Starting the Improvement Conversation

How does improvement happen? This seemingly straight-forward question often has no easy answer—especially in the context of our large and somewhat complicated healthcare system. In reality though, we all know that across Canada, ideas are turned into innovations that make lasting impacts in the lives of communities and individuals. So how then, do people and organizations come to understand not only what needs to be done, but move to make it happen? 

It Starts with a Conversation

For the Victoria Glen Manor (VGM)—a 60-bed nursing home located in Perth-Andover, New Brunswick—improvement began by starting a conversation.

Like many LTC facilities in Canada, a significant number of residents living at VGM had been prescribed antipsychotics despite not having a diagnosis of psychosis. In many cases, these prescriptions pre-dated the resident’s arrival at VGM, and in others, the medications were prescribed as part of VGM’s strategy to help manage behaviours associated with dementia (such as verbal and physical abuse).

 

Although rates vary greatly between LTC homes and jurisdictions across Canada, more than one in four seniors in LTC is on antipsychotic medication without a diagnosis of psychosis.

 

And--like many LTC staff in Canada--the care team at VGM understandably accepted this ‘prescribing culture’ as simply common practice…until staff began to challenge the status quo by starting a conversation that was motivated by an improvement project that began almost 4 years earlier and over 3000 km away.  

Winnipeg Roots

In 2011, Joe Puchniak and Cynthia Sinclair – at the time, Managers with the Winnipeg Regional Health Authority (WRHA) Personal Care Home Program – took part in CFHI’s 14-month EXTRA Executive Training Program. Through EXTRA, leaders from across Canada come together to gain skills and knowledge and work collaboratively to design, implement and evaluate an improvement project addressing a pressing clinical, organizational, regional, or provincial/territorial priority or challenge. In their EXTRA improvement project, Sinclair and Puchniak advanced an approach to reduce inappropriate prescribing that relied on increasing staff capacity to use data to inform care planning and better understand and respond to resident behaviours through implementing tailored person-centred approaches to care. In six months, 27 percent of the cohort of residents being followed in one PCH were taken off their antipsychotic medication without causing any increase in behavioural symptoms or an increase in the use of physical restraint. Patients and family’s lives were improved. Front-line staff members were empowered. And the project yielded savings of $10,000.

Given these impressive results, a business plan has been advanced to expand the improvement to the remaining 38 personal care homes in the Winnipeg Regional Health Authority. And, in 2014, Sinclair & Puchniak’s EXTRA improvement project formed the basis of CFHI’s Reducing Antipsychotic Medication in Long Term Care collaborative.

Building on Success

In 2014, CFHI launched the Pan-Canadian Reducing Antipsychotic Medication in Long Term Care collaborative to spread this innovation. Fifty-seven LTC facilities across seven Canadian provinces and one territory participated in adopting an approach of using data to inform care planning, regular medication reviews, multi-disciplinary team work, engagement of families and the implementation of tailored person-centred approaches to resident care by front-line staff. The results—more than fifty-percent of the targeted residents in the Pan-Canadian collaborative had their antipsychotic medication discontinued or significantly reduced, without an overall increase in falls, or challenging behaviours. Family members and healthcare providers expressed how the initiative improved care for residents and changed the prescribing culture of these organizations.

Bringing the Conversation to Victoria Glen Manor

In 2016, with funding support from the Government of New Brunswick, CFHI and the New Brunswick Association of Nursing Homes (NBANH) began working together to improve dementia care through the New Brunswick Appropriate Use of Antipsychotic (NB-AUA) Collaborative.

As news of collaborative spread across NB, management at VGM began to ask important questions: could we train our staff to better use data to inform care and planning? Could we build capacity to understand and respond to resident behaviours--such as verbal abuse-- through decreased use of antipsychotic medications and more appropriate care? Would this help to improve the quality of life for our residents and their families?

As luck would have it, they didn’t have to wait long to get a glimpse into the answer to their question.

As part of the NB-AUA collaborative work, VGM staff attended an introductory workshop in Fredericton where they heard former NB cabinet minister Eugene McGinley, whose sister Anna Hanley (1923-2016) went through an antipsychotic reduction program at York Care Centre—tell his story.

 

Research shows that antipsychotic medications are minimally effective in managing the psychological and behavioural symptoms associated with dementia and are associated with worsening cognitive functions and serious adverse events.

 

McGinley told the audience of 15 collaborative teams that although Anna had never had a diagnosis of psychosis, she had been prescribed anti-psychotic drugs and seemed ‘sluggish’ when he visited her. However, when York Care Centre staff put into practice the skills they learned through the education – to work with physicians and pharmacists to safely titrate antipsychotic medications, and implement alternative therapies to treat Anna’s behaviour, for example - she soon became more calm, the sparkle returned to her eyes—and she became “Anna” again.  

Being Anna

Being Anna Program

When VGM staff returned to Perth-Andover, the conversation shifted from knowing what they needed to do, to focusing on how to make it happen. They also had a name for their new program—Being Anna.

As 1 of 15 NB teams in phase I of the collaborative (the rest of the 50 nursing homes in New Brunswick are set to join next year), their aim is to improve care by reducing the use of antipsychotic medication for residents without a diagnosis of psychosis from the baseline 20 % to less than 11% by 2017.

On July 20 of this year, they launched their initiative with a roll-out party that included staff, residents, families and the community. Their approach to improvement includes weekly staff huddles, all-staff education sessions to build capacity in interpreting behaviours, using data to inform care planning and implementing person-centred approaches to care. Never short of creative ideas, VGM has also launched innovative theme-dedicated days—including having staff “put themselves in the residents’ shoes” to better understand the individual experience.

To be Continued

Phase I of the NB-AUA Collaborative will run until May 2017--so how the conversation that lead to this improvement story will end, is still to be continued. We have a feeling though that it will indeed be a ‘happily ever after’.   

Being Anna Team

Attending the July 20 launch of the "Being Anna" pilot program to reduce the use of anti-psychotic medicine were, left to right: Eugene McGinley, whose sister Anna Hanley (1923-2016) went through an antipsychotic reduction program at York Care Centre; Sheila Cummings, Deputy Mayor, Village of Perth-Andover; Josee Beaulieu, director of Nursing, VGM; Julie Weir, clinical resource nurse, NB Association of Nursing Homes (NBANH); Donna Miller-Wallace, Executive Director, VGM; Jodi Hall, Director of Operations, NB Association of Nursing Homes; Ronald Cummings, President, Board of Directors, VGM.
(Photo courtesy of VGM.)