan
One of the initiatives arising from the plan:
“Effective & efficient treatment of the
elderly in the hospital”
Genesis of the SFH Initiative
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Steering Committee mandated by RGAC to:• Improve patient outcomes• Reduce suboptimal use of resources• Improve patient/family satisfaction
Recruited a chairperson and a consultant to help develop a conceptual framework
Partnered with the Council on Aging to collect information on the broader aspects from consumers & providers with focus groups and a conference
Implementing a Strategy for SFHs
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1. Physical Environment
Is the physical environment sensitive to the capacities of elderly clients and visitors?
2. Emotional/Behavioural Environment
Do the staff interact with the elderly client in a respectful, supportive and caring way?
5 Major Elements and Key Questions
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3. Process of Care
Does the care and treatment take into consideration research and evidence regarding the physiology and pathology of aging as well as the social science research?
Is the knowledge gained through orientation and education translated into practice?
Major Elements (con’t)
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4. Organizational Support
Does the organization show its support for being a senior friendly hospital in its organizational structures and processes?
5. Ethics in Clinical Care and Research
Do care providers, researchers and others ensure that ethical issues are fully addressed with elderly clients or research subjects?
Major Elements (con’t)
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• Assessment and diagnosis with special emphasis on age related changes• Planning emphasis on avoiding hazards of hospitalization• Implementation-use of aids to compensate for sensory losses• Evaluation - consider response to hospitalization, impact of treatment
Process of Care
Emotional and Behavioural Environment
• Courtesy of staff• Respect• Information sharing and listening• Individualized approach to each patient• Culturally and gender sensitive
Ethics in Clinical Care and Research
• Confirm patient’s understanding of informed consent
• Use of Advanced Directives• Thoughtful discussion of treatment options and palliative care options
Organizational Support• Relevant policies and procedures• Inclusion into program development• Staff recruitment, orientation, ongoing education• Membership and TOR for committees dealing with patient outcomes
Physical Environment• Visual aspects• Physical space including external surfaces/crosswalks,speed bumps, sidewalks / grounds• Sensory Comfort• Furniture
Senior Friendly HospitalMajor Elements
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Letters to CEOs introduced the Senior Friendly Hospital conceptExtended invitation to be involved and have a representative on the Steering Committee
Coincided with introduction of the Accessibility Act Provided helpful documentation
Strong endorsement received from local and Ottawa Valley hospitals
Getting Started—Building Organizational Commitment
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Overall Environment
• Lighting• Noise / Sound• Décor• Orientation / Wayfinding
Safe Mobility
• Flooring
• Doors
Specific Functional Areas
• Bedrooms
• Telephone
• Light Switches
• Hallways, Waiting Rooms, Washrooms
Furniture
• Tables
• Beds, and bedside tables
• Chairs
Other Factors
• Large print on written materials
• Hearing amplifiers for all staff
• Consider nutrition needs
Physical Environment Criteria
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Joanne O’Keefe O.T. developed senior friendly guidelines for physical environment (Geriatrics Today, www.rgapottawa.com)
“Free” expert consultation for building plans
St. Joseph’s Buying Group
Algonquin College Design Program
From Theory to Practice… (Embedding the Environment Work)
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Patients and their families report a need to improve the way we communicate and demonstrate respect
Respect/dignity is an illusive element to measure
Clustered around questions in the NRC Hospital Patient Satisfaction Survey
Patient Satisfaction Survey Reports will inform quality improvement
Built on Accreditation Standards
Is there a correlation between the hospital’s patient satisfaction score and the checklist score
Emotional & Behavioural Environment
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OHA Patient Satisfaction Survey
Accreditation Standards
Hospital specific indicators/balanced score cards
Best Practice Guidelines
Merging SFH with Quality
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Process of Care
Emotional and Behavioural Environment• Emotional support• Information and education• Respect for Patient Preferences• Involvement of Family• Overall Impressions
Ethics in Clinical Care and Research
Item not included in NRC(Picker/Smaller World ) Patient Survey
Organizational Support
• Additional questions
Physical Environment• Amenities
• Access
• Continuity and Transition• Coordination of Care
• Physical Comfort• Overall Impressions• Additional Items
Building on NRC Patient Satisfaction
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Process for Comparative Analysis using OHA Patient Satisfaction Survey
Cluster items that are most senior sensitive
Analysis
Dr S. Amos-RGP and Dr. A. Brown, University of Toronto
Expected Outcomes
Senior Specific Hospital Report Card
Comparison of SFH achievement across the region and provincial hospitals
Evaluation Strategies: Building on Existing Tools
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Patient Satisfaction Questions Senior Friendly Guidelines
Respect Did staff demonstrate respect and dignity in interactions with patients
and families?
1. Rate the courtesy of staff
2. Treated with respect and dignity
3. Staff discussed anxieties/fears about treatment/conditions
4. Staff spoke in front of you as if you were not there
5. Enough to say about your treatment
1. Introduce themselves, their roles, proposed intervention
2. Avoid exposing patient, properly covered/pull curtains, speak in a discrete voice
3. Time is available for emotional support
4. Speak directly to patient when asking for and giving information
5. Information about tests/treatments so patient/family are fully informed/involved in decisions
Comparison of Hospital Patient Satisfaction Survey with SFH Guidelines
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Patient Satisfaction Questions
1. Staff answered important questions
2. Staff explained results of test in a way you could understand
3. Information was given to family about your condition/treatment
1. Inform patients/ family what to expect.
2. Use common spoken/written language.
3. Family participate in care and discharge planning
Information Sharing/Listening
Senior Friendly Guidelines
Are staff’s communications senior friendly?
Comparison of Hospital Patient Satisfaction Survey with SFH Guidelines
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Respect for Patient’s Preferences54.2% Had enough to say about their treatment80.1% Treated with respect/dignity
Emotional Support 62.5% All Dimensions combined47% Nurse discussed anxieties/fears57.9% Ease of finding someone to talk to
Information & Education64.8% All Dimensions combined
Continuity & Transition58.2% When to resume normal activities
Involvement with Family60.9% Amount of information given to family62.3% Family had enough recovery information
NRC Results
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Process of Care
Emotional and Behavioural Environment• Emotional support• Information and education• Respect for Patient Preferences• Involvement of Family• Overall Impressions
Ethics in Clinical Care and Research
Item not included in NRC(Picker/Smaller World ) Patient Survey
Organizational Support
• Additional questions
Physical Environment• Amenities
• Access
• Continuity and Transition• Coordination of Care
• Physical Comfort• Overall Impressions• Additional Items
SFH Dimensions of Quality
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Process of Care
Emotional and Behavioural Environment
• Comment Cards, Complaints/Compliments
• Focus Groups
Ethics in Clinical Care and Research
• Audits for informed consents
• Proportion of seniors enrolled in Research projects
Organizational Support
• Audits of Policies and Procedures to ensure sensitivity to seniors’ needs
Physical Environment
• Adherence to Senior Friendly Guidelines
• Accessibility Working groups
• Focus Groups
• Audits
• Develop and implement Senior Sensitive Protocols Falls, Restraints, Delirium, etc
• Adverse Events ( Encon)
• Patient / Family Comment Cards, Complaints/Compliments
• Utilization: readmission, discharge disposition etc.
Other Quality Initiatives/Measures
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More Evaluation Building on Existing Tools
Use other data collection tools and stratify by age
Prevalence reports : Falls, Restraints, PressureIncidence reports: Adverse Incidents,Patient/Family Comment Cards
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Pressure Ulcer Prevalence (PUP) 2002
83% of patients are “at risk”
Of these, 65% have a deficit in
nutrition
18% prevalence rate in ulcers
Seniors represent 77% of ulcer population
37% of ulcers develop within first 7 days
after admission
Average LOS 31 days vs 21 days patients
with intact skin
Other Quality Indicators-Skin
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Falls – 2003/04
Of the ~2200 falls, those > 71 yrs. experienced
41% of all falls
Those >71 yrs. had 64% of population with
moderate degree of injury Those >71 yrs. had 74%
of serious degree of injury
Use of Restraints 2002/2003
Those >70 yrs. represent 39.4% of population
using restraints
Those >70 yrs. 26.4% with both physical and
chemical restraints
Other Indicators-Falls and Restraints
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Care Processes
First steps:Expert Panel convened Oct 03
Possible foci for care processes collated, debated, clustered, and priorizedEach member exploring topic e.g. 3D’s
Possible next steps:Use Steering Committee as focus group Find champion(s) and support them
Vision: a checklist for best processes for senior friendly hospital care
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Continue work on Conceptual Framework Elements
1. Physical Environment-Completed
2. Emotional/Behavioural Environment Nov03
3. Care Processes-June 04
4. Organizational Support- tbd
5. Ethics in Clinical Care and Research-tbd
Continue Dialogue and Education
• OHA- Toronto Nov 03
• Publication of Guidelines
Where to Go From Here?
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W.H.O. recommends senior friendly health-care centers
Patients receive targeted approaches and best practice care
Care providers note increased job satisfaction and morale
Impacts on patient safety and functional level (quality and risk)
Decreases LOS and cost- in human and financial terms
Benefits of Being Senior Friendly
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Seniors are 1/3 of hospital admissions but 2/3 of days
ER Readmission rates are 42% in patients >75 years
Frail elderly experience further functional decline not related to acute episode but to hospital practices (even when adjusted for age/co morbidity)
Frailest elderly ~3% of population use 30% of health-care resources
Supports Accreditation Process
Seniors are the largest group of foundation donors
The Pitch To Boards and Administration
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“Best Practice” depends upon an environment where
choices are guided by clinical expertise, developed
through education, based on research, and
incorporating the wishes of seniors
Success requires building on the strengths of our
communities, leaders, care receivers and providers
We are just beginning, and would welcome other
partners
In Closing….
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Vancouver Island Health Authority- “Elder Friendly Hospital” adopted the gerontology perspective for all programs/services
System-wide approach-all levels and types of staff
High-risk screen at admission on all patients
Objectives:Predict and prevent adverse consequences of hospitalization
Preserve functional ability
Early discharge planning and return to the community
Other Initiatives
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Edmonton-”Senior Friendly” Toolkit
Sponsored by the Alberta Council on Aging
Targeted the community (retail sector) to direct changes in facilities & services
Guide book, Workshops/seminars, Presenters Kit, Tee shirts, Stickers
Senior Friendly Checkup with manual, checklist & rating scale
Other Initiatives
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• Assessment and diagnosis with special emphasis on age related changes• Planning emphasis on avoiding hazards of hospitalization• Implementation-use of aids to compensate for sensory losses• Evaluation - consider response to hospitalization, impact of treatment
Process of Care
Emotional and Behavioural Environment
• Courtesy of staff• Respect• Information sharing and listening• Individualized approach to each patient• Culturally and gender sensitive
Ethics in Clinical Care and Research
• Confirm patient’s understanding of informed consent
• Use of Advanced Directives• Thoughtful discussion of treatment options and palliative care options
Organizational Support• Relevant policies and procedures• Inclusion into program development• Staff recruitment, orientation, ongoing education• Membership and TOR for committees dealing with patient outcomes
Physical Environment• Visual aspects• Physical space including external surfaces/crosswalks,speed bumps, sidewalks / grounds• Sensory Comfort• Furniture
Senior Friendly HospitalMajor Elements
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• maintains and/or improves functional abilities
• has a safe and comfortable physical and emotional environment
• provides respectful and responsive care and services
• has staff who ask questions and listen for responses without making assumptions
• encourages and supports patients and families having input into decisions
Remember…A Senior Friendly Hospital…