Park Place Seniors Living

1. Park Place Seniors Living Ethics in a Client Centered Model A Successful Journey Louise Johnson RN., B.H.Admin

2. Defining Ethics For example, limiting the freedom of another human being would be considered unethical in most situations. But if the person is a young child; or a senior with Alzheimer’s, it would be unethical to not limit that person’s movements, given the risk an unsecured environment poses to his or her safety. “We are discussing no small matter but how we ought to live.” Even among the experts, there is no universally accepted definition of “ethics” or ethical behaviour. This is because ethics are culture and situation-specific: what is seen as ethical in one situation or culture may not be ethical in another. - Socrates, from Plato's Republic, Book 1:352d

3. Ethics are in the eye of the Beholder What is defined as ethical choices may be influenced by: • Acceptance of what is “good” and what is “right” within the broader culture; • Conventions within a particular professional discipline; • Personal belief systems; • The desired outcome of any action/decision; and • The situation to which those conventions and belief systems are to be applied. Asking individuals or an organizations to make choices based on ethics is much more complex and requires a higher level of thought than simply providing checklists, rules, or guidelines. This presentation outlines how Park Place Seniors Living instituted client-centred ethical decision making throughout the company’s 11 complex care homes.

4. Flexible Decision Making Ethics-based decision making can be attuned to achieving desired end goals, instead of just following pre-determined rules. It provides solutions in situations for which there may be no established rules. At Park Place, the following shared values were identified as the end goals of our interactions with residents, families and each other. In all our interactions, we want to maintain: Dignity, Respect, Trust and Empathy Integrating an ethical choice process into decision making gives care givers the flexibility to respond better to individual situations and needs. Maintaining dignity, respect, trust and empathy across the generations. Establishing shared goals is a precursor for ethical decision-making. noun (plural)/ˈeTHiks/ethics, plural 1. Moral principles that govern a person's or group's behaviour (i.e. Judeo-Christian ethics) 2. The moral correctness of specified conduct (i.e. the ethics of euthanasia) 3. The branch of knowledge that deals with moral principles - Dictionary.com

5. Steps towards Ethical Decision Making • Creating an Ethical Environment • Establishing a value-driven culture • Clearly defining desired values • Ethical decision-making framework • Teaching the decision-making process • Developing new resources • Integrating into day-to-day operation • Ethical decision-making in action • Measuring Success • Lessons Learned • Future Direction • About Park Place Seniors Living

6. Step 1: Creating an Ethical Environment Ethical choice is dependent on the culture and environment in which the choice is made. Therefore, the first requirement for success in making Ethical Choices is to develop the appropriate Ethical Environment. • Park Place has created the appropriate Ethical Environment by implementing: • A values based organization with a true commitment to enriching quality of life for • residents and quality of work life for staff. • Clearly defined and cohesive Mission, Vision and Values statements which • support ethical behaviours and goals. • Integration of the company’s Mission, Vision and Values in the development of • company policies and operational choices. • Educational and informational initiatives which repeatedly reiterate the core • values of the company. Park Place has established a values-driven culture of care.

7. Step 1: Creating an Ethical Environment Park Place Mission THE MISSION All photos are Park Place Seniors Living residents or staff – used with permission. PARK PLACE SENIORS LIVING EXISTS TO PROVIDE ENRICHED LIFE EXPERIENCES TO SENIORS BY PURSUING STRATEGIES FOR INNOVATION, CREATIVITY AND LONG-TERM GROWTH IN A MANNER THAT IS SUSTAINABLE AND SECURES FAIR RETURNS FOR INVESTORS. The Park Place mission statement underlies the choices made by the company and balances the responsibility of providing exemplary care with the responsibility to be financially prudent. Financial stability allows the company to hire and retain the best people, maintain buildings, and offer enhanced programs.

8. Step 1: Creating an Ethical Environment VISION & VALUES • VISION: Guiding Principles • Treat others with dignity, • respect, trust and empathy • Involve stakeholders • Provide appropriate services • Deliver services that • meet/exceed standards • Build capacity with • supportive frameworks • Honour commitments, • agreements and words • Provide high quality • and exceptional value • Invest in growth • and sustainability • Minimize financial risk • VALUES • Strive to serve our clients with excellence and build strong & • mutually beneficial partnerships • Attract, hire, retain, develop and deserve the best people • at all levels • Develop facilities and services that have high quality • and exceptional value • Be good stewards of the company’s physical, financial • and human resources • Treat all people with respect, in a manner we would • like to be treated • Demand the best of ourselves and from others • Tell the truth and be trustworthy • Be the difference we wish to see in the industry • Make sound financial decisions that support our mission; and • Honour our words, agreements and promises. The above are Park Place’s Vision and Values and are provided only as examples. Use your organization’s accepted values as the basis of an ethical decision-making process.

9. Step 1: Creating an Ethical Environment BRINGING IT HOME • At the individual site level, the staff at each home work together to establish site goals • which are consistent with the company Mission, Vision, Values and Strategic Directions. • These Strategic Directions include: • Enriching Lives of Seniors resident in the home and beyond; • Embracing a Culture of Learning; • Maintaining a Culture of Safety; • Engaging in Ethical Decision Making; • Establishing an Effective Communication Framework; • Ensuring Human Resources Allocations support • Work-Life balance; and • Adhering to the sound financial processes which • support the financial viability of the care home • and the company. Enriching the lives of seniors, as shown by this resident’s smile. • Park Place clearly defines desired values as a first step • in making ethical decisions.

10. Step 2: Ethical decision-making framework ESTABLISHING GOALS The key measure of Ethical decision making is not whether a rule is upheld but whether a goal – such as enriching a resident’s life – is achieved. At Park Place, the goals are always clearly articulated, visible and front-of-mind for all staff. The Park Place Resident Bill of Rights is clearly posted in all care homes. The Bill-of-Rights gives staff an ever-present reminder of resident rights, which must be respected and honoured. • Park Place core values include treating others with: • Dignity; • Respect; • Trust; and • Empathy • These values are stressed throughout the company. • Education on upholding these values is provided • to staff, service providers, clients and families. Dignity must be maintained so all residents can continue to enjoy their lives and relationships. Goals in care are front-and-centre every day in every care home.

11. Step 2: Ethical decision-making framework THE CARE MODEL • The Care Model establishes the operational • framework under which the Mission, Vision • and Values are transformed into action. Throughout the company, ethical decisions are made within the context of the Park Place Residential Care Model. Illustrated at right in a visual, poster format, the care model establishes the following five core commitments to: • An Enriching Culture (for seniors & staff) • Follow Standards • (Maintain) Holistic Focus • Measure Performance; and • Continuous Improvement

12. These commitments are honoured when developing the standards and policies which govern the following seven operational areas: Philosophy Staffing Environment Policies & Standards Programs Education Quality Improvement By developing this values-based operational framework, Park Place Seniors Living created a work and management environment conducive to ethical decision making. Step 2: Defining Ethical decision-making VALUE-BASED OPERATIONS A contented resident at Hilton Villa in Surrey, B.C.

13. Step 2: Ethical decision-making framework A VOICE AND A CHOICE • Additional core documents which establish a • framework for ethical decision-making are known as “Resident’s Day.” • Each resident of a Park Place Seniors Living home has a Resident’s Day document. These Resident Day documents are based on interviews with incoming residents – and/or family & friends – to determine how the resident wishes to live in the home. • The resulting Resident Day document ensures each resident will be cared for as an individual with a right to a voice and a choice in his or her care. A sample is shown on the following page. Residents have a voice and a choice in their daily care. Resident’s Day was identified as a leading practice by Accreditation Canada in the 2011 Park Place Seniors’ Living review.

14. RESIDENT’S DAY: A VOICE AND A CHOICE If an ethical decision affects one resident, the decision made must fall within the provisions of That individual’s Resident Day document. If an ethical decision affects more than one resident – or the operation of the entire care home – then the combined Resident’s Day documents of all affected residents must be considered. Resident’s Day documents are amended as required to address resident’s changing needs.

15. Step 3: Teaching the decision-making process DEVELOPING NEW RESOURCES Integration of Ethics and Ethical Decision Making across all Park Place operations began in 2006. The new initiative included development of materials, policies, procedures and training to turn ethics into day-to-day reality for everyone. By 2007, the company had a completed Ethics Resource Manual which included: • Code of Ethics • Terms of Reference • Consent Policy and Procedure • Ethical Dilemmas • Ethics Framework • Education and Research Function • Disclosure • Case Studies • Articles relating to Ethics issues

16. Step 3: Teaching the decision-making process DEVELOPING NEW RESOURCES The 2007 Ethics Resource Manual is available in each neighbourhood within every Park Place care home, so staff have an immediate reference should an ethical issue arise. Park Place developed an easy-to-follow Ethical and Clinical Decision-Making Framework Template, which is attached to the agenda of each Professional Practice Council. This encourages immediate discussion and review of ethical issues as they occur. The formal ethics framework guides staff and management through a step-by-step ethical decision-making process. The framework also addresses issues of consent, disclosure and research. Ethical frameworks protect frail elderly residents.

17. Step 3: Teaching the decision-making process INTEGRATING INTO DAY-TO-DAY OPERATIONS The following practices integrate ethical choice into day-to-day work. • Ethics orientation and staff development sessions provide staff with the • knowledge and skills required to guide discussions when making decisions • on ethical issues; • All interdisciplinary Care Conferences include a review of care from an ethical • perspective. All members of the care team meet on a regular basis to discuss the • care provided to each resident. Ethical choices made for an individual are measured • against that resident’s wishes, as identified in the Resident’s Day. • Ethical issues are also discussed at Resident and Family Councils. These • councils promote the collective interests of all residents and provide an avenue for • consultation regarding any changes to policies and procedures.

18. Step 3: Teaching the decision-making process INTEGRATING INTO DAY-TO-DAY OPERATIONS A user friendly brochure about ethics and ethical decision-making is widely available for use by staff, volunteers, residents and families. Copies of the brochure are free. A brochure is freely available to help residents and family understand ethical issues. The ethics committees uses case-based learning – with identifying details removed from examples - to transform ethical dilemmas encountered at Park Place into instructional materials.

19. Step 4: Ethical Decision-Making in action Sample of the step-by-step Ethical & Clinical Decision Making Framework

20. Step 4: Ethical Decision-Making in action SAMPLE DECISION – the issue Resident has a diagnosis of Parkinson’s with Speech Language Therapist repeated assessments, the latest stating “pureed to minced textures as tolerated, thin fluids by straw (small sips). Sit fully upright. Whole meds, as tolerated.” Resident wishes to eat totally minced or cut-up versus puree. Professional assessment states puree and minced as tolerated, therefore not agreeing with resident wishes of minced or cut-up only. The conflict is between two important values: safety vs. quality of life. Pureed is the safest option but the resident has expressed a clear desire for minced or cut-up food. The son has signed a release to allow a one week trial of minced, with staff monitoring. ISSUE: The resident wishes to eat only minced or cut-up food but the professional assessment includes pureed food. Which takes precedence: the resident’s wishes or the professional health advice?

21. Step 4: Ethical Decision-Making in action SAMPLE DECISION – the debate For staff, the conflict is between an obligation to do what is safest versus increasing the resident’s quality of life. Resident eats in room alone without supervision and refuses to come to dining room, making monitoring more difficult. The resident also refuses to move to a table closer to Nurses to allow closer monitoring. The son wants the resident to have the quality-of-life choice to eat what she wants and has signed a Managed Risk Authorization for a one-week trial of minced or cut-up food. Possible responses are: Do nothing? Change residents’ behaviour – but how? Consider a policy change Agreement and understanding of risks INVOLVED: Those affected by this decision include the Resident, Son/Family, Dietician, Nurses, Care Aides, Care Coordinator, Physician, Speech/Pathology, Administrator, Dietary Supervisor

22. Step 4: Ethical Decision-Making in action SAMPLE DECISION – options Under Resident’s Day and the resident-centered care model, “doing nothing” is not a viable choice since it ignores the resident’s wishes. Give cut-up to minced for one week – this honours the resident’s wishes and permits a trial period to assess the outcome. Check the legal authority of son to sign Managed Risk Agreement to ensure the care home is protected. Consider Companion Care Assists for meals GOAL: Honour the wishes of the resident/son within medically safe parameters. Ensure staff are comfortable with the outcome and revised care plan. Ensure all stakeholders have an opportunity to discuss the plan.

23. Step 4: Ethical Decision-Making in action SAMPLE DECISION – The Outcome The Resident is considered to be competent to make her own decisions so the goal is to support Resident’s wishes and to achieve a balance of those wishes with the professional recommendations. Staff will monitor at meals which must be in the dining room. The Resident has some loss of freedom but staff are protected from having to closely monitor in Resident’s room. Beverages may be offered in room with a straw i.e. milkshakes and smoothies. Behaviour Mapping to commence regarding Resident’s feelings of satisfaction and tolerance of the diet. The Resident’s swallowing abilities often fluctuate day to day which will necessitate frequent revisiting of a diet that can be tolerated. The son will be contacted to review/modify the Managed Risk Agreement. DOCUMENT OUTCOME: To ensure consistent action, the revised plan will be documented in the Resident’s Day, Progress Notes, Care Plans, and Managed Risk Agreement.

24. Step 5: Measuring Success EXTERNAL MEASURES Park Place measures both the company’s ability to create an ethical environment and the individual ethical decisions made within that environment. • To evaluate the company’s Ethical Environment, Park Place measures itself against Accreditation Canada standards. These established standards are used across Canada to measure ethics within the health care field. • Internally, Park Place maintains an extensive program of Quality Improvement Measures, which evaluate the provision of care throughout the company against recognized standards of practice. Quarterly reporting helps the company flag and investigate any variances in care outcomes.

25. Step 5: Measuring Success INTERNAL MEASURES Ethical issues are a standard agenda item for Park Place staff meetings. This ensures timely review and assessment of any issues which occur. Continual on-site monitoring of ethical issues and decisions proves the program works.

26. Step 5: Measuring Success ANNUAL REVIEWS • Annual Performance/Accomplishment Reviews include consideration of • ethical issues. Included is discussion of ethical dilemmas the staff may have • faced and resolved during the previous year AND/OR discussion of ethical • issues which may arise. Questions asked include: • Have you faced an ethical dilemma • in the past year related to health care? • If yes, please share highlights of the • dilemma and how it was resolved. • If no, state what could be an ethical • dilemma related to health care and • your role in resolving it. Better care is an outcome of including ethics in annual reviews.

27. Step 5: Measuring Success EXTERNAL PRAISE • In June 2011 Park Place Seniors Living completed a comprehensive • Accreditation Canada review at 10 care homes. The review included a close look by • the six surveyors at how successfully Park Place handled Ethics, which is a priority • practice for Accreditation Canada. • The Accreditation review assessed Park Place’s: • Ethics • Ethics framework • Ethics education • Effectiveness in resolving ethical dilemmas • In its preliminary report, the survey team • noted, “There is a very strong ethics • framework. Staff know what ethics issues are.” Accreditation Canada survey team with (far left) Park Place Owner and President Al Jina and (far right) Accreditation Coordinator Louise Johnson.

28. Lessons Learned In order to champion ethics, Park Place educated itself by researching various ethics frameworks and developing an easy-to-read ethics manual for staff. This manual includes a decision-making framework and terms that “make sense” to frontline staff. This resource guide includes a seven step decision-making model with flowchart and related policies. It is a very practical guide for a long term care environment and is useful in helping staff understand the role that they play in making ethical decisions, whether on administrative or clinical issues. The framework and seven step decision-making process have been used effectively at all PPSL Homes. Park Place Seniors Living has also integrated ethical issues into operations by including Ethics as a standing agenda items on departmental and quality meetings held throughout the year. Attaching the ethics reporting template to each meeting agenda encourages staff to Identify ethical issues and record decisions, experiences, and outcomes. This builds a larger company-wide pool of experience in handling ethical issues.

29. Lessons Learned The combination of print material, readily available manuals, and inclusion of Ethics as a standard topic in staff meetings has resulted in clear communication to staff on how to approach ethical decisions. Management at each home have been able to use the tools to build capacity for ethical decision making in their specific home. By developing the ethics process within the framework of the company’s Resident’s Day and Care Model, the resulting decisions reflect Park Place’s core values and focus on resident-centered care. Residents and/or their family members, friends or advocates are involved whenever there is an ethical issue which affects that resident. Their input is invited. Throughout, Park Place Seniors Living strives to ensure that every resident’s wishes are honored. The best advocates when resolving ethical dilemmas are often the resident, or a friend or family member who speaks on behalf of the resident.

30. Future Direction • Continue to develop an inventory of case • studies, administrative and clinical, as a • resource for all Homes. • Continue to review ethical issues monthly • at Practice Council Meetings • and Leader Meetings. • Include Ethics as an agenda item at • quarterly Home Quality Meetings in • each Park Place Care Home • Include Ethics within the program for the • twice-yearly Leaders Forum held with all • care home leaders and executive staff. Moving forward with enthusiasm!

31. About Park Place Seniors Living Park Place Seniors Living is family owned company, founded, owned and operated by Al & Jenny Jina. Al is a lawyer by profession and Jenny is a nurse who specializes in geriatrics and adult education. The company was founded in 1993 with one small, private Care Home in Nelson B.C. Since then the company has grown to include 15 sites, offering a continuum of care from independent living to assisted living to complex, continuing and dementia care. All sites are owned and operated by the company from a small head office in Vancouver, B.C. Owner Al Jina (left) with a Park Place resident and her husband. Park Place Seniors Living works in partnership with six regional health authorities in Alberta and British Columbia. Enriching the Lives of Seniors

32. Thank You – Questions? We are discussing no small matter but how we ought to live. - Socrates