Examining Safety Within An Acute Mental Health Setting: Building On Lessons Learned

1. Examining Safety Within An Acute Mental Health Setting: Building On Lessons Learned 2nd Annual International Patient Safety Symposium Sonja Grbevski, PhD Director Mental Health Robert Moroz, MSW Mental Health Manager

2. Objectives • Definition- Safety & Mental Health • Program Overview • Identified Challenges • Safety & Mental Health • Program Changes • Future Direction

3. Definition • Canadian Patient Safety Dictionary (Davies, Hebert, & Hoffman, 2003) developed in response to an identified need for a common language of patient safety, recommends • “that patient safety be defined as the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient outcomes” • A Patient safety incident is defined as “ an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient, and has a more constrained meaning than the term incident which, when used in a general context, has a wider meaning as an event or circumstance which could have resulted, or did result, in harm to any person and/or a complaint, loss or damage (WHO, 2007, p.7)

4. What Does Patient Safety Mean for Acute Mental Health Services? Creating and ensuring safety within acute adult inpatient units presents a range of challenges: • Medication adverse events • Misdiagnosis • Slips and Falls • Violence & Aggression • Patient Risk for Injury • Staff Risk for Injury • Physical Environment • Risk Assessments-Suicide and Self Harm • Clinical Advancements

5. What Does Patient Safety Mean for Acute Mental Health Services?Continued • Creating and ensuring safety within acute adult inpatient units presents a range of challenges: continued • Absconding and Missing patients • Seclusion and Restraint • Other Areas for Consideration: • Privacy Violations • Infectious Disease • Human Resource • Mixed-sex environments, limited physical space, and the acuity of patients’ illnesses are just some of the difficulties

6. Program Overview Hotel Dieu Grace Hospital Mental Health services: • 68 Inpatient Acute Beds • Partial Hospital Program • Injection Clinic • Neuro-psychology • Psychiatric Assessment Nurse Team–ED • Community Crisis Program • Inpatient Psychiatric Liaison • Outpatient Urgent Assessment Clinics • Mental Health Hospitalists

7. Hotel Dieu Grace Hospital Mental Health Program- continued • HDGH Mental Health services is dedicated to providing services for all individuals in the Windsor-Essex County area in a safe and dignified manner. • The Mental Health program continues to identify opportunities for improvement: • Physical layout of units- Environmental Assessment • Safety practice • Clinical Practice enhancements & education- 5 year plan • Cohesive/Comprehensive Interdisciplinary Patient Care Model for Mental Health-Recovery focus • Improve Patient/Family Involvement with Patient Safety • Improve Work-life and job satisfaction • Fiscal Stability

8. Deliverables of Mental Health Services: • Evaluate admission criteria-manage increased volumes /divert patients to appropriate level of care • Decrease ER wait times (enhancement of the PATeam- psychiatric assessment nursing team) • Time for patient-staff interaction • Monitor length of stay • Patient safety & security • Strengthening partnerships within HDGH and the community • Model of care-defined and standardized • Charting process and plans of care

9. Safety Measures • Medication Errors • Falls • Critical Incidents • Suicide Risk Assessment • Elopement • Code White/AOB • Therapeutic Milieu • Environmental Risk Assessment Tool

10. Safety Measures • Establish model of care to ensure patient safety and measure treatment outcomes: • Seclusion and Restraints • Recovery Model and Approach to Treatment • Suicide Risk Assessment • Risk of Elopement Assessment • MH operational manual-revised September 2011 • Coordinate psychiatric practice with MH clinicians and community partners in providing team approach to mental health treatment: • Community partnerships: (transfer of care to community) • CMHA • Mental Health Connections • Maryvale • Crisis Program and ED • Windsor Police Services • Integrated MH Emergency Clinic (Urgent Response) • WRH ED

11. Safety Measures • Enhancing the security of the units • Access to unit • Enhanced security features on doors- alarm • Blinds • Over bed light fixtures • Weekly safety walk rounds • Daily safety rounds- • Elopement risk assessment • Falls • AOB (acting out behaviour) • Formal standardized clinical structure • Standardize & enhance practice between 3 N & 3 S • Enhanced utilization of RAI-MH Tool • Residential Assessment Instrument for Mental Health)

12. Program Development: Exploring The Last 5 years • PROGRAMME DEVELOPMENT: A3 Day • Value stream mapping was conducted in 2007, and considered the current and future state of the entire mental health stream. • From that mapping, completed 3 A3s focusing on: • Emergency Department/Inpatient flow, • Inpatient flow, and • Handoffs to outpatient areas. • (Development has also been reflective of MoHLTC, the LHIN and HDGH requirements) • Value stream mapping and A3s considered structural changes in three main areas: • ED/CCC/PANs • inpatient units • outpatient services.

13. PROGRAMME DEVELOPMENT: continued • PROGRAMME IMPROVEMENT • Overall • Updated roles and responsibilities for all mental health positions • Integrated Mental Health Services into HDGH’s admission process, in order to improve transparency in bed availability. • Developed document describing mental health flow from admission to discharge • Adapted SBAR communication tool to meet specific needs of Mental Health Services, and implemented tool to facilitate flow • Introduced Clinical Liaison position, which provides reliable and regular psychiatric services to medical/surgical inpatient areas

14. PROGRAMME DEVELOPMENT: continued • Emergency Department/Community Crisis Centre/Psychiatric Assessment Nurse • Introduced enhanced PAN coverage in Jan 2010 (24 hours- 7 days per week) • CCC enhanced staffing in ED after hours in order to meet demand (identified peek times) • Mobile Crisis Response implemented in 2006 • COAST services started in partnership with Windsor Police Services (currently under review)

15. PROGRAMME DEVELOPMENT: continued • ED/CCC/PANs • Developed protocol enabling PANs to facilitate pull system from ED to inpatient areas(reduction in LOS in ED) • Developed and distributed staff orientation guide for new employees • Local mental health services providers describe crisis services on after hours telephone messages

16. PROGRAMME DEVELOPMENT: continued • Inpatient Units • PICU (Psychiatric Intensive Care Unit) reduced in size to current 8 bed format in 2007. This balanced 3N and 3S, and so reduced bottlenecks. Also, it created more acute care beds to meet demand • PICU layout was modified in 2010 to facilitate improved patient care and safety • “Quiet Rooms” added to 3N and 3S to assist patients in skill development to reduce AOB (acting out behaviour)

17. PROGRAMME DEVELOPMENT: continued • Inpatient Units-continued • Implemented daily flow meetings, utilizing multidisciplinary team that includes community partners. • Allows for improved direction of flow and early identification of barriers to discharge • Unit security/accessibility has been extensively reviewed in May 2010, and Jan 2011. • Currently this has resulted in major revision in inpatient pass and smoking policies, and in more controlled access to inpatient units • Patient/family handbooks have been updated

18. PROGRAMME DEVELOPMENT: continued • Inpatient Units-continued • Inpatient group programming has been extensively revised, with a highlight being the development of improved module materials regarding patient education and coping • Inpatient staff has participated in three revisions to inpatient charting- ongoing • Safety and security rounds are regularly conducted, and lessons learned applied • Pass policies have been streamlined with pharmacy requirements in order to reduce costs

19. PROGRAMME DEVELOPMENT: continued • Outpatient Services • Former OT services restructured in 2007, largely to create a Partial Hospital Programme • The PHP is designed to be an active bridge in the patient’s journey from inpatient to community care, or to provide acute care for patient’s not requiring inpatient admission. • This support offers psychiatrists the opportunity to confidently discharge at the earliest opportunity, or to avoid unnecessary psychiatric admissions • In partnership with physicians developed a crisis clinic for patients requiring psychiatric care. This has facilitated the diversion of those appropriate patients away from ED

20. PROGRAMME DEVELOPMENT: continued • Outpatient Services-continued • Utilized HDGH e-mail system to establish timely referral process to outpatient services • time for referrals went from several weeks to next business day • Dedicated crisis worker assigned to PHP to support patients in crisis, and when appropriate to divert those patients from ED • PHP programming extensively revised to reflect new mandate • PHP resources improved to allow for access to supporting psychiatrist and a RN

21. PROGRAMME DEVELOPMENT: continued • Staff Education • Dimensions of Suicide. • Essential Skills for Health Care Professionals • Psychiatric Refresher Day • Borderline Personality Disorder • Long Acting Injectables • Mood Disorders • Threat- Ready – Violence Prevention

22. PROGRAMME DEVELOPMENT: continued • Community Partnerships • Developed working arrangement to have two CMHA (Canadian mental Health Association) workers based at HDGH to ensure appropriate handoffs during discharge (2006). • An additional CMHA worker was based at HDGH in 2010; this worker is dedicated to working with ED patients to ensure smooth transition to community care providers. • A CMHA manager was also based at HDGH in late 2010. In addition to other duties, this manager administers Community Treatment Orders (CTOs). • Maryvale (Child/Adolescent Services) • City Centre Heath Care • Alive Canada and Distress Centre of Windsor-Essex County

23. PROGRAMME DEVELOPMENT: continued • Mental Health Services Community Committee Participation • Human Services and Justice Coordination Committee • Difficult to Serve Committee - ACCESS • Elder Abuse Committee • Dual Diagnosis Committee • LHIN working groups as requested & subgroups

24. CURRENT MAJOR PROJECTS • Work continues to address improvements in handoffs in care for long acting injectables. • With the recent resolution of technical issues, videoconferencing services in support of psychiatric care at WRH ED will be available in a few weeks • Improved care planning utilizing the Resident Assessment Instrument – Mental Health (RAI-MH) is a departmental priority • Means of improving access to hand washing/sanitizing equipment are being investigated • Reviewing changes to physical layout of outpatient waiting area, in order to reduce chronic flow issues • Liaise with local Police Services regarding potential for further active partnerships in programme delivery • Visioning Exercise scheduled for November 15, 2011

25. Future Direction • Good morale among staff on inpatient psychiatric units is an important requirement for the maintenance of strong therapeutic alliances and positive patient experiences, and for the successful implementation of initiatives to improve care • Increase employee voice, design roles to maximize autonomy within clear and well-structured operational protocols, promoting greater staff-patient contact and improving responses to violence may contribute more to inpatient staff morale than formal support mechanisms • Start a Community Advisory Panel- November 2011 • Monitor and develop diversion plan for individuals that have more than 2 emergency department visit within a 30 day timeframe

26. Thank you • Contact Information Sonja Grbevski, PhD Director, Mental Health Services Hotel Dieu Grace Hospital Windsor, Ontario Sonja.grbevski@hdgh.org Robert Moroz, MSW Manager, Mental Health Hotel Dieu Grace Hospital Windsor, Ontario Robert.moroz@hdgh.org