Spring 2010

IN THIS ISSUE

2 PUAP Collaborative Results in Significant Decrease in Resident Pressure Ulcers 3 Improving Continence Care Collaborative (IC3) in Long-Term Care Homes

Linking Best Practices with Quality Improvement 4 The Bridges to Care Project 5 What Do Inukshuks, Apples, and By Josephine Santos, RN, MN percent during the year they participated in Falls in Long-Term Care Have in Program Manager, LTC Best Practices Initiative the Collaborative. The PUAP Collaborative is a Common? In November 2009, the partnership between the Ministry of Health 6 Announcements Long-Term Care Best and Long-Term Care, Ontario Health Quality Practices Initiative received Council, Canadian Association of Wound Care the Minister’s Award of and RNAO. RNAO and Safer Healthcare Now!, share with Excellence for Innovation us the importance of team work and Carleton Lodge, one of the LTC homes involved for Improving Quality and measuring progress within the Collaborative in the Improving Continence Care Patient Safety. Although as well as having the opportunity to engage in Collaborative (IC3) through the Seniors Health this news has been discussion with colleagues in order to share Research Transfer Network, also shares with us Josephine Santos featured in several RNAO ideas. their challenges in participating in a publications, I would like to highlight it here in Collaborative. They describe how they The four articles featured in this newsletter our very own newsletter in order to share this overcame these challenges and how proud illustrate how quality improvement award with all the Long-Term Care (LTC) they are of the improvements that they were methodology using a collaborative approach homes and the staff in the sector. Our able to achieve in residents’ quality of life by to implement guideline can significantly Initiative has been successful because you implementing strategies they learned in IC3. improve resident outcomes. This approach is have welcomed us into your homes and have gaining more popularity in the LTC sector and worked with us in various creative ways to The work being done in the Bridges to Care as more LTC homes participate in the Ontario bring best practices to the point of care. I Project, a Ministry of Health and Long-Term Health Quality Council’s Resident First would like to congratulate my team of LTC Best Care funded initiative through Project, we will definitely have more stories Practice Coordinators and all of you who work HealthForceOntario, is also highlighted in this to share. in the LTC sector for your dedication and newsletter. LTC homes in the North West and commitment to improving quality and resident East Regions such as Pinewood safety using best practices. Court, Helen Henderson, Rideaucrest, Providence Manor, Since the category of the award that we Maxville Manor and Residence St. received was on improving quality and Louis share their quality resident safety, our team has decided to focus improvement experiences and the this issue of our newsletter on best practices significant progress they have and quality improvement collaboratives. Over made in reducing transfers to acute the past year, our team has been involved with care for pneumonia, reducing falls, many LTC homes in implementing best improving resident focused practices using the quality improvement communications and reducing the collaborative methodology. behavioural and psychological

In this issue, we learn from two LTC homes symptoms of dementia during (The Cardinal Ambrozic Houses of Providence mealtime.

and Sun Parlor Home) that were involved in The Davis Centre and Kristus Dārzs the Pressure Ulcer Awareness and Prevention Latvian Home, two of ten Ontario RNAO received the Minister’s Award of Excellence (PUAP) Collaborative . They share how quality homes in a group of 32 from across Innovation for Improving Quality and Patient Safety at the improvement methodology used to support November 2009 Celebrating Innovations in Health Care Expo Canada that participated in the guideline implementation significantly reduced for its innovative program, “Strategies to Support Long-Term National Falls Collaborative led by the prevalence of pressure ulcers by over fifty Care in the Uptake of Best Practices.”

| www.RNAO.ca/bestpractices/long-term-care | p1 PUAP Collaborative Results in Significant Decrease in Resident Pressure Ulcers

By Beverly Ann Faubert, RN, BScN, Long- High risk rounds were done Term Care Best Practice Coordinator, South weekly by the Improvement West Region and Susan Bailey, RN, BA, Facilitator, Sharon Beggs, RPN, MHScN, Long -Term Care Best Practice a dietitian and physiotherapist. Coordinator, Region Sharon indicated that by using the Braden scale, the team The Pressure Ulcer Awareness and discussed the care of residents Prevention (PUAP) Collaborative was a one who had a high risk score and year program that involved 30 Long-Term developed a plan of care to Care (LTC) homes from across Ontario. This address identified pressure initiative married evidence-based clinical ulcer risks. For example, if the practice from the RNAO best practice high score was due to moisture, guidelines and the Canadian Association for a strategy was developed to Wound Care PUAP program with quality address moisture, reducing the improvement methodology shared by the risk score from high to "Wear your Pajamas to Work Day” at the Houses of Providence was a way to Ontario Health Quality Council (OHQC). The moderate. When a high score make it fun for residents and staff to change the routine for the morning and get all the skin assessments done. Collaborative was funded by the Ministry of was due to reduced mobility, Health and Long-Term Care and its AIM was the physiotherapist helped determine what to reduce the incidence and prevalence of appropriate actions could be taken to improve Integrating Resident Assessment Instrument – pressure ulcers to zero with a midway target mobility, turning and positioning, reducing the Minimum Data Set (RAI-MDS) with PUAP of a reduction of 50%. Here are the score to moderate. Staff followed a turning resulted in staff studying a sample of residents experiences of two of the participating LTC schedule that identified when residents had on a unit to determine if those who are homes: been repositioned. When residents were deemed independent with repositioning are positioned on their left side at the end of a shift, actually turning themselves during the night. The Cardinal Ambrozic Houses of the turning schedule had been followed. Any Providence residents sitting in a chair at the end of the shift A non-registered staff member assesses to see The Cardinal Ambrozic Houses of were also repositioned. Sun Parlor Home no if residents classified as being independent turn Providence at Providence Healthcare was longer has residents with high risk Braden themselves during the night. It was discovered one Toronto LTC home that joined the 2009 scores. that one of the residents did not turn at all PUAP Coll aborative. Myrna Loyst, Resident during the night, resulting in a referral to Care Manager, relates that The Houses was The Quality Improvement (QI) methodologies physiotherapy to improve the plan of care for able to realize their personal AIM of used included the Defect Checklist and Plan-Do- this resident. reducing pressure ulcers by 50% within four Study-Act (PDSA) cycle to assess and develop months. Other positive outcomes of change strategies. The Defect Checklist used Due to the training received in QI methodology belonging to the PUAP Collaborative throughout the facility for two weeks helped and improvement facilitation, Sharon has been included team development, strengthening determine why staff were bringing in their own selected as the Improvement Facilitator for of assessment skills and facilitation soap products for use on residents, rather than other projects including improving dining and techniques. Ongoing team leadership is using the pH balanced soap provided by the meal times, reviewing the job posting process, evident as staff continue to gather together Home. Staff was asked to provide the reasons Residents First and least restraint/falls. Sharon for weekly wound and skin rounds for why they did not use the supplied pH balanced states she enjoys the quality initiatives as they residents at high risk of pressure ulcer soap, which is a best practice guideline create better care for residents and help to development, as determined by the Braden recommendation. They were instructed to ease the nursing workload a little bit too. Scale. Staff, and many residents and families select only one reason from an established list. Eighty-two percent of LTC homes involved in are benefiting from the learning sessions There were 10 reasons provided, however, 50% the PUAP Collaborative were successful in which were offered by the PUAP Champion of staff indicated there was urine or body odour reducing pressure ulcers by fifty percent over Team. after being bathed. A new trial using a different their Collaborative year, reported by Maryanne pH balanced soap product for a few weeks will D’Arpino, OHQC’s Improvement Facilitator Sun Parlor Home be completed followed by another checklist. Lead. Ongoing support is available from Sun Parlor Home in Leamington met and This demonstrates the use of a PDSA cycle to internal improvement facilitators, the dramatically exceeded their AIM of having a test a change. This example also demonstrates Residents First legacy group and RNAO LTC Best 50% reduction in pressure ulcers by June one of the key principles testing a change, to Practice Coordinators. 2009 and are now working towards test on a small scale. sustainability and spread.

| www.RNAO.ca/bestpractices/long-term-care | p2 Improving Continence Care Collaborative (IC3) in Ontario Long-Term Care Homes

By Heather Woodbeck, RN, HBScN, MHSA with their residents, including those with Other IC3 teams were also able to implement Long-Term Care Best Practice Coordinator, dementia. prompted voiding in their LTC homes. Other

North West Region and Co-lead, IC3 successes included: a decrease in constipation As the Team Leader, Rebecca’s first task was by encouraging defecation in a squatting Improving Continence Care Collaborative (IC3) to recruit another Registered Nurse (RN), a position at the time when the resident is most is a 3.5 year old Community of Practice (CoP) Registered Practical Nurse (RPN), and two likely to have a bowel movement; a decrease that has involved over 20 Long-Term Care (LTC) Personal Support Workers (PSWs) to form a in the prevalence of urinary tract infections; homes in Ontario using quality improvement Continence team. At the kick-off Learning and, less continence product usage. Most methods to make measurable improvements Session in June 2009, teams met through homes noted increased communication with and sustained changes in continence care. IC3 video conference and participated in sessions staff and family members with any is funded by the Seniors Health Research on continence and the Rapid Cycle Method of incontinence issues/concerns. Transfer Network (SHRTN). RNAO has been Improvement (RCMI). Carleton Lodge set an the sponsor for the CoP for the last year. aim that was consistent with the overall aim of Carleton Lodge, like many of the other IC3 the IC3 CoP, which was to improve the Quality teams, faced many challenges along the way. IC3 Phase III included seven LTC homes from of Life (QOL) for all residents by reducing An outbreak in the winter stalled progress. At Ottawa, Hamilton and Toronto areas who met prevalence of bowel and bladder incontinence. that time, the team focused on holding the over a one year period from June 2009 to May This first Learning Session was followed with gains that they had made by continuing to 2010. Participants were a mix of urban and three additional full-day video conference toilet residents with prompted voiding rural homes including: workshops held quarterly. Between sessions, according to their individualized routines. • Baycrest Jewish Home for the Aged-Apotex Team Leaders met and shared their activities Centre, Toronto, with 372 residents; Resident Assessment Instrument – Minimum in monthly teleconferences. • Lakeside Long-Term Care, with 128 residents, Data Set (RAI-MDS) was a competing initiative Carleton Lodge had many successes in that required time as well. However, it also which is part of Toronto Rehabilitation Institute and professionally managed by improving continence in their residents. benefited IC3 because by the end of Phase III, Starting on their Nepean Unit, they adapted a all of the teams were able to track their Extendicare; • Carleton Lodge, Ottawa, with 160 residents; 3-day urinary assessment tool to assess all of progress using the RAI-MDS questions on the residents who could use the toilet and bladder and bowel continence. RAI-MDS gives • Salvation Army Grace Manor, Ottawa, with 128 residents; needed staff assistance, and used the results the teams an ongoing way of monitoring to create an individualized toileting schedule continence changes. • John Noble Home, Branford, with 156 for each assessed resident. Next, a toileting residents; Another challenge was getting all staff worksheet was created which tells staff the • Maple View Lodge, Athens, with 60 involved in the continence care time when the resident is to be toileted and residents; and, improvements. Although it was slow work at allows for communication between staff. By • Rosebridge Manor located near Smiths Falls, times, providing knowledge and skills to better March 2010, ten residents on the unit who with 78 residents. manage continence care helped staff were previously incontinent were continent , understand the importance of prompted Carleton Lodge was in the planning phase of during the day and evening. Other benefits for voiding. Having enough time to work on making improvements in continence care when some residents included: being able to use continence improvements was a big challenge Rebecca Séguin, their Best Practice liners instead of briefs because incontinence for not only staff, but also for the IC3 team Coordinator, heard about the IC3 at an Ontario became occasional, and a decrease in anxiety members leading change in the homes. Health Quality Council (OHQC) Workshop in as they are aware when staff will be in to Teams/staff were encouraged to connect with March 2009. She was impressed with the assist them with toileting. stories she heard from other Homes about short meetings at different times of the day to Team members are proud of the improvement successfully implementing prompted voiding accommodate different schedules. Huddles or in the resident’s quality of life brought about quick talks at the end of shift helped keep through the implementation of the program. everyone involved in the improvement and working towards achieving the goal of Promote urinary continence and prevent continence.

constipation IC3 Teams learned many lessons along the Urinary incontinence is a symptom, not a disease. It is not a natural way related to successful changes leading to part of aging. improved continence, such as keeping focused There are many ways to prevent constipation. Understanding the on the aim, taking baby steps in moving reasons for constipation is the first step. forward and not giving up. Incorporating the new approaches into orientation programs for Visit http://ltctoolkit.rnao.ca to obtain resources on new staff has also helped to maintain Continence and Constipation. improvements in continence care.

| www.RNAO.ca/bestpractices/long-term-care | p3 The Bridges to Care Project

By Janet Evans, RN, BScN Long-Term Care Best Practice Coordinator, East Region

The Bridges to Care (BTC) project is a knowledge to practice (KTP) initiative for long-term care (LTC) funded by the Ministry of Health and Long-Term Care through HealthForceOntario. The project aims to facilitate improvements in resident outcomes through the delivery of KTP resources in key areas by trained internal champions and supported by local external facilitators Knowledge to Practice, Learning Session 1 in Kingston, Ontario 2009 following a quality improvement (QI) model.

LTC homes were invited to submit letters of e) Define the changes – what changes can we Facilitators used the projects’ educational interest to participate in QI process in one of make that will result in improvement? resources and the principles of adult learning, the three topic areas: falls and osteoporosis, f) Get ready to test changes – what changes supported by the fields of appreciative inquiry, behavioural and psychological symptoms of should be tested and implemented first? coaching and quality improvement, in order to dementia (BPSD), and LTC acquired infections achieve organizational change. g) Test the changes (Plan-Do-Study-Act or including pneumonia and bacteriuria. Local PDSA) – how can we test, refine, and widely The project developed enhanced relationships project leads performed an environmental implement our changes? through the collaborative process with project assessment on interested sites, resulting in h) Demonstrate the impact – how do we and community partners, and fostered a the selection of three homes from Kingston, assess the impact? sustainable model of knowledge exchange and two homes from Ottawa and one home from transfer within LTC and other sectors. Thunder Bay participating in the project. These eight QI aspects were the guiding principles for the project which built upon This collaborative process was demonstrated Each participating LTC home nominated three existing knowledge. during the second KTP two-day workshop held internal facilitators including a non-registered in Kingston in March 2010. The participating staff, a registered health professional and an Pinewood Court in Thunder Bay developed LTC homes presented their work to date on administrati ve staff member. In addition, each procedures to reduce residents’ transfer to their respective topics. Significant progress was site identified external facilitators with an acute care as a result of pneumonia. Their made in reducing transfers to acute care for ability to facilitate the quality improvement challenge initially was internal stakeholder pneumonia, reducing falls, improving resident initiative. The science of QI was lead and engagement, but through education, this focused communications and reducing BPSD supported by the Ontario Health Quality hurdle was overcome. behaviours during mealtime. Council (OHQC) and used to guide the KTP Helen Henderson, Rideaucrest, and process and workshop development. Providence Manor, all from the Kingston area, Participants expressed satisfaction with the learning that occurred throughout the project. In November 2009, Kingston hosted the first used PDSA cycles to develop protocols to Comments made by the internal facilitators KTP two-day workshop where the LTC homes reduce the frequency of falls in residents who echoed the learning about QI as a new way of were introduced to the clinical topic, its are known to fall frequently. Aspects that thinking. The LTC homes identified the need related resources, and the science of QI. they looked at included staff education, for a strong AIM statement, and having PDSA organizational policy reviews, and linkages to The QI journey for the LTC homes in this existing initiatives within the home. cycles that were easy to follow and tracked the QI teams’ actions in relation to achieving the project looked at eight aspects: Maxville Manor in Maxville and Residence St. AIM. a) Assemble the team – who should be on the Louis in Orleans focused their AIM statement LTC QI team? on developing strategies to decrease the Overall, the project continues to meet with b) Define the AIM – what are we trying to incidence of BPSD on site. Residence St. Louis rave reviews and positive comments from all accomp lish? focused on mealtimes with environmental and participants, including internal and external c) Understand the problems – what are our procedural changes providing the greatest facilitators, community partners and project quality issues? success. Maxville Manor focused their AIM leaders. Next steps for this project include d) Identify the measures – how will we know if statement on resident focused staff presentation at key conferences and further a change is an improvement? communications by using the PIECES 3 project development opportunities for the question template as a guide. homes involved.

| www.RNAO.ca/bestpractices/long-term-care | p4 What Do Inukshuks, Apples, and Falls in Long-Term Care Have In Common?

By Heather Thompson, RN, Long-Term Care Change categories included: develop A year after closing congress for the Falls Best Practice Coordinator, North East Region standardized routine practice; design system Collaborative both homes are still involved in and Natalie Warner, RN, MN, BFA to avoid mistakes; engagement of the maintaining and growing changes related to Long-Term Care Best Practice Coordinator, resident, family, care provider; and, improve decreasing falls and severity of falls although Central East Region environmental design. The combination of both admit competing priorities are a The National Falls Collaborative was an intention and change resulted in a challenge. Echoing Barb Swail, Lauma Stikuts initiative of the RNAO and Safer Healthcare recommended intervention and examples to notes the importance of keeping it on the Now! (SHN) which involved 32 homes across test. For example, the Inukshuks and apples agenda and “just doing something” toward Canada of which 10 came from Ontario. The are exemplars of using symbols to identify the effort rather than becoming overwhelmed Collaborative was structured around four residents at high risk of falling. by not being able to do something large and learning sessions in Halifax, Toronto, Montreal intense. and Edmonton with expert and peer support In order to know whether the goal of While the National Falls Collaborative between sessions facilitated by decreasing falls and severity of falls was met wrapped up in May 2009, Safer Healthcare teleconferences and a web based community the Collaborative had a database into which Now! and RNAO are preparing to launch a new of practice. homes entered data on falls each month. Charts generated by the database allowed free "Getting Started Kit" that shares The Inukshuks became the symbol used to homes to compare their own progress over successful strategies from the Collaborative identify residents at risk of falling at the Davis time and amalgamated data from all homes and provides information on using the SHN Centre in Peel Region. The symbol was a within the Collaborative. database to track your home’s falls rate. suggestion by one of the care staff on the falls Information can be obtained from the Safer prevention team. It seemed a natural choice Data was an overall measure, but actual Healthcare Now! website at because it echoed the Inukshuk at the entry to practice change was important and the www.saferhealthcarenow.ca. There is also the building and embodies the home’s falls Collaborative encouraged participative going to be a Virtual Falls Collaborative for strategies such as huddles on units to prevention motto “we will stand tall, we will health care organizations across Canada. not fall”. decrease the falls of individual residents. Watch out this summer for Calls-for- Lauma Stikuts, Executive Director at Kristus Participants or contact Brenda Dusek, RNAO Project Granny Smith was the initiative of falls Dārzs Latvian Home explains how statistics Program Manager at [email protected]. alone would not accurately reflect the change. collaborative team at Kristus Dārzs Latvian Home in Woodbridge. Apples which in nature She gives the example of the story of a Visit the LTC Best Practices Toolkit at resident who fell frequently on nights. Staff on http://ltctoolkit.rnao.ca for more detailed fall from trees, became not only an identifier of falls risk but also a theme associated with this shift met with representatives from the stories about the falls implementation at Davis falls team to develop and refine strategies to Centre and Kristus Dārzs Latvian Home in the all falls changes and events, carried through in materials and snacks provided at events. assist this resident and decreased his falls rate future. and the Home’s fall rate. However, in

The goal of the Collaborative was to reduce respecting the resident’s autonomy, some falls the number and severity of falls in long-term still occurred – this was still within the goals of care using recommendations from the Best the Collaborative but not captured effectively Practice Guideline Prevention of Falls and Falls by the statistics. and Injuries in the Older Adult and quality improvement methodology. The focus was on Barb Swail, Administrator at the Davis Centre, assessment and modification of risk factors has a similar story about a resident that fell and maintaining the dignity of the residents frequently during the evening and on nights living in the LTC Home while using principles and the changes the front-line staff made to of least restraint. try to prevent these falls. In discussing the story, a different message emerges, Barb Participating Homes were encouraged to concludes that: “small things that you do, develop teams which were guided by a change make a big difference”. package containing four key interventions which could be effected by four change categories. Key interventions areas included: awareness of level of risk; prevention of falls; falls intervention or actions; and, reduction of injuries if falls occur.

| www.RNAO.ca/bestpractices/long-term-care | p5 Announcements

Who are the LTC Best Practice Coordinators? Welcome to Below is the contact information of the LTC Best Practice Coordinators and their Host Homes.

LTC Region LTC Best Practice Coordinator Host Home the Team! CENTR AL EAST Natalie Warner, RN, MN, BFA Covers: York, Durham, Mobile: (705) 768-8434 Hillsdale Estates Northhumberland, Kawartha Phone: (905) 579-1777 ext. 235 590 Oshawa Blvd. N.

Lakes, Peterborough, Haliburton, Fax: (905) 579-3911 Oshawa, ON L1G 5T9 and Simcoe Email: [email protected]

Elaine Calvert, RN

CENTRAL SOUTH Mobile: (289) 407-9658 John Noble Home Covers: Hamilton, Brant, Phone: (519) 756-2920 Ext 236 97 Mt Pleasant St

Haldimand, Niagara, and Norfolk Fax: (519) 756-7942 Brantford, ON N3T 1T5 RNAO is delighted to introduce Elaine Calvert (left) and Susan Bailey (right) as the new LTC Best E-mail: [email protected] Practice Coordinators in the Central South and Saima Shaikh, RN CENTRAL WEST Specialty Care Toronto regions, respectively. Both Elaine and Sue Mobile: (519) 520-7283 Covers: Waterloo, Wellington- Road joined RNAO in January 2010. Direct: (905) 817-7074 Dufferin, Halton & Peel including 4350 Mississauga Road Fax: (905) 812-1173 Mississauga and Mississauga, ON L5M 7C8 E-mail: [email protected] EAST Mark Your Calendars! Janet Evans, RN, BScN Covers: Renfrew, Ottawa, Mobile: (613) 864-0238 Miramichi Lodge June 7-9, 2010 Eastern Counties, Kingston, Direct: (613) 735-4693 ext. 213 725 Pembroke St. West OANHSS 2010 Annual Meeting & Convention – Frontenac, Lennox & Addington, Fax: (613) 735-8061 Pembroke, ON K8A 8S6 “Get Inspired” Lanark, Leeds & Grenville, and Email : [email protected] Hastings Prince Edward June 13-18, 2010 NORTH EAST Heather Thompson, RN RNAO’s Annual Nursing Best Practice Covers: Algoma, Cochrane, Mobile: (705) 206-3344 Algoma Manor Guidelines Summer Institute Manitoulin, Nippising, Muskoka, Direct: (705) 842-2840 ext. 232 135 Dawson Street

August 8-13, 2010 Sudbury, Timiskaming, and Parry Fax: (705) 842-2650 Thessalon, ON P0R 1L0 RNAO’s Creating Healthy Work Environments Sound Email: [email protected] Summer Institute Heather Woodbeck, RN, HBScN, MHSA NORTH WEST Phone: (807)-768-4432 St. Joseph's Heritage September 26 – October 1, 2010 Covers: Thunder Bay, Kenora, Fax: (807)-768-7793 63 Carrie Street Chronic Disease Management Fall Institute and Rainy River Cell: (807) 621-1127 Thunder Bay ON P7A 4J2 Email: [email protected] October 18-20, 2010 SOUTH WEST Beverly Ann Faubert, RN, BScN RNAO’s Knowledge, the Power of Nursing: Covers: Grey-Bruce, Huron, Mobile: (519) 401-8485 Vision Nursing Home Celebrating Best Practice Guidelines and Perth, Middlesex, Oxford, Elgin, Phone: (519) 336-6551 ext. 207 229 Wellington Street Clinical Leadership Lambton, Kent, Essex, and Fax: (519) 336-5878 Sarnia, ON N7T 1G9

London Email: [email protected] Visit www.RNAO.org/CentreEvents for Susan Bailey, RN, BA, MHScN TORONTO Ukrainian Canadian Care more information! Mobile: (416) 889-9956 Covers: , York, East Centre Phone: (416) 243-7653 ext. 251 York, Scarborough, , 60 Richview Road Fax: (416) 243-7452 and Toronto Toronto, ON M9A 5E4 Email: [email protected] RNAO’s Long-Term Care Best Practices Initiative Newsletter Editors: Natalie

Warner, Josephine Santos, and Heather McConnell. RNAO’s Delirium, Dementia and Depression e-Learning Course is FREE and can be found at: http://elearning.rnao.ca Newsletter Designed by: Citlali Singh

Please send comments/inquiries either by email [email protected], fax (416) 907-7962, or mail to RNAO 158 Pearl Street, Toronto, ON M5H 1L3.

Made possible through funding by the Government of Ontario.

| www.RNAO.ca/bestpractices/long-term-care | p6