10/31/2012

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The BSO Project at The Wenleigh LTC

By Luciana Capitao NRRCC/BSOC

Old problem… New solution?

Insanity… doing the same thing over and

over again and expecting different

results. ~ Albert Einstein

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Overview of Project Framework Components

And now… where do we begin?Establish baseline number of Responsive Behaviors

to be able to compare for effectiveness of new interventions!

Baseline gathered through RAI MDS data and multidisciplinary progress notes on point click care were reviewed and compared to actualobserved responsive behaviors over period of one month.

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Conclusion: Through reviewing data collected, we identified that

the number of documented responsive behaviors was greatly inaccurate, and under captured.

Point of care and registered staff were noted to witness responsive behaviors on a daily basis,

several times a day but yet documentation didn’t capture even 1% of these incidents.

Within the 1% of documentation that was present it was observed that:

o The quality of information was poor, containing inadequate use of terminology to describe what was occurring.

o It lacked quantity of information in regards to what had occurred, what pre disposing factors triggered occurrence,

who was involved, etc. o They also consistently lacked mention of follow up

interventions to prevent further incidents, or mention of change in plan of care.

o Information on electronic documentation done by registered staff did not always correspond with the paper

documentation by point of care staff.

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Our plan:Short term goal: To increase recognition and management of responsive behaviors by staff, promote interdisciplinary communication of information identified and increase number of thorough and congruent documentation, as well as follow up of responsive behavioral incidents.

Long Term goal: To decrease number of responsive behavioral incidents. Promote improved quality of life (and work) for all stakeholders.

Integrated service delivery: inter-sectoral and interdisciplinary:

Several educational training sessions and webinars attended by both the BSO team, as well as other staff from multidisciplinary team to build capacity.

Mandatory education session on Dementia, recognition and management of Responsive Behaviors done for all disciplines.

Educational session done for Program and Support Services staff on how to recognize, intervene, document and report responsive behaviors occurring during programs according to best practice guidelines, with excellent turn out.

Post behavioral huddles held post each incident by BSO team, staff from all departments involved where applicable including, housekeeping, dietary, programs and nursing. PIECES assessments completed by BSO team with input of all disciplines and assistance provided as needed by external resources.

Several family members and residents provided with 1:1 nursing teaching as well as support.

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System Coordination and Management:

Excellent ongoing support to project by facility Medical director, family physicians, leadership and

multidisciplinary team (registered dietitian, physiotherapist, occupational therapist, programs and

support services manager, speech pathologist, restorative coordinator, etc).

Outside resources that collaborated with BSO project at facility during the quarter include HMGOP, PRC,

Palliative Consultant, NP stat, local hospitals’ Mental Health Intake departments, pharmacist, Alzheimer’s

Society Volunteer program.

CQI (tests of change, tools used and data collection

methodologies):

Data collected and analyzed through: Behavioral Line Listing PCC Flow sheets, Intake sheets, Lab work, Hx data Chartwell Behavioral Audit Pain flow sheet DOS Cornell Depression Scale MMSE MoCa Cohen Mansfield Agitation Inventory PIECES SBAR Behavioral Huddle form Monthly graphs for comparison Pareto Chart to identify main issues for quality improvement. PDSA cycle to test effectiveness of interventions implemented to increase

point of care staff’s recognition and documentation of Responsive Behaviors. PDSA cycle also used to test effectiveness of care planned interventions.

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0

10

20

30

40

50

60

70

1-Jun 1-Jul 1-Aug 1-Sep

Total number of staff trained from BSO funding sources

Total number of staff trained from BSO funding sources

The Wenleigh LTC - Clients served – Monthly comparison

0

10

20

30

40

50

60

Jun-12Jul-12

Aug-12Sep-12

Clients served

Clients served

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Total Responsive Behaviors & clients served - by month comparison

0 50 100 150 200 250 300

Clients served

Total Responsive Behaviors

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The Wenleigh’s Run Chart with # of responsive behaviors shows number of incidents identified over length of time.

In spite of increase in responsive behaviors observed in both July and August, chart demonstrates success in achieving our short term goal set in June 2012, which was to increase staff members’ knowledge of what responsive behaviors were, and increase number of proper documentation and follow up of responsive behavioral incidents.

Run Chart discussion:

The Wenleigh LTC - Responsive Behaviors by type –Monthly comparison

0

10

20

30

40

50

60

70

Jun-12

Jul-12

Aug-12

Sep-12

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0

2

4

6

8

10

12

OH

PC

SV

ER

CV

CC

The Wenleigh LTC - Responsive Behaviors by Home area and type – September 2012

Summary of progress, Highlights, Accomplishments and Issues:

Noted further increase in both Registered staff and point of care staff’s recognition and documentation of Responsive Behaviors in both September and October.

Noted drastic decrease in incidence of responsive behaviors by identified residents as well as improved care planning and implementation of successful interventions in month of September and October 2012 compared to previous quarter.

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Lessons Learned and Recommendations for broader roll-out

New quality improvement tools learned at Improvement Facilitator training in August invaluable to better analyze data collected and to reach quality improvement goals.

Pareto Chart one of these tools, was used to identify focus area to decrease # of responsive behavioral incidents in September.

0

5

10

15

20

25

30

12-Jun

Jul-12

Aug-12

Sep-12

Responsive Behaviors by Home area - Orchard Heights –September 2012

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0

2

4

6

8

10

12

14

16

DAY (0701-1500)

EVE (1501-2300)

2301-0700

The Wenleigh LTC Total Responsive Behaviors by type and time of day – September 2012

Opportunities or challenges that presented since project roll-out:

47 y/o requiring at home consultation by a psychiatrist was denied service by HMGOP due to age group, by other

services in the community due to being in a LTC home. All available resources were involved in trying to get service for this gentleman who was finally sent out on a form to a local

hospital and is now waiting until November for a f/u appt with a psychiatrist. We are continuing to follow him closely.

It may be beneficial for others to learn from process and maybe in the future things may be done more efficiently, or

perhaps the concern about the lack of visiting services in our community for residents who are under 65 at a LTC

facility can be raised.

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Ongoing Interventions Increased engagement of leadership and multidisciplinary team in BSO

referral process as well as participation in huddles promoted over month of October with success.

Education to be provided by BSOC to registered staff on use of Clinical Pathway, behavioral huddles as well as documentation of behaviors, with the goal of rolling-out to home areas the use of immediate post behavioral huddles and clinical pathway during month of November.

Home area where staff have been identified to be the most resistive to change will be trialed first, since if those staff members comply chances are entire home will adhere to change. Several PDSA cycles to be done to track effectiveness of huddles.

Imperative for project’s success that point of care staff buy in and analyze each incident as they occur, just like fall huddles were done previously.

“Like I said, I’m just trying to continue to improve and get better.” ~ Henry Taube

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Thank you!