Veterans Centre Review February 20 th , 2013

1. Veterans Centre ReviewFebruary 20th, 2013

2. Some brief background • Sunnybrook is the largest veterans facility in Canada. We care for 500 of the country’s war veterans who served in Korea and the Second World War. • Funding received from both Veterans Affairs Canada and Ministry of Health and Long Term Care. • One of the many benefits veterans have at Sunnybrook is access to leading acute and critical care.

3. Some brief background

4. Some brief background

5. What brought us here today? • News reports in late 2012 highlighted concerns from a small number of families. • Veterans Affairs Canada announced an audit in November • Due to the dual funding from the provincial and federal governments, Sunnybrook proposed terms of reference for a review of the beds that are primarily funded by the provincial government.  The province supported these terms of reference and recommended that the review be conducted by Dr. Karima Velji from Baycrest Centre for Geriatric Care

6. Karima Velji, RN, PhD, CHE • Dr. Velji, Chief Operating Officer and Chief Nursing Executive at Baycrest Centre for Geriatric Care, a global leader in innovations in aging and brain health. • Dr. Velji's 10 years of progressive executive leadership success spans the full continuum of care, including acute care, rehabilitation, long term care and community.

7. Objectives of the Review • Conduct review of quality of care and supporting system, with a particular focus on complaints process • Identify any systemic issues that may be contributing to quality, with a particular focus on complaints process • Formulate recommendations to address gaps • Suggest action plan to guide implementation

8. Methods • Document review • Focus groups • Interviews • Analysis of complaints process • Deep dive of selected issues • Observation of processes of care Total = 110 people participated(cross section of all level 3 units)

9. Third Party Assessments • Accreditation Canada (November 2010) – all 121 standards were met or exceeded, two leading practices were identified; “Flagship for LTC in Canada.” • NRC Picker (Sep 2011) – better than provincial average or high performer in overall resident and family response rate and satisfaction; higher family scores. • Veterans program is considered to be a leading practice in the field. • Better than provincial average on most indicators.

10. Quality Indicators

11. Quality Indicators

12. Provincial Comparison *Sunnybrook is tied for second among its provincial comparators

13. Family Satisfaction Overall Ratings - 2011

14. Resident Satisfaction Overall Ratings 2011

15. Focus Groups and Interviews • All groups expressed deep respect for the veterans and the privileged position to care for them. • Residents consistently expressed satisfaction with quality of care. • Families expressed variable satisfaction with quality of care and expressed common concerns about staffing levels, staff attitudes, management response, and patient moves. • Staff and leaders expressed concerns about not being able to meet needs of a small number of families.

16. Complaints Process • Where we do well: • Good structures and processes to address concerns • Escalation procedures in place • Effective tracking system and action logs. • Concerns are followed through and addressed. • Noted Concerns: • Variation among different units. • Reactive vs. proactive approach. • Variable safety nets for high need families. • Disagreements about solutions.

17. Patient Safety, Staffing and Transfers • Where we do well: • Robust critical incident reporting and action system. • Just culture philosophy • Best practices such as executive walkabouts. • Noted Concerns: • Staffing changes over the past year have become a lightening rod issue however staffing levels are comparable or higher than field (RN staff mix is higher than field). • High number of patient moves for a “home” setting; most moves are related to changing clinical conditions

18. Velji Review Conclusions • No systematic gaps in structures and processes of care; selected areas of enhancement and focus. • Good structures, policies, procedures for quality and safety, and complaints process. • Family concerns have common themes. • Small number of families pose specific challenges. • Key opportunity to build bridges with families and align stakeholders to a lofty goal.

19. Recommendation 1 • Recommendation • Develop a method to survey residents and families more frequently than NRC Picker process (every 18-months) • Enhance proactive and two-way communications with residents and families. • What we’re doing • Establish the Office of the Resident & Family Experience. • Initiate focused surveys midway through NRC Picker Cycle. • Introduce a Veterans Centre Volunteer Ambassador Program.

20. Recommendation 2 • Recommendation • Implement enhanced protocols for family centeredness; particularly during transitions. • Enhanced family education about dementia. • Lessen the amount of resident moves and transfers • Evaluate impact of staffing changes • What we’re doing • Offer earlier and more frequent family conferences. • Increase educational forums for residents and families on requested topics (such as managing dementia) • Investigate ways to decrease resident moves. • Ongoing quality indicator monitoring to ensure appropriate allocation of resources.

21. Recommendation 3 • Recommendation • Further strengthen the visibility and presence, and approaches used by patient care managers across the Veterans Centre. • Managers to implement unit based mechanisms to engage residents and families, thus catching issues before they escalate. • What we’re doing • Establish an expected standard for Patient Care Managers and Advanced Practice Nurses regarding their presence and activities on the patient care units

22. Recommendation 4 • Recommendation • Extend respect agreements to all stakeholders, including residents and families. • Ongoing support system for patient care units and staff to address complex family dynamics and expectations. • What we’re doing • Plan unit meetings with families to review and revise the Respect Agreements. • Formalize a process for identification of and response to expectations regarding the delivery of care. • Develop a process for early identification and response to high needs families.

23. Recommendation 5 • Recommendation • Articulate and pursue a lofty goal for the program – a bigger purpose – one that can become the unifying force to engage all stakeholders including residents, families and staff. • What we’re doing • To be Canada’s leader in caring for war veterans, in partnership with their families.

24. The Veterans Centre“Advancing our legacy of caring . . . every moment, every day.”