CFHI Interview with Heather Mattson McCrady, Manager, Family Centred Care, Stollery Children's Hospital, Edmonton, Alberta

May 2016

In an occasional feature, we interview leads of CFHI-supported projects. This month we profile the Stollery Children’s Hospital Family Centred Care Network in Edmonton, Alberta where they implemented the Family Bedside Orientations project with support from CFHI’s Partnering with Patients and Families for Quality Improvement collaborative.

Stollery Children's Hospital

Christie Oswald, Family Centred Care Coordinator

Please describe your involvement in CFHI’s Patient and Family Engagement (PFE) program?

In July 2014, the Stollery Children’s Hospital Family Centred Care Network implemented the Family Bedside Orientations project with support from the Canadian Foundation for Healthcare Improvement (CFHI), Partnering with Patients and Families for Quality Improvement Collaborative. The objectives of the initiative were to further a culture of patient and family centred care and improve patient experience at the Stollery by:

  • Introducing a peer support presence for families on one medicine inpatient unit;
  • Improving patient safety; and,
  • Encouraging families to engage with their child’s care and care team.

The initiative invited former patient families back onto the unit as volunteer peer mentors responsible for orienting current families to hospital surroundings and providing information related to hand hygiene, patient bedside whiteboards, medication awareness, medical rounds participation, and family involvement in patient care.

The initiative was coordinated and evaluated by a Family Bedside Orientations Leadership Team, comprised of 14 members and two Senior Leader Executive Sponsors with representatives from Stollery staff and physicians, a Family Centred Care Network representative, and Evaluation Services staff.

What improvement project is your team undertaking as part of PFE?

To further a culture of patient and family-centred care on a Medicine Inpatient Unit, staff, families and physicians collaborated in providing a peer supported bedside orientation to patients and their families. The aim and objectives of this improvement project, Family Bedside Orientations (FBO), are to:

  • Embed a Peer Support Initiative on an Inpatient Medicine Unit – peer presence for families on the unit, ensuring families are aware of available services and staff roles, and to share effective ways for inpatient families to participate in their child’s care and care team.
  • Improve Patient Safety – Improve both staff and family practices and communication in regards to hand hygiene, medication reconciliation and education.
  • Support family engagement with their child’s care team – help staff support inpatient families to participate in rounds and ongoing communication with medical staff. Increase level of family engagement at medical rounds, and use of bedside whiteboards.

How does your innovation improve care for patients, families and caregivers?

In the 163 visits completed since the program’s inception, the topics discussed most frequently between peer mentors and families concerned family involvement in the child’s care; use of patient bedside whiteboards; and participation in medical rounds. In questionnaire responses, peer mentors noted that families require orientation checklist information within 24 hours after admission, but the best time for a visit is usually two to three days post admission. From one week to one-month post admission, families benefit from an empathetic and listening ear of a Peer mentor, learning about coping strategies, breaking from routines, and continued encouragement to advocate and be involved in their child’s care.

Across all four quarters, patient bedside whiteboards were well supplied with patient/nurse names and correct dates accurately recorded most of the time. In the last quarter, pens and erasers were noted as present 100% and 90% of the time (respectively) with the names of nurses and patients recorded in 93% and 97% of observed instances (respectively). Over the course of the project, physician names were recorded in a handful of instances (i.e., 25% or less of the time). With MRP name excluded from analysis, the 80% project measurement target for staff whiteboard use was generally met or exceeded throughout the project.

Consistent with earlier findings, fourth quarter data suggest that medication reconciliation forms are not fully completed by staff, but rather, are used on an as needed basis, particularly at the end of a patient’s hospital stay. This information has been forwarded to both Stollery and AHS wide Quality initiatives addressing medication reconciliation.

H-CIES results obtained throughout the initiative indicate that the majority of caregivers were always or usually told the name (86% or more) and the purpose of their child’s medications (89% or more). Fewer caregivers were told the possible side effects of their child’s medications (79% or fewer).

During interviews, leadership team members felt that the project helped to increase caregiver awareness of some safety protocols e.g. seeing more identification bracelets left on patient wrists. Informants were unsure as to whether the initiative specifically contributed to other behavioural changes given that many quality improvement initiatives were happening concurrently in the unit.

In fourth quarter post-visit interviews, most families (n=10) responded positively when asked for their thoughts about their visit with a peer mentor; one family felt neutral about the visit. The majority of families felt ‘very’ included in their child’s care (n=9, 78%) and ‘very’ confident with asking questions of care providers (n=10, 80%). Nine families (n=10, 90%) indicated that the family mentor was extremely or very important in their family’s overall care experience (one family of 10, 10% responded ‘neutral’ to this question). Caregivers mentioned that the visit allowed them the opportunity to talk about their experience and receive important information about how to access services and advocate for their child. One family noted that the visit helped pass the time.

In quarterly H-CIES results obtained throughout the evaluation, 77% or more caregivers felt they had a clear understanding about their role in caring for their child. Similarly, 75% or more caregivers felt that they were appropriately involved in decisions made about their child’s treatment and care.

Members of the leadership commented that while the Family Bedside Orientations project encouraged and supported caregivers to actively participate in their child’s care, it was difficult to determine if changes in caregiver behaviours or interactions with staff on the unit occured as a result of the initiative.

Are there any cost savings that can be realized from your project? If yes, please describe.

Cost savings were not tracked. However, we have considered developing a logic model to show how peer support can have an impact on costs. For example, some of the qualitative outcomes can be linked to safety and staff satisfaction that has a direct impact on patient care costs. The Family Bedside Orientation initiative has demonstrated improved patient experience and staff experience and is therefore linked to outcomes directly related to cost savings.

What has your experience been like working with CFHI?

The budgeted dollars from CFHI allowed us to:

  • Contract with evaluation services (a fee for service department) which has been invaluable
  • Backfill the FCC Coordinator position
  • Share the results of this initiative nationally and internationally

Since the initiative was aligned with hospital safety and quality priorities there was a commitment from Stollery Senior leadership to dedicate staff time to champion the initiative through the project leadership team. The well laid out timelines and expectations from CFHI supported us in staying focused on the initiative and not letting other work priorities supersede the implementation and evaluation of this initiative. As a result we have had dedicated time and resources to focus on implementing this initiative as a team, and it has created a result that exceeded our expectations.

What kind of support did CFHI provide to you and your teams?

As the project lead, I knew I had coaches who were assigned to our project that I could contact, and also the team of staff at CFHI. I also, on occasion, went to the Desire-to-Learn link to explore other resources CFHI had to help support our project. While we only participated in the half day reporting webinar presentations that our project was scheduled to present on, we were able to learn from the other presentations which stimulated conversations about other initiatives we are currently involved in, or will potentially be embarking on in the future. The conversations with the coaches and faculty staff helped us to recognize the bigger context of which our project is a part. Their questions and suggestions helped us refine our work and feel confident in the actions we were taking.

What challenges did you encounter during the project? How were these challenges overcome?

Challenges encountered during the initiative concerned scheduling family bedside orientations at optimal times for families, as well as identifying families who would benefit from an orientation or support visit. Through the feedback from family mentors it was recognized that the second or third day after admission is the best time to approach families. They were able to identify families and prioritize their visits by admission dates. Mentors also continued to check in with the social worker on the unit and /or the charge nurse for suggestions. As the mentors became better known by staff, this became less of a challenge.

Additional learnings captured during the evaluation period pertained to integrating peer mentors as part of the unit staff, while ensuring patient confidentiality and the emotional wellness of volunteers. Two actions were taken that helped the mentors become better integrated on the unit: 1) after each mentor visit with a family, the mentors now go the nurse assigned to that child / family to say they had a visit. As a result the unit staff have gotten to know the mentors and have then been able to talk about the visit with the families. Feedback from the unit staff has been much more positive since this change in practice and the family mentors are being recognized immediately when they come on the unit and being given suggestions of families to visit. 2) With input from Family Mentors, Social Work staff and Family Centred Care staff “Guidelines for Sharing Patient and Family Information with Family Mentors” were developed. This has helped build trust and understanding with all involved.

Collecting data for quarterly evaluation reporting was a reoccurring challenge, due to patient turnover and the intense and busy nature of the unit. While this is an ongoing challenge, the Unit Managers and Evaluation staff have been great at working together to collect the data in a timely manner.

Recommendations stemming from evaluation data and insights from leadership team members and peer mentors centred on: further communication about results of initiative to unit staff and physicians, clarity around breadth of information to share with peer mentors, the provision of ongoing support and training for volunteers. Informants also suggested ways to expand the family bedside orientations volunteer base and enhance the overall effectiveness of visits. Location, patient population, and staff support and championing were noted as key considerations when expanding and implementing on another unit. Additional recommendations were provided for further dissemination of project learnings and an enhanced approach for future evaluation planning.

What feedback have you received concerning your project so far?

In the course of a year, family bedside orientations were successfully implemented and became routine practice on the unit. Leadership team members and unit staff viewed the program as beneficial for families staying on the unit, with peer mentors helping to reinforce important information and awareness about patient safety and family involvement in patient care. Other notable program achievements included, volunteer contributions to peer support goals at the Stollery and value added service the initiative provides to the 5G4 environment; a unit that has traditionally received positive ratings from caregivers, based on H-CIES data collected prior to the introduction of the peer support visits, but feels isolated from the rest of the Stollery due to location on a different floor from other Stollery inpatient units and family services (the Stollery is a children’s hospital in a combined facility with adult care University of Alberta hospital). Most families in post-visit interviews (80 – 90% over the 4 quarters) responded that the visits were very or extremely important to them.

Do you have any results from your improvement project that you can share?

The purpose of the Family Bedside Orientations Evaluation was to determine the extent to which peer support visits became an established practice in the medicine inpatient unit, and whether they helped to improve patient safety and support families to be involved in their child’s care. To measure impact in these key areas, the evaluation employed several lines of data collection, including:

  • Weekly whiteboard audits conducted by unit management to document frequency of use, as well as accuracy and presence of pertinent information (e.g., date, patient name, nurse name, and most responsible physician name1 );
  • Hand hygiene audits carried out by trained health care workers to monitor hand hygiene practices at key bedside touch points;
  • Quarterly medical reconciliation patient chart audits to determine whether medical reconciliation is performed when patients are admitted and discharged from the hospital;
  • Staff focus groups to obtain 5G4 unit staff perspectives on the implementation, effectiveness and impact of family bedside orientations;
  • Key informant interviews with Family Bedside Orientation Leadership Team members to explore key considerations and factors for success should the project be extended and/or implemented on another unit;
  • Family mentor field notes completed by peer mentors after each family visit describing the volunteers’ overall impression of the caregiver and whether the visit achieved the peer support goals set out by the Stollery;
  • Family mentor questionnaires administered twice during the project to capture peer mentor reflections and personal approach to meeting with families;
  • Post mentor visit surveys administered by Family Centred Care and unit staff to families after they are visited by a peer mentor to capture their perceptions of the family bedside orientation and overall care experience2 ;
  • Status reports sent from the Family Centred Care Coordinator to the evaluation team to help track resource development, volunteer recruitment and training, and the number of peer mentor visits completed each quarter;
  • Project feedback from key stakeholders, leadership personnel and family mentors as documented in meeting minutes or e-mail messages; and,
  • Hospital – Child Inpatient Experience Survey (H-CIES) data to describe what is known about child-patient and family care experiences on the 5G4 unit in relation to the Family Bedside Orientations evaluation findings3.

1 Most responsible physician name was added to the whiteboard auditing process during the second quarter.
2 To enhance data collection, clinical and non-clinical field note templates were combined to create the post mentor visit survey in the second quarter.
3 Data collection for the H-CIES occurs on a quarterly basis and coincides with the fiscal year. H-CIES 2014/2015 Q3, Q4 and 2015/16 Q1 data, respectively align with the first, second and third quarters of the Stollery Family Bedside Orientations project evaluation. Data for the final quarter of the project was not available for inclusion in this report.

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