A Quality Improvement Project CMHA Conference

2nd April, 2019

Presented by:Zahra Bolouk – Harm Reduction CoordinatorKimia Ghomeshi – Consultant, Research and Evaluation

Reducing Conflict Amongst Participants with Multiple Presenting Issues within a Low Barrier 24/7 Drop-in

• About Sistering• About CMHA E-QIP Project • Sistering’s E-QIP Process:

• Identifying problem and aim statement• Diagnostic tools• Change Ideas

• Discussion

Agenda

• A low-barrier, trauma-informedplace for all women

• Reaching the most marginalizedo Homelesso Complex mental health issues o Substance users and sex workerso Racialized populations

• Women-identified, non-binary, and gender expanisive peoples

About Sistering

• 24/7 Drop In o 3 Meals/Dayo Rest areao Laundry & Showerso Donations

• Harm reduction program • Case support workers• Medical clinic and counselling• Spun Studio• Peer employment program• Social and recreational activities• Advocacy

About Sistering

• Over 3200 participants have used Drop In• 80% of participants surveyed used Drop In• Over 50 participants overnight (avg), most

are living at Sistering• 400+ meals served daily

With increased homelessness and precarious housing in Toronto, the Drop In isovercapacity

24/7 Drop In

• Partnership between Addictions & Mental Health Ontario, Health Quality Ontario, and CMHA

• Promote and support quality improvement in the communitymental health and addictions sector.

• Workshops on quality improvement processes and tools• Coaching• Community of practice• Several participating organizations

About E-QIP project

Reducing participant-participant conflictin 24/7 Drop In

Sistering E-QIP Project

PART 1: PREPARING FOR QI

Sistering E-QIP Project

Identify the Problem

• Increased participant-to-participant altercations, primarily in the Drop In. Altercations include:o Physical violence o Harassment / verbal o Racism & discrimination

• Participants and staff are emotionally and physically impacted and feel unsafe –triggered, trauma

• Significant time and human resources to manage

• Since the Drop In extended its hours to 24/7, demographics have shifted and conflict perceived to increase.

PART 2: UNDERSTAND THE PROBLEM

Sistering E-QIP Project

Step 1. Understand the problem

• Analyze existing data on violent incidents • Determine times of greatest frequency • Understand nature of conflict – where, when, what

18%

13% 13%

6%

23%

28%

1am-5am 6am-9am 10am-12pm 1pm-3pm 4pm-8pm 9pm-12am

Time period of incidents

33%

28%

20%

14%

9%

5%

3% 3%1%

Dining room Outdoor infront of Drop In

Hallway byfront desk

Rest area Entrance -indoors

Other (pleasespecify)

Bathroom Upstairs Basement

Where did incident take place?

Step 2. Aim Statement

By December 31, 2019, Sistering will reduce physical violent incidents in the dining room that take place between 9pm-12am

by 10%.

Step 3. Root Causes of Violence

Diagnostic Tools:• Process Map• Fishbone• Needs assessment surveys• Pareto chart• 5 Whys

Process Map: Incident reporting

Fishbone diagram

Participants Physical Space

Policies Staff

Bullying and discrimination: racism, transphobia etc.

Lack of trusting relationships developed with each other

Fear of losing belongings Conflict over limited supplies:

phones, computers, chairs

Limited space: storage, sleeping, renovations

Lack of amenities/elements shown by research to reduce violence: natural light, bright colours, greenspace, etc.

Lack of clarity/consistency in policies and procedures to deal with incidents

Limited staff skills on de-escalation

Lack of mental health/social workers Inadequate time for self-care &

debriefing after violent incidents

Lack of staff/participant interaction & monitoring drop-in floor

Violent incidents at Sistering

5 Why’s exercise

• To dig deeper into root causes of conflict • Based on fishbone factors with greatest ‘votes’• Conducted with participants and staff• Conducted 2 rounds of 5 Whys

1. Based on general problem statement (why violence happening)2. Based on more specific problem statement (why physical, after 9pm, in dining room)

5 Why’s exercise

Participant Example: Why more conflict after 9pm in dining room?

Why? Bc women start attacking cleaners after 9 p.m.Why? Women are resistant to moving their stuff

Why? Women don’t like their space being invadedWhy: Lack of clarity on how to live in a shared space

Why: No consistency among staff

5 Why’s

Beware of: tendency for circular arguments, or lack of congruence

Example: Staff Response

Why? People who have mental health issues are triggering othersWhy: Because they are mad, and yelling

Why: Not enough space for everyone and the fact that they are living thereWhy: Staff lacking empathy

Why: Staff don’t have the same and right training

3 Root Causes of conflict

1. Lack of clarity and consistency in policies

2. Limited space

3. Lack of participant engagement and monitoring on

the Drop In floor

Part 3. Understanding Measurement Plan

Sistering E-QIP Project

Run Chart: # of violence incidents/mth

Considerations: • Consistency in

reporting• How to define conflict• Limit variations in

interpretations of data • Staff training required• How to monitor0

5

10

15

20

25

Oct Nov Dec Jan Feb March April May June July Aug Sept

Frequency of incidents (Oct '17 - Sept '18)

Part 4. Developing and Planning Solutions

WORK IN PROGRESS

Sistering E-QIP Project

• Hierarchy of Effectiveness• Idea Generation Tools • Driver Diagram• Impact/Effort Grid• Cost-benefit Grid

E-QIP Tools

Hierarchy of Effectiveness

Idea Generation

• Random Words • Mental Benchmarking • TRUZ

By December 2019 Sistering will reduce physical incidents in the dining room from 9pm-12am by 10%.

Clarity in safetyprocedures

Procedures to revaluate:

Define respite criteria

Length of respites

How to reintegrate participant coming back from respite

Repeat incidences

Violation of respite

Staff communications re:conflict

Enforcing AOAR principles

One Drop In staff on each shift to update next shift staff on incidents and respites, including representative from upstairs

Criteria for all staff emails/ develop codes

What behaviour is and is not acceptable, respite procedures , AOAR policy, and healthy relationships

Update all staff on new procedures and provide training

New staff receive specialized training

Develop safety protocols for each of these areas, through consultation with staff, participants and management

Consistency in safety procedures

# trained staff

# Town halls

Staff manual developed

Written procedures

Participant education on safety procedures

Consistency in staff practices

Consistency between upstairs

and Drop In a

Develop AOAR and safety procedures poster and mini-guides

Develop system around staff communications re: conflict and

respites (fast track emails, calls, etc)

Daily announcements in Drop In

Town Hall meetings weekly – share policies

Train peers to share new policies with participants

Conduct training AOAR and non-violent communication # participant

trainings

Communications plan

# peer trainings and # peer-led sessions

Posters posted all over building

Primary Drivers Secondary Drivers Change Ideas Process Measures

Aim and Big Dot

DRIVER DIAGRAM(DRAFT)

Next step: Impact Grid

Part 5. Measuring and Testing Ideas

Sistering E-QIP Project

Part 5. Measuring and Testing Ideas

Sistering E-QIP Project

What kind of engagement strategies could we considerin the Drop In to foster a more peaceful, non-violent

environment?

A. Individual engagement B. Group engagement

DISCUSSION

Zahra Bolouk, Harm reduction coordinatorzbolouk@sistering.org

Kimia Ghomeshi, MKG ConsultingResearch and evaluation consultant

Kimia.ghomeshi@gmail.com

Excellence through Quality ImprovementProject:

THANK YOU!

https://ontario.cmha.ca/provincial-programs/e-qip-excellence-through-quality-improvement-project