Veterans Centre Review
February 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 background
Beds Contracted by VAC
Level 2
Veterans
Level 3
Veterans
Total
Physical
Support
128
Cognitive
Support
62
Total
130
180
310
258
242
500
190
Some brief background
Demographics
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 Support
17= Level 2 Cognitive Support
9 = Level 2 Physical Support
28
Transfers within the VC
(annualized)
2011-12 = 53
2012-13 = 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
50.00%
Sunnybrook QIs Exceed Provincial Performance
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Sunnybrook
Improved or remained independent in mid-loss ADL - ADL05
Improved or remained independent in early-loss ADL - ADL06
Improved late-loss ADL - ADL1A
Worsened or remained dependent in early-loss ADL - ADL6A
Improved locomotion - MOB1A
Worsened cognitive ability - COG01
Worsened communication ability - COM01
Worsened mood from symptoms of depression - MOD4A
Taken antipsychotics without a diagnosis of psychosis - DRG01
Has fallen - FAL02
Has one or more infections - INF0X
ADL05
ADL06
ADL1A
ADL6A
MOB1A
COG01
COM01
MOD4A
DRG01
FAL02
INF0X
Provincial
Has a stage 2 to 4 pressure ulcer - PRU05
Worsened stage 2 to 4 pressure ulcer - PRU06
Has a new stage 2 to 4 pressure ulcer - PRU09
Daily physical restraints - RES01
Worsened/unchanged respiratory condition - RSPX2
Has urinary tract infection - CNT04
Improved bowel continence - CNT2A
Improved bladder continence - CNT3A
Has a feeding tube - NUT01
Has pain - PAI0X
Has had weight loss - WGT01
PRU05
PRU06
PRU09
RES01
RSPX2
CNT04
CNT2A
CNT3A
NUT01
PAI0X
WGT01
Quality Indicators
Sunnybrook QIs do not Exceed Provincial Performance
50.00%
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
ADL01
ADL5A
ADLD7
MOB01
BEHD4
BEHI4
COG1A
Sunnybrook
Worsened late-loss ADL - ADL01
Worsened or remained dependent in mid-loss ADL- ADL5A
Worsened ADL - ADLD7
Worsened locomotion - MOB01
Worsened behavioural symptoms - BEHD4
Improved behavioral symptoms - BEHI4
Improved cognitive ability - COG1A
ADL01
ADL5A
ADLD7
MOB01
BEHD4
BEHI4
COG1A
COM1A
DELOX
CAT02
CNT02
Provincial
Improved communication ability - COM1A
Has symptoms of delirium - DELOX
Has an indwelling catheter - CAT02
Worsened bowel continence - CNT02
Worsened bladder continence - CNT03
Worsened pain - PAN01
COM1A
DELOX
CAT02
CNT02
CNT03
PAN01
CNT03
PAN01
Provincial Comparison
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
35
Number of Quality Indicators
30
25
20
Above Provincial
Average
15
10
5
0
*Sunnybrook is tied for second among its
provincial comparators
Below Provincial
Average
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.”