Patient Safety at Whitby Mental Health Centre

1. Patient Safety at Whitby Mental Health Centre Doris Doidge, Former Director of Quality Janice Dusek, CNO, VP Professional Practice & Strategic Development

2. Agenda A little bit about us Patient Safety at Whitby Mental Health Centre Our Balanced Scorecard Lessons learned Next Steps Our agenda for the next 15 minutes is to First, tell you a bit about Whitby Mental Health Centre We will then discuss the model of integration of quality, risk and patient safety that we have at the Centre We will then move on to discuss the challenges of patient safety in mental health and the implications for quality and Risk Management We will end with a brief discussion of some of the lessons we have learnedOur agenda for the next 15 minutes is to First, tell you a bit about Whitby Mental Health Centre We will then discuss the model of integration of quality, risk and patient safety that we have at the Centre We will then move on to discuss the challenges of patient safety in mental health and the implications for quality and Risk Management We will end with a brief discussion of some of the lessons we have learned

3. About Whitby Mental Health Centre 1100 employees serving a population of 2.5 million Serving 4 LHINs, located in the Central East LHIN Located east of Toronto, on the shores of Lake Ontario on 78 acres 5 Clinical Service Areas: Adolescents & Dual Diagnosis, Special Services, Forensics, Assessment & Reintegration, Integrated Health Services 329 tertiary mental health care inpatient beds and 11 other community sites Two 10-bed residential treatment programs Support for 24 Homes for Special Care (191 beds) Outreach services in a variety of locations Vocational rehabilitation and ACT teams Education activity and Research Just over 1000 employees serving a population of 2.5 milion\ We are located in the Central East LHIN but provide care to patients in three other LHINS (Central, We are located about 45 km east of Toronto on the shores of Lake Ontario We have 332 tertiary mental health care inpatient beds and 11 community sites divided into 4 clinical programs (adolescents & dual diagnosis, special services (includes are geriatric patient), forensics and assessment and reintegration). The Integrated Health Service area includes our pharmacy, medical clinic and We have 5 clinical service areas One of the goals of Whitby is reducing mental health stigma. Whitby has been activity pursuing this goal for a number of years and about 5 years ago the TAMI or Talking About Mental Illness coalition was formed. The TAMI coalition recently was the recipient of the Minister of Health Award for Innovations in Health Promotion at the Celebrating Innovations in Healthcare Expo for their Stomp Out Stigma summit for teaching students in Durham Region about Mental IllnessJust over 1000 employees serving a population of 2.5 milion\ We are located in the Central East LHIN but provide care to patients in three other LHINS (Central, We are located about 45 km east of Toronto on the shores of Lake Ontario We have 332 tertiary mental health care inpatient beds and 11 community sites divided into 4 clinical programs (adolescents & dual diagnosis, special services (includes are geriatric patient), forensics and assessment and reintegration). The Integrated Health Service area includes our pharmacy, medical clinic and We have 5 clinical service areas One of the goals of Whitby is reducing mental health stigma. Whitby has been activity pursuing this goal for a number of years and about 5 years ago the TAMI or Talking About Mental Illness coalition was formed. The TAMI coalition recently was the recipient of the Minister of Health Award for Innovations in Health Promotion at the Celebrating Innovations in Healthcare Expo for their Stomp Out Stigma summit for teaching students in Durham Region about Mental Illness

5. Patient Safety – A Board Strategic Priority WMHC will provide quality programs and services which are safe and effective for patients, staff, and community.

6. WMHC Integrated Safety Model

7. Patient Safety Challenges for Mental Health Environmental Particular vulnerability of patient population Need to provide ‘safe haven’ for patients to obtain help i.e. advocates, privacy, patient rights Behaviours associated with illness create challenge in attending to personal safety of co-patients, staff, visitors Community stigma over aggression or bizarre behaviour, associated with fear and anxiety Yeager KR, et. al. Measured Response to Identified Suicide Risk and Violence: What You Need to Know About Psychiatric Patient Safety IN Brief Treatment and Crisis Intervention (2005) 5, 121-141. Although the models and frameworks for Quality, Risk, and Patient Safety are applicable regardless of the healthcare environment and can easily be transitioned from for example an acute care environment into rehabilitation, long term care, and mental health, we have discovered there are some distinct special needs when applying these processes in mental health. Yeager (2005) has identified a number of aspects in Mental Health that pose a challenge for Patient Safety. Removal of structural barriers to enable high level of visibility of patients, staff, visitors; locked versus unlocked units/rooms; seclusion rooms; physical plant make-up (construction materials) Patients may/may not have family/friends advocating for their care/treatment; determining capacity to treatment/placement/financial management imperative to prevent patients from being taken advantage of Need to protect patient’s rights – ethical considerations – unique opportunity in having Patient Advocate and Rights Advisor on site from Provincial Psychiatric Advocacy Office Determining the impact of patient’s behaviours associated with their respective illness on other patient/visitor/staff safety – Risk Assessments are embedded within continuous clinical care of patients Education needs of the community to reduce/eliminate misunderstanding of patients & impact gradual reintegration into the community – Doris mentioned the TAMI projectAlthough the models and frameworks for Quality, Risk, and Patient Safety are applicable regardless of the healthcare environment and can easily be transitioned from for example an acute care environment into rehabilitation, long term care, and mental health, we have discovered there are some distinct special needs when applying these processes in mental health. Yeager (2005) has identified a number of aspects in Mental Health that pose a challenge for Patient Safety. Removal of structural barriers to enable high level of visibility of patients, staff, visitors; locked versus unlocked units/rooms; seclusion rooms; physical plant make-up (construction materials) Patients may/may not have family/friends advocating for their care/treatment; determining capacity to treatment/placement/financial management imperative to prevent patients from being taken advantage of Need to protect patient’s rights – ethical considerations – unique opportunity in having Patient Advocate and Rights Advisor on site from Provincial Psychiatric Advocacy Office Determining the impact of patient’s behaviours associated with their respective illness on other patient/visitor/staff safety – Risk Assessments are embedded within continuous clinical care of patients Education needs of the community to reduce/eliminate misunderstanding of patients & impact gradual reintegration into the community – Doris mentioned the TAMI project

8. Patient Safety Challenges for Mental Health Patient Safety initiatives may pose a clinical risk (e.g. Hand washing) Patient length of stay Line of demarcation between patient residence and treatment facility Line of demarcation to establish therapeutic clinician-patient relationship Integrating the justice system requirements with patient care and treatment needs Safety occurrences related to self harm and violence, ULOA, patient accidents, sexual safety, and medication safety11. Scobie S, et. al. With safety in mind: mental health services and patient safety Patient Safety Observatory Report 2 July 2006. -- National Patient Safety Agency: UK, c 2006. All Patient Safety initiatives must undergo a risk analysis prior to implementing within the Mental Health environment – although they have been proven to enhance patient outcomes, their implementation without modification may increase risk in other areas, for example the careful placement and monitoring of hand washing stations in the facility. Average length of stay for mental health patient appreciably longer than a patient attending an acute care hospital. Many patients don’t have a permanent residence to return to after inpatient treatment is complete, that coupled with longer length of stay and/or legal requirement to remain at the Centre for a period of time established by the Ontario Review Board (for our forensic patients) could potentially confuse the hospital as being their “home”. Potential for objectivity to be skewed when establishing boundaries in the clinician-patient relationship, as there is heightened familiarity of the patient due to significant length of stay, patient vulnerability, limited familial involvement. In forensic patients, assessment, treatment, and detention is ordered through the judicial system, which poses a special challenges in providing therapeutic assessment, treatment for patients who may/may not be willing to receive same. According to the National Patient Safety Agency July 2006 Report, the highest propensity of safety occurrences in a Mental Health environment are patient accidents such as slips & falls; self harm & violence; absconding patients; sexual safety; and medication safety. Tracking and trending safety reports over several months have certainly affirmed the NPSA’s report findings. All Patient Safety initiatives must undergo a risk analysis prior to implementing within the Mental Health environment – although they have been proven to enhance patient outcomes, their implementation without modification may increase risk in other areas, for example the careful placement and monitoring of hand washing stations in the facility. Average length of stay for mental health patient appreciably longer than a patient attending an acute care hospital. Many patients don’t have a permanent residence to return to after inpatient treatment is complete, that coupled with longer length of stay and/or legal requirement to remain at the Centre for a period of time established by the Ontario Review Board (for our forensic patients) could potentially confuse the hospital as being their “home”. Potential for objectivity to be skewed when establishing boundaries in the clinician-patient relationship, as there is heightened familiarity of the patient due to significant length of stay, patient vulnerability, limited familial involvement. In forensic patients, assessment, treatment, and detention is ordered through the judicial system, which poses a special challenges in providing therapeutic assessment, treatment for patients who may/may not be willing to receive same. According to the National Patient Safety Agency July 2006 Report, the highest propensity of safety occurrences in a Mental Health environment are patient accidents such as slips & falls; self harm & violence; absconding patients; sexual safety; and medication safety. Tracking and trending safety reports over several months have certainly affirmed the NPSA’s report findings.

9. Implications for Patient Safety Measurement - What & How? Achievement of standards – e.g. mental health assessment Identifying benchmarks Meaningful indicators/measures Expected outcomes Mental health specific Generic measures & their applicability e.g LOS, waiting times Big Dot? What is an incident/complaint versus pathology for the illness Security and patient safety Navigating involvement of external authorities & claims processes Community stigma Quality The elements of a quality program used in other organizations are applicable to mental health. For example, measurement of patient satisfaction is just as applicable to mental health patients as it is to patient’s in acute care. However, the areas of importance to patients in mental health are different. For example access to the legal system is important for our patients but our patients are also concerned with their environment such as the quality of food and the cleanliness of the facility. Measurement which is part of all quality programs is also used mental health but what do you measure and how you measure it may be different. Standards for mental health care are in place such as the completion of a daily mental health assessment Identification of benchmarks can be difficult. Data is not easily available and thus comparisons are sometimes made to acute care but may not be reasonable. For example, in mental health, just as in acute care, an emergency code that may be called is a Code White for an aggressive or violent patient. In an acute care hospital you would expect to have less Code White calls than in a mental health environment. But what would be reasonable benchmark for our clients. Are 16 code white calls a month more than average, average, less than average. If you have more forensic patients would you expect to see less Code White calls than in another facility. What are indicators that are meaningful. What outcomes can we expect for our clients? For example, is return to work or school an important measure for our organization and perhaps not important in acute care. Other potential measures and that may be important to measure include family support, financial resources, number of arrests, elopements, medication taking behaviors, etc. Some measures are the same as in other sectors of healthcare such as LOS, wait times for admission, number and type of incidents. The specifics of the measure may be different. A LOS in acute care of 7 days may be considered long. A LOS in mental health may be 90 days, which depending on the population may be short.Quality The elements of a quality program used in other organizations are applicable to mental health. For example, measurement of patient satisfaction is just as applicable to mental health patients as it is to patient’s in acute care. However, the areas of importance to patients in mental health are different. For example access to the legal system is important for our patients but our patients are also concerned with their environment such as the quality of food and the cleanliness of the facility. Measurement which is part of all quality programs is also used mental health but what do you measure and how you measure it may be different. Standards for mental health care are in place such as the completion of a daily mental health assessment Identification of benchmarks can be difficult. Data is not easily available and thus comparisons are sometimes made to acute care but may not be reasonable. For example, in mental health, just as in acute care, an emergency code that may be called is a Code White for an aggressive or violent patient. In an acute care hospital you would expect to have less Code White calls than in a mental health environment. But what would be reasonable benchmark for our clients. Are 16 code white calls a month more than average, average, less than average. If you have more forensic patients would you expect to see less Code White calls than in another facility. What are indicators that are meaningful. What outcomes can we expect for our clients? For example, is return to work or school an important measure for our organization and perhaps not important in acute care. Other potential measures and that may be important to measure include family support, financial resources, number of arrests, elopements, medication taking behaviors, etc. Some measures are the same as in other sectors of healthcare such as LOS, wait times for admission, number and type of incidents. The specifics of the measure may be different. A LOS in acute care of 7 days may be considered long. A LOS in mental health may be 90 days, which depending on the population may be short.

10. WMHC Balanced Scorecard

11. Evaluating Our Performance

12. Patient Safety Measures Wait List % ALC Mean Hours of Restraint for Safety Mean Hours of Seclusion % Self-inflicted Injury Occurrences % Sentinel Events Infection Rates – C Diff Medication Reconciliation Mean # of undocumented intentional discrepancies Mean # of unintentional discrepancies

13. Other Measures Being Monitored Emergency Codes Code White Unauthorized Leave of Absence Staff Sentinel Events % Staff Mask Fit Tested % Staff Completed Safety Syringe Education % Staff Completed Core Competency eduction Hand Washing Chain of Transmission Personal Protective Equipment (PPE)

14. Lessons Learned Don’t wait for perfection – just begin Measures are constantly evolving Communicate, communicate, communicate. Staff education - ongoing Engage patients in the process Greet, Treat & Meet Patient Safety Role Collaboration between Quality, Risk, Patient Safety, and Professional Practice

15. Lessons Learned Use of Quality, Risk Management & Patient Safety Tools are applicable regardless of the clinical environment Need for enterprise understanding, knowledge, spread and sustainability of quality, risk and patient safety through all clinical programs and non-clinical services.

16. Next Steps Continue to refine measures Cascade BSC to Programs / Service areas Quality Risk & Patient Safety Goals for 2008/09 Communicating expectations re metrics Restraints Clozapine Therapy Patient Safety ROP’s Organizational Learning from Incident Review Research Exploration of near misses in Mental Health Kathleen MacMillan, PhD & Janice Dusek CPSI Applied Research Grant

17. Thank You For more information please contact: Janice Dusek, CNO & VP Professional Practice & Strategic Development, dusekj@wmhc.ca