Bruyère Reports

Using Concept Mapping to Build Coordinated, Person-centered, High-quality Care at Saint-Vincent Hospital: Summary of Evidence 

 

Report Authors:  Beverley Shea, Sandra Schmidt, Vivian Welch, Jason Nickerson

 

Executive Summary

Saint-Vincent Hospital is a 336-bed Complex Continuing Care* (CCC) hospital affiliated with Bruyère Continuing Care. The patient population at Saint-Vincent Hospital (SVH) has changed with medically complex patients admitted for short-term sub-acute care instead of long-term care. To ensure that the care it provides continues to be commensurate with the needs of its patients, the ‘Transforming the Patient Care Experience’ project was launched in partnership with the Bruyère Research Institute (BRI), to understand the experience of care at the bedside and during care transitions. Six stakeholder groups took part in concept-mapping exercises to identify and prioritize themes. The main objective of the concept-mapping sessions was to identify local person-focused indicators to help with the development of an instrument that would measure the patient and family experience at SVH. 

 

Based on the concept mapping sessions, 12 themes were identified: Communication and Understanding; Safety; Equipment and Infrastructure; Funding; Person-centered Care; Coordinated Care; Accountability; Care at Transitions; Clinical Outcomes; Culture of Learning; Hiring and Management; Organizational Support.

 

The following recommendations were also made:

 

• SVH should develop and implement an educational safety program for all staff, volunteers, patients,
• and families to ensure high-quality care. This stems from SVHs’ organizational commitment to provide kind and safe care to all patients.
• SVH should implement an effective equipment-maintenance program to prevent breakdowns and to extend the lifespan of expensive equipment.
• Funding should be patient-based, and should relate directly to patient needs and acuity to provide kind and safe care.
• SVH should focus on establishing a welcoming, healthy, safe, and stimulating environment for patients and their families.
• SVH should explore opportunities to establish partnerships both within and between clinical disciplines. Through coordinated care, SVH could eliminate gaps in patients’ medical, social, developmental, behavioural, and educational support systems. SVH should develop and consolidate procedures and checklists to address the lack of standardization and consistency of care at transitions. Discussion of this issue should continue, as there were a number of potential solutions suggested by participants that warrant further exploration.
• SVH should develop a local retention strategy to improve its retention of high-performing staff at all levels.

The full report is available for download.

  

Table of contents

• Key Messages
• Theme 1: Communication and Understanding
• Theme 2: Safety
• Theme 3: Equipment and Infrastructure
• Theme 4: Funding
• Theme 5: Person-Centred Care
• Theme 6: Coordinated Care
• Theme 7: Accountability
• Theme 8: Care at Transitions
• Theme 9: Clinical Outcomes
• Theme 10: Culture and Learning 
• Theme 11: Hiring and Management
• Theme 12: Organizational Support

Key messages

The patient population at Saint-Vincent Hospital (SVH) has changed with medically complex patients admitted for short-term sub-acute care instead of longterm care. To ensure that the care it provides continues to be commensurate with the needs of its patients, the ‘Transforming the Patient Care Experience’ project was launched in partnership with the Bruyère Research Institute (BRI), to understand the experience of care at the bedside and during care transitions. Six stakeholder groups took part in concept-mapping exercises to identify and prioritize themes. The main objective of the concept-mapping sessions was to identify local person-focused indicators to help with the development of an instrument that would measure the patient and family experience at SVH.

 

Based on the concept mapping sessions, 12 themes were identified: Communication and Understanding; Safety; Equipment and Infrastructure; Funding; Person-centred Care; Coordinated Care; Accountability; Care at Transitions; Clinical Outcomes; Culture of Learning; Hiring and Management; Organizational Support.

 

 

Theme 1: Communication and Understanding (Direction toward Sub-Acute Care)

 

Participant priorities: 

The following priorities were listed by all stakeholder groups unless otherwise specified: 

• Understand the complex care needs of SVH patients.
• Clarify SVH’s role in the context of a large-scale healthcare system.
• Provide an adequate description of the types of services SVH provides when all communication materials are distributed both internally and externally.
• Ensure engagement and transparency with patients, families, and caregivers pertaining to challenges and potential for improvement in the communication of care activities. 
• Improve two-way communication at all organizational levels, from patients and families through to senior leadership (always smiling and displaying a positive attitude). 
• Nurses: manage care for an increasingly complex patient population with multiple health problems. 
• Allied health professionals: better understand and convey the allied health professionals’ collaborative role in the provision of SVH’s care.

Recommendations:

• Capitalize on partnerships with BRI for research on complex continuing care patient populations. Provide staffing levels that can accommodate patient complexity. 
• Provide educational opportunities to staff that address the increasingly complex needs of patients. 
• Change SVH’s identity and mission to those of a sub-acute hospital. 
• Seek more consistency between the branding of SVH and the branding of Élisabeth Bruyère Hospital (EBH). 
• Develop a plan to improve communication at SVH that incorporates patient and family input. Implement the plan and measure its success over a period of two years. 
• Provide adequate communication materials to facilitate explaining each staff member’s role. 

• The Patient and Family Advisory Committee will be initiated in May 2015. 
• Partnership with BRI continues through the Canadian Foundation for Healthcare Improvement’s (CFHI) ‘Partnering with Patients and Families for Healthcare Improvement at Transitions’ program. 
• Changes have been implemented in Decision Support and the admissions process for SVH with the addition of a Bruyère admission coordinator at the Ottawa Hospital, Bruyère’s largest patient referral source. 
• To meet the increased complexity of care required by a sub-acute patient population, the care provider skill mix has been changed to consist predominately of registered nurses. 
• Specialized unit-based orientation and educational modules have been developed for nurses. 
• The Nursing Professional Practice Team has been reorganized to include nursing practice leaders and practical support nurses 

SVH needs to adapt to an increasingly acute patient population. It must shift its focus to providing sub-acute care and maintain clarity and consistency when branding itself. All stakeholders emphasized that this change in direction requires a unified transformation and excellent communication at all organizational levels. All staff and patients should know where SVH is headed and what its goals are.

 

 

Theme 2: Safety

 

Participant Priorities:

• Patients, allied health: answering call bells within 10 -15 minute.s
• Patients: ensuring rooms are clean.
• Families: caring for patients during staff breaks.
• Families: washing hands regularly.
• Nurses: ensuring nursing environments are safe, particularly against falls.
• Nurses: caring for wounds quickly and safely.

Recommendations:

• Take advantage of Bruyère’s Best Evidence Review Group (BERG) to establish an evidence-based program that addresses safety and quality of care.
• Provide Situational Awareness training for staff and volunteers.

Progress to date:

• Call bells are now managed by clinical managers to ensure all team members answer patient call bells in a reasonable time frame. We have implemented unit-based quality team initiatives directed at improving response time to call bells and improving patient and family satisfaction and experience.Hourly rounding (during which nurses check on each patient to ensure their comfort and safety) has been implemented.
• An inventory of all medical equipment has been completed. All additional supplies have been returned to a central location.
• To increase nursing time at the bedside, patient cupboards have been redesigned to hold patient-specific supplies.
• A preventative equipment maintenance program is now in place. The feasibility of using RFID technologies for locating and maintaining equipment is being explored.
• Nursing staff are now able to provide point-of-care documentation with the introduction of electronic patients’ records and workstations on wheels.

Summary:

Higher-acuity patients generally require more expensive and complicated equipment. As the complexity of SVH’s patient population increases, so too will the demand for equipment and maintenance. Effective equipment maintenance programs should be implemented to prevent equipment breakdown and to extend the life cycle of expensive equipment.

 

 

Theme 3: Equipment and Infrastructure

 

Participant priorities: 

• Patients: fixing equipment regularly to prevent breakdown rather than waiting until the equipment is dysfunctional.
• Allied health professionals: ensuring allied health professionals have the supplies they need.
• Physicians: devoting more resources to purchasing adequate equipment for all patients.

Recommendations;

• Relocate equipment so that it is easily accessible for preventative maintenance. Equipment in nursing stations, medication rooms, family visiting rooms, treatment rooms, supply rooms, staff lounges, and patient dining areas is particularly important.
• Ensure each unit has the equipment it needs to care for a patient population with increasingly complex health needs.
• Develop and share an inventory of medical equipment available across facilities to increase accessibility.
• Keep central areas tidy and clear of equipment. This requires that all medical equipment be returned to a central area when it is not in use.
• Develop and implement Equipment Maintenance Programs for all equipment belonging to long-stay patients.
• Clear guidelines for the cleaning and repair of medical equipment that SVH is responsible for.

Progress to date:

• An inventory of all medical equipment has been completed. All additional supplies have been returned to a central location.
• To increase nursing time at the bedside, patient cupboards have been redesigned to hold patient-specific supplies.
• A preventative equipment maintenance program is now in place. The feasibility of using RFID technologies for locating and maintaining equipment is being explored.
• Nursing staff are now able to provide point-of-care documentation with the introduction of electronic patients’ records and workstations on wheels.

Summary:

Higher-acuity patients generally require more expensive and complicated equipment. As the complexity of SVH’s patient population increases, so too will the demand for equipment and maintenance. Effective equipment maintenance programs should be implemented to prevent equipment breakdown and to extend the life cycle of expensive equipment.

 

 

Theme 4: Funding

 

Participant priorities:

• The following priorities were listed by all stakeholder groups unless otherwise specified:
• Allocating funding to units based on the type and number of patients they care for.
• Funding for forming research partnerships.
• Physicians: allocating funding to improve SVH’s clinical environment (For example, hiring more MDs andphysicians` assistants).

• Pursue more internal and external partnerships with BRI; SVH represents an untapped research resource.
• Allocate funding in proportion to complexity of patient needs and the resources each unit requires.

Progress to date:

• To meet the care needs of an increasingly complex patient population, the Director of CCC now regularly performs a review of the skill mix pattern on each unit.
• The BERG has been established in partnership with BRI to fund 10 rapid reviews designed to improve the care and services provided at Bruyère. 

 

Theme 5: Person-Centred Care (Including Improved Communications) 

Patient Priorities:

• Patients: involving patients in calendar planning and providing desirable food options to patients.
• Families, nurses, managers, physicians: taking a person-centred approach to care; explaining rationale to patients and asking patients what they need.

Recommendations:

• Consider adopting a model of care like the one provided by the International Alliance for Patients’ Organizations (IAPO).1
• Receive and incorporate patient and family input when developing relevant programs and policies. 

Implement the following changes:

• Require that staff regularly ask patients what their priorities are.
• Institute effective use of whiteboards at bedsides.
• Introduce hourly to two-hourly comfort rounds for patients.
• Require that staff perform regular safety scans of their environments.
• Provide more onsite computers for patient and family use.
• Make SVH more welcoming by making use of open spaces (i.e. learning resources).
• Provide long-stay patients with alternative activities.
• Reintroduce food menus with more desirable, healthy food selections.
• Extend the cafeteria’s hours of operation.

Progress to date:

• The Three Priorities for Care initiative has been established, in which patients and families are asked to identify three specific care activities they would like to be performed each time they are visited by nursing staff, volunteers, and other hospital staff. Posters promoting the initiative have been made and displayed in each patient room.
• Customized “Care Boards” have been installed to meet the specific needs of each patient and family.
• An hourly rounding procedure (to assess positioning; pain; personal items; and toileting) with safety scans has been implemented.
• An additional computer has been added in the “Path to Home Resource Lounge” in the Atrium.
• Cafeteria hours have been extended by one hour.
• A volunteer-friendly visiting program has been established to improve patient quality of life.

Summary:

All focus groups emphasized the importance of patient-focused care. SVH should seek and incorporate patient and family input when developing programs and policies. SVH should focus on establishing a welcoming, enjoyable, and stimulating environment for patients and families.

 

Theme 6: Coordinated Care (Inter– and Intra-professional Collaboration)

Participant Priorities:

• Families, nurses: observe an apparent lack of team cooperation with some nurses and staff.
• Patients, families: eliminating “not-my-patient” mentalities.
• Nurses: provide more education on workplace teamwork.
• Nurses: developing unit-based mobile teams; assign casual staff to floors; and single managers in order to decentralize the casual pool.
• Nurses, allied health, managers: establish inter-professional collaborative teams and partnerships.

Recommendations:

• Review the processes for inter-professional collaboration.
• Provide more education to staff on ways to improve inter-professional collaboration.
• Explore opportunities for ongoing inter-professional collaboration as roles change to meet the needs of an evolving patient population. 
• Consider establishing joint appointment partnerships with universities for allied health, nursing, and physicians.

Progress to date:

• Collaborative inter-professional unit quality teams have been established to co-design, plan, implement, and evaluate quality improvement initiatives in each unit. This has resulted in a reduction of waste and greater efficiency of staff. For example,
• On one floor at SVH a successful quality improvement project now mandates hourly rounding. This has resulted in greater patient satisfaction and an 18% decrease in bell usage.
• Patients first working group established to develop a patient oriented discharge package, a web-based frequently asked questions and take-home discharge place mat.

Summary:

All of the stakeholder groups emphasized the importance of both intra- and inter-professional unity and collaboration. SVH should explore opportunities to establish partnerships both within and between clinical disciplines. Coordinated care should eliminate potential gaps within patients’ medical, social, developmental, behavioural, and educational support needs 

 

 

Theme 7: Accountability (Respect and Empathy) 

 

Participant priorities:

• All groups: give and receive respect.
• Patients, families, nurses and allied health professionals: ensure staff is accountable for their responsibilities and decisions.
• Patients, families, nurses and allied health professionals: inform staff of problems as they arise.
• Patients, families, physicians, managers and directors: share knowledge; provide patients and families with contacts upon admission.
• Patients: ensure nurses, clinicians, and other staff  speaks in the language of the patient or provide adequate translation services.
• Nurses: limit the degree to which the GRASP system increases nursing workload.
• Nurses: report more efficiently; nurses spend a great deal of time on reporting and would like to improve efficiency to spend more time on direct patient care.
• Allied health professionals: consider more collaborative sharing of data and patient information among team members.

Recommendations:

• Share system-wide data related to errors and near-misses.
• Make unit clinical managers more visible.
• Consider implementing a two-way complaints management system to respond to patient and family complaints.
• Educate staff on cultural safety.
• Provide an accessible and detailed explanation of GRASP’s usage and convey the benefits it provides.
• Review best-evidence practices for reporting and standardize reporting for all units.
• Develop and implement a method for reporting on sub-acute patients that best communicates outcomes relevant to patient and family goals.

Progress to date:

• The clinical manager and allied health offices are now easily accessible to patients and families on each unit.
• The clinical manager is now the primary contact person to manage concerns, complaints, and compliments.
• The electronic patient record (EPR) has been established and has standardized assessments, processes, and reporting throughout all clinical units.
• As of the EPR “Go Live” date on April 20, 2015, all documentation will be accessible and integrated.
• GRASP has been integrated into the EPR and is no longer a stand-alone task for the care team to complete.

Summary:

All stakeholder groups identified the importance of respect. Nurses should be aware of their power over patients and the importance of respecting the patient’s culture.2 Stakeholder groups also emphasized the importance of professional accountability; stakeholder groups tended to prioritize consistent accurate reporting and sharing data as a means of realizing accountability.

 

 

Theme 8: Care at Transitions (Admissions, Discharges and Transfers)

 

Participant priorities:

• Patients, families, nurses and allied health professionals: standardize admission and discharge processes across the organization and ensure consistency at all internal and external patient appointments.
• Patients and families: address the needs and desires of all patients (recruit a volunteer ambassador to assist with transitions). 
• Managers and directors: require that nurses who carry out admission procedures possess adequate clinical expertise. 
• Managers and directors: develop an appropriate intake process so that there is an opportunity to refuse inappropriate admissions. 
• Physicians, managers and directors,: reduce the number of transfers out that occur for non-medical reasons. 
• Physicians: improve communication with nurses, allied health, and other physicians. 

Recommendations:

• Develop standard patient-centred protocols for all admissions, transfers, and discharges.
• Hire a nursing admissions coordinator to ensure that all admission requirements are met. 
• Develop checklists for room preparation upon admission, transfer, and discharge. 
• Consolidate the checklists for admissions, transfers, and discharges. 
• Minimize the number of patient transfers motivated by nonclinical factors. 
• Develop and implement a formal and efficient program for internal and external transfers.

Progress to date:

• The CFHI ‘Partnering with Patients and Families at Care Transitions’ program has been established with multiple patient and family centred initiatives.
• Two transitions coordinators have been hired at each site of the Ottawa Hospital to assist with the admissions process. The volunteer ambassador role has been created to assist with transitions.
• Checklists for transitions have been developed for roles involved in patient transition. 
• Admission, transfer, and discharge protocols have been built into the EPR. 
• Stakeholder groups have been involved in streamlining the admission and discharge processes to improve efficiency and patient flow. 
• All transfers for non-clinical reasons must now be approved by the Director of CCC. 
• The new manager for patient flow has been appointed. 
• The ’Path to Home Resource Lounge‘ has been initiated to provide discharge information for patients, families and staff.

Summary:

Stakeholder group participants identified several barriers that prevent efficient admissions, transfers and discharges. SVH should develop and consolidate procedures and checklists to address the lack of standardization and consistency of care at transitions. Discussion of this issue should continue, as there were a number of potential solutions suggested by participants that warrant further exploration.

 

Theme 9: Clinical outcomes (Establish person-centred outcomes)

Participant priorities:

• Patients: ensure that staff members identify themselves to patients. 
• Managers and directors: adjust SVH’s healthcare workers to the increasing acuity and complexity of patients; a different skill mix of expertise may be required (e.g. adopting a complement of registered RNs and RPNs). 
• Physicians: assess the per-individual workload presently faced by allied health.

Recommendations:

• Consider developing person-centred clinical pathways for specialized programs.
• Co-design with patients and families when developing clinical pathways. 

 Progress to date:

• Work is underway to operationalize the ideas brought forth during the Discharge Kaizen (Japanese for “change for the better”) Event that was held as part of the work with CFHI’s ‘Partnering with Patients and Families for Healthcare Improvement’ program.
• Work is underway to co-design clinical milestones within the rehabilitation programs. These milestones can be recognized and celebrated with patients and families. 
• Information to prepare for discharge would begin at the time of admission and would be provided at specific milestones. Information will pertain to community resources, falls prevention, evidence-based practices to self-manage chronic diseases, and a new person-centred discharge kit for safety considerations.

Theme 10: Culture and learning (Education and mentorship)

Participant priorities:

• Patients: ensure physicians listen carefully to patients and pass on their information to the care team.
• Patients and families: provide learning opportunities and training for staff, volunteers, patients and families. 
• Families and nurses: provide approved professional development activities for staff. • Nurses: provide mentorship for staff. 
• Nurses and allied health professionals: provide inhouse educational opportunities. 
• Physicians, managers and directors: provide more education and resources to patients, families, and the professional care team. 
• Physicians: look at strategies to work in partnership with the physician groups to develop criteria and processes to facilitate the efficient use of physician expertise. 

Recommendations:

• Improve nurses’ and allied health professionals’ access to educational sessions. 

Progress to date:

• A Patient and Family Advisory Committee has been established to develop, plan, implement, and evaluate patient-centred activities, including educational opportunities.
• Online e-learning modules are being developed by the Bruyère learning department, which staff can access at any time. 
• The new Directors of Nursing Professional Practice, Nursing Professional Practice Leaders, and Nursing Practice Nurses are now on each unit to provide scheduled and just-in-time educational opportunities. 
• Unit Quality Teams coached by continuous quality-improvement Green Belts (from within the organization) and led by Health Quality Ontario facilitators (clinical managers) now provide continual learning to inter-professional teams (including physicians, patients, and families) and participate in quality-improvement initiatives and projects At each unit level. 

Summary:

All focus groups identified education and training as a priority. SVH should focus on providing more accessible educational opportunities as part of a continuing professional development program. 

 

 

Theme 11: Hiring and management

Participant priorities:

• All groups: retain talented staff.
• Patients, families, nurses and allied health professionals: post and distribute job opportunities. 
• Patients: assess volunteer performance.
• Families: ensure staff follow dress codes. 
• Families: ensure staff name tags are worn at all times and are large-print. 
• Nurses: provide a mix of 12-hour and 8-hour shifts. 
• Allied health professionals: increase the number of on-site physicians. 
• Physicians: ensure managers have had experience as nurses. 

Recommendations:

• Develop and implement easy-to-use and efficient hiring tools.
• Develop and implement a program to retain talented staff. 
• Conduct exit interviews with staff. 
• Implement a stricter dress code and redesign name tags to ensure legibility. 
• Allow family members to become true partners in care. 
• Pursue the adoption of 12-hour shifts. 
• Develop assessment tools for volunteers.

Progress to date:

• Interview guides that combine behavioural interviewing with assessment of knowledge, skills and attitudes have been developed for all categories of staff to ensure better recruitment and hiring.
• A new ‘Leadership Legacy’ program is underway to provide executive coaching opportunities for all managers and senior leaders. 
• All management staff has now received the Canadian College of Health Leaders (LEADS) in a caring environment training. 
• All management staff is participating in an Individual Development Plan process with an executive coach. 
• Dress codes (including having a visible name badge) have been reinforced for all staff. 
• Porters now have standardized uniforms. 
• Planning for the ‘Partners in Care’ program – in which family members are provided with education and support to assist with basic care in preparation for discharge – is underway. 
• In partnership with the unions, 12-hour shifts are being introduced. Additional full-time positions are being created. 

Summary:

All stakeholder groups identified the retention of high-performing staff as a priority. SVH needs to redesign nametags and implement a stricter dress code policy to facilitate the identification of staff and their roles. Additionally, adopting 12-hour shifts may ensure better continuity of care, less staff turnover, and reduced numbers of part-time staff .

 

Theme 12: Organizational support

Participant priorities:

• Patients and families: provide support groups for caregivers.
• Nurses: develop a system to deal with complaints and concerns. 
• Allied health professionals, managers and directors: recognize staff burnout. 
• Physicians, managers and directors: provide psychological support to staff, patients, and families. 
• Physicians: provide more opportunity for direct physician interaction with the senior leadership team and Board of Directors. 

Recommendations:

• Engage staff and caregivers by seeking their input when developing organizational changes.
• Provide opportunities for staff to provide feedback on organizational changes so they feel their opinions, voices, and recommendations are heard and acted on. 
• Consider further developing SVH’s physicians’ assistant program. 
• Clarify the responsibilities of certain clinical staff positions. 

Progress to date:

• A pilot project with Pastoral Care designed to provide support to patients and families has been initiated.
• A new complaint process has been developed for patients and families, as well as staff. 
• The ‘Employee Assistance’ program is now in place to confidentially assist all staff. 
• The Director of Professional Practice position and the Nursing Professional Practice Team are now in place to provide education to staff. 
• The Learning department is developing e-learning modules for all staff available on InfoNet with flexible accessibility. 
• The new volunteer ambassador role will provide a patient- and family-centred care approach to assisting patients at admission and discharge. 

Summary:
Many focus groups identified staff burnout as a significant issue.