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How to Get There: A Regional Approach to Senior Friendly Hospitals

Kathleen Graham RN MN CHEVP Patient Care & CNO

Queensway Carleton HospitalOttawa

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Ottawa RGAP developed “Vision for Care” Strategic Plan

One of the initiatives arising from the plan:

“Effective & efficient treatment of the

elderly in the hospital”

Genesis of the SFH Initiative

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Steering Committee mandated by RGAC to:• Improve patient outcomes• Reduce suboptimal use of resources• Improve patient/family satisfaction

Recruited a chairperson and a consultant to help develop a conceptual framework

Partnered with the Council on Aging to collect information on the broader aspects from consumers & providers with focus groups and a conference

Implementing a Strategy for SFHs

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1. Physical Environment

Is the physical environment sensitive to the capacities of elderly clients and visitors?

2. Emotional/Behavioural Environment

Do the staff interact with the elderly client in a respectful, supportive and caring way?

5 Major Elements and Key Questions

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3. Process of Care

Does the care and treatment take into consideration research and evidence regarding the physiology and pathology of aging as well as the social science research?

Is the knowledge gained through orientation and education translated into practice?

Major Elements (con’t)

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4. Organizational Support

Does the organization show its support for being a senior friendly hospital in its organizational structures and processes?

5. Ethics in Clinical Care and Research

Do care providers, researchers and others ensure that ethical issues are fully addressed with elderly clients or research subjects?

Major Elements (con’t)

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• Assessment and diagnosis with special emphasis on age related changes• Planning emphasis on avoiding hazards of hospitalization• Implementation-use of aids to compensate for sensory losses• Evaluation - consider response to hospitalization, impact of treatment

Process of Care

Emotional and Behavioural Environment

• Courtesy of staff• Respect• Information sharing and listening• Individualized approach to each patient• Culturally and gender sensitive

Ethics in Clinical Care and Research

• Confirm patient’s understanding of informed consent

• Use of Advanced Directives• Thoughtful discussion of treatment options and palliative care options

Organizational Support• Relevant policies and procedures• Inclusion into program development• Staff recruitment, orientation, ongoing education• Membership and TOR for committees dealing with patient outcomes

Physical Environment• Visual aspects• Physical space including external surfaces/crosswalks,speed bumps, sidewalks / grounds• Sensory Comfort• Furniture

Senior Friendly HospitalMajor Elements

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Letters to CEOs introduced the Senior Friendly Hospital conceptExtended invitation to be involved and have a representative on the Steering Committee

Coincided with introduction of the Accessibility Act Provided helpful documentation

Strong endorsement received from local and Ottawa Valley hospitals

Getting Started—Building Organizational Commitment

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Overall Environment

• Lighting• Noise / Sound• Décor• Orientation / Wayfinding

Safe Mobility

• Flooring

• Doors

Specific Functional Areas

• Bedrooms

• Telephone

• Light Switches

• Hallways, Waiting Rooms, Washrooms

Furniture

• Tables

• Beds, and bedside tables

• Chairs

Other Factors

• Large print on written materials

• Hearing amplifiers for all staff

• Consider nutrition needs

Physical Environment Criteria

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Joanne O’Keefe O.T. developed senior friendly guidelines for physical environment (Geriatrics Today, www.rgapottawa.com)

“Free” expert consultation for building plans

St. Joseph’s Buying Group

Algonquin College Design Program

From Theory to Practice… (Embedding the Environment Work)

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Patients and their families report a need to improve the way we communicate and demonstrate respect

Respect/dignity is an illusive element to measure

Clustered around questions in the NRC Hospital Patient Satisfaction Survey

Patient Satisfaction Survey Reports will inform quality improvement

Built on Accreditation Standards

Is there a correlation between the hospital’s patient satisfaction score and the checklist score

Emotional & Behavioural Environment

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OHA Patient Satisfaction Survey

Accreditation Standards

Hospital specific indicators/balanced score cards

Best Practice Guidelines

Merging SFH with Quality

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Process of Care

Emotional and Behavioural Environment• Emotional support• Information and education• Respect for Patient Preferences• Involvement of Family• Overall Impressions

Ethics in Clinical Care and Research

Item not included in NRC(Picker/Smaller World ) Patient Survey

Organizational Support

• Additional questions

Physical Environment• Amenities

• Access

• Continuity and Transition• Coordination of Care

• Physical Comfort• Overall Impressions• Additional Items

Building on NRC Patient Satisfaction

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Process for Comparative Analysis using OHA Patient Satisfaction Survey

Cluster items that are most senior sensitive

Analysis

Dr S. Amos-RGP and Dr. A. Brown, University of Toronto

Expected Outcomes

Senior Specific Hospital Report Card

Comparison of SFH achievement across the region and provincial hospitals

Evaluation Strategies: Building on Existing Tools

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Patient Satisfaction Questions Senior Friendly Guidelines

Respect Did staff demonstrate respect and dignity in interactions with patients

and families?

1. Rate the courtesy of staff

2. Treated with respect and dignity

3. Staff discussed anxieties/fears about treatment/conditions

4. Staff spoke in front of you as if you were not there

5. Enough to say about your treatment

1. Introduce themselves, their roles, proposed intervention

2. Avoid exposing patient, properly covered/pull curtains, speak in a discrete voice

3. Time is available for emotional support

4. Speak directly to patient when asking for and giving information

5. Information about tests/treatments so patient/family are fully informed/involved in decisions

Comparison of Hospital Patient Satisfaction Survey with SFH Guidelines

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Patient Satisfaction Questions

1. Staff answered important questions

2. Staff explained results of test in a way you could understand

3. Information was given to family about your condition/treatment

1. Inform patients/ family what to expect.

2. Use common spoken/written language.

3. Family participate in care and discharge planning

Information Sharing/Listening

Senior Friendly Guidelines

Are staff’s communications senior friendly?

Comparison of Hospital Patient Satisfaction Survey with SFH Guidelines

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Respect for Patient’s Preferences54.2% Had enough to say about their treatment80.1% Treated with respect/dignity

Emotional Support 62.5% All Dimensions combined47% Nurse discussed anxieties/fears57.9% Ease of finding someone to talk to

Information & Education64.8% All Dimensions combined

Continuity & Transition58.2% When to resume normal activities

Involvement with Family60.9% Amount of information given to family62.3% Family had enough recovery information

NRC Results

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Process of Care

Emotional and Behavioural Environment• Emotional support• Information and education• Respect for Patient Preferences• Involvement of Family• Overall Impressions

Ethics in Clinical Care and Research

Item not included in NRC(Picker/Smaller World ) Patient Survey

Organizational Support

• Additional questions

Physical Environment• Amenities

• Access

• Continuity and Transition• Coordination of Care

• Physical Comfort• Overall Impressions• Additional Items

SFH Dimensions of Quality

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Process of Care

Emotional and Behavioural Environment

• Comment Cards, Complaints/Compliments

• Focus Groups

Ethics in Clinical Care and Research

• Audits for informed consents

• Proportion of seniors enrolled in Research projects

Organizational Support

• Audits of Policies and Procedures to ensure sensitivity to seniors’ needs

Physical Environment

• Adherence to Senior Friendly Guidelines

• Accessibility Working groups

• Focus Groups

• Audits

• Develop and implement Senior Sensitive Protocols Falls, Restraints, Delirium, etc

• Adverse Events ( Encon)

• Patient / Family Comment Cards, Complaints/Compliments

• Utilization: readmission, discharge disposition etc.

Other Quality Initiatives/Measures

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More Evaluation Building on Existing Tools

Use other data collection tools and stratify by age

Prevalence reports : Falls, Restraints, PressureIncidence reports: Adverse Incidents,Patient/Family Comment Cards

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Pressure Ulcer Prevalence (PUP) 2002

83% of patients are “at risk”

Of these, 65% have a deficit in

nutrition

18% prevalence rate in ulcers

Seniors represent 77% of ulcer population

37% of ulcers develop within first 7 days

after admission

Average LOS 31 days vs 21 days patients

with intact skin

Other Quality Indicators-Skin

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Falls – 2003/04

Of the ~2200 falls, those > 71 yrs. experienced

41% of all falls

Those >71 yrs. had 64% of population with

moderate degree of injury Those >71 yrs. had 74%

of serious degree of injury

Use of Restraints 2002/2003

Those >70 yrs. represent 39.4% of population

using restraints

Those >70 yrs. 26.4% with both physical and

chemical restraints

Other Indicators-Falls and Restraints

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Care Processes

First steps:Expert Panel convened Oct 03

Possible foci for care processes collated, debated, clustered, and priorizedEach member exploring topic e.g. 3D’s

Possible next steps:Use Steering Committee as focus group Find champion(s) and support them

Vision: a checklist for best processes for senior friendly hospital care

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Continue work on Conceptual Framework Elements

1. Physical Environment-Completed

2. Emotional/Behavioural Environment Nov03

3. Care Processes-June 04

4. Organizational Support- tbd

5. Ethics in Clinical Care and Research-tbd

Continue Dialogue and Education

• OHA- Toronto Nov 03

• Publication of Guidelines

Where to Go From Here?

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W.H.O. recommends senior friendly health-care centers

Patients receive targeted approaches and best practice care

Care providers note increased job satisfaction and morale

Impacts on patient safety and functional level (quality and risk)

Decreases LOS and cost- in human and financial terms

Benefits of Being Senior Friendly

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Seniors are 1/3 of hospital admissions but 2/3 of days

ER Readmission rates are 42% in patients >75 years

Frail elderly experience further functional decline not related to acute episode but to hospital practices (even when adjusted for age/co morbidity)

Frailest elderly ~3% of population use 30% of health-care resources

Supports Accreditation Process

Seniors are the largest group of foundation donors

The Pitch To Boards and Administration

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“Best Practice” depends upon an environment where

choices are guided by clinical expertise, developed

through education, based on research, and

incorporating the wishes of seniors

Success requires building on the strengths of our

communities, leaders, care receivers and providers

We are just beginning, and would welcome other

partners

In Closing….

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Vancouver Island Health Authority- “Elder Friendly Hospital” adopted the gerontology perspective for all programs/services

System-wide approach-all levels and types of staff

High-risk screen at admission on all patients

Objectives:Predict and prevent adverse consequences of hospitalization

Preserve functional ability

Early discharge planning and return to the community

Other Initiatives

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Edmonton-”Senior Friendly” Toolkit

Sponsored by the Alberta Council on Aging

Targeted the community (retail sector) to direct changes in facilities & services

Guide book, Workshops/seminars, Presenters Kit, Tee shirts, Stickers

Senior Friendly Checkup with manual, checklist & rating scale

Other Initiatives

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• Assessment and diagnosis with special emphasis on age related changes• Planning emphasis on avoiding hazards of hospitalization• Implementation-use of aids to compensate for sensory losses• Evaluation - consider response to hospitalization, impact of treatment

Process of Care

Emotional and Behavioural Environment

• Courtesy of staff• Respect• Information sharing and listening• Individualized approach to each patient• Culturally and gender sensitive

Ethics in Clinical Care and Research

• Confirm patient’s understanding of informed consent

• Use of Advanced Directives• Thoughtful discussion of treatment options and palliative care options

Organizational Support• Relevant policies and procedures• Inclusion into program development• Staff recruitment, orientation, ongoing education• Membership and TOR for committees dealing with patient outcomes

Physical Environment• Visual aspects• Physical space including external surfaces/crosswalks,speed bumps, sidewalks / grounds• Sensory Comfort• Furniture

Senior Friendly HospitalMajor Elements

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• maintains and/or improves functional abilities

• has a safe and comfortable physical and emotional environment

• provides respectful and responsive care and services

• has staff who ask questions and listen for responses without making assumptions

• encourages and supports patients and families having input into decisions

Remember…A Senior Friendly Hospital…

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