Veterans Centre ReviewFebruary 20th, 2013

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.

Some brief backgroundBeds Contracted by VAC

Physical Support

Cognitive Support

Total

Level 2 Veterans

128 62 190

Level 3 Veterans

130 180 310

Total 258 242 500

Some brief backgroundDemographics

Annual Admissions 175-200

Gender 94% Men, 6% Women

Average Age 90 Yr Men, 91 Yr Women

Occupancy 475 or 95% (excludes Veterans in SB Acute Care)

Current Wait List to January 18, 2013

2 = Level 3 Cognitive Support28 17= Level 2 Cognitive Support 9 = Level 2 Physical Support

Transfers within the VC (annualized)

2011-12 = 532012-13 = 95

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

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.

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

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)

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.

Quality Indicators

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50.00% Sunnybrook QIs Exceed Provincial Performance

Sunnybrook Provincial

Improved or remained independent in mid-loss ADL - ADL05 ADL05 Has a stage 2 to 4 pressure ulcer - PRU05 PRU05Improved or remained independent in early-loss ADL - ADL06 ADL06 Worsened stage 2 to 4 pressure ulcer - PRU06 PRU06Improved late-loss ADL - ADL1A ADL1A Has a new stage 2 to 4 pressure ulcer - PRU09 PRU09Worsened or remained dependent in early-loss ADL - ADL6A ADL6A Daily physical restraints - RES01 RES01Improved locomotion - MOB1A MOB1A Worsened/unchanged respiratory condition - RSPX2 RSPX2Worsened cognitive ability - COG01 COG01 Has urinary tract infection - CNT04 CNT04Worsened communication ability - COM01 COM01 Improved bowel continence - CNT2A CNT2AWorsened mood from symptoms of depression - MOD4A MOD4A Improved bladder continence - CNT3A CNT3ATaken antipsychotics without a diagnosis of psychosis - DRG01 DRG01 Has a feeding tube - NUT01 NUT01Has fallen - FAL02 FAL02 Has pain - PAI0X PAI0XHas one or more infections - INF0X INF0X Has had weight loss - WGT01 WGT01

Quality Indicators

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Sunnybrook Provincial

Worsened late-loss ADL - ADL01 ADL01 Improved communication ability - COM1A COM1AWorsened or remained dependent in mid-loss ADL- ADL5A ADL5A Has symptoms of delirium - DELOX DELOXWorsened ADL - ADLD7 ADLD7 Has an indwelling catheter - CAT02 CAT02Worsened locomotion - MOB01 MOB01 Worsened bowel continence - CNT02 CNT02Worsened behavioural symptoms - BEHD4 BEHD4 Worsened bladder continence - CNT03 CNT03Improved behavioral symptoms - BEHI4 BEHI4 Worsened pain - PAN01 PAN01Improved cognitive ability - COG1A COG1A

Provincial Comparison

A SBK-VC

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Below Provincial Average

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Q2 '12/'13 Facility Performance on all 35 CIHI Quality Indicators Compared to the Provincial Average for all Large, Urban, Ontario Hospital-Based (CCC) Facilities

*Sunnybrook is tied for second among its provincial comparators

Family Satisfaction Overall Ratings - 2011

Resident Satisfaction Overall Ratings 2011

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.

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.

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

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.

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.

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.

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

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.

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.

The Veterans Centre

“Advancing our legacy of caring . . . every moment,

every day.”