CFHI Interview with Charmayne LeRuyet
Project Lead, Regina Qu’Appelle Health Region (RQHR)
June 2015
In a new, occasional feature, we interview leads of CFHI-supported projects currently underway. This month we profile Regina Qu’Appelle Health Region, one of 15 organizations taking part in CFHI’s Reducing Antipsychotic Medication Use in Long Term Care collaborative. Charmayne LeRuyet, project lead, describes her team’s progress in addressing inappropriate use of antipsychotic medications for patients with dementia since the project formally launched in September 2014. The quality improvement collaborative was created to address a serious issue in long term care (LTC) facilities across Canada, where one in three residents is on antipsychotic medication without a diagnosis of psychosis from a doctor.
Could you please describe your initiative and your target population?
Following review of facility MDS QI scores and in consultation with Santa Maria Senior Citizens’ Home, it was decided to proceed with this quality improvement initiative. The target population was the residents on the second floor, a 49-bed unit. Thirty-eight residents or 78% of the floor’s resident population triggered the Quality Indicator called “Potentially Inappropriate Use of Anti-psychotics without a Diagnosis.” The plan is to replicate and spread the initiative to the 3rd and 4th floors at Santa Maria, and then to other long term care facilities in our region.
Why was this initiative important to RQHR?
Our region believes in “Patient First….Safety Always.” By 2017, our goal is to achieve a culture of safety with a shared ownership for the elimination of defects. Safety in the way we deliver care to those we serve includes ensuring that the decision to administer antipsychotic medication is based on careful assessment and diagnosis of each resident’s conditions and care needs. This initiative perfectly aligned with this goal.
Had you wanted to implement this type of quality improvement prior to joining the CFHI collaborative?
Regionally, we had begun to focus on the need to develop a multidisciplinary review process that would apply to all medication regimes, to ensure that decisions to prescribe medications are based on careful assessment and appropriate diagnosis. However, no formal process had been initiated in respect to quality improvement work specifically for anti-psychotic medications. There was recognition of an opportunity here for improvement.
How did you hear about this opportunity?
We received a general communication, via email, from CFHI, informing us of this initiative and inviting interested health authorities to submit a proposal.
What strategies have you been using to ensure appropriate prescribing and to improve care for residents with dementia?
Prior to the ‘Go Live” date, there were a number of pre-implementation activities. To engage the facility staff, management hosted information meetings where they described the project and provided comparative information comparing Santa Maria’s score on the Quality Indicator “Antipsychotics Without a Diagnosis” to the provincial average. Communication with the physicians was primarily achieved via email and letters and we spoke with our Medical Advisor.
Near the project’s inception, a clinical sub-committee of the project team was established. This committee reviewed the many tools that are available to assess residents’ conditions/care needs and develop care plans. Tools were prioritized and education on how to use the tools was provided. An algorithm was developed, supporting the staff to follow a standardized process in the reduction pathway. Prior to each resident commencing the reduction pathway, his or her clinical information was discussed at a care huddle which established the assessment cycle and care planning. Staff were encouraged and supported to become actively engaged in the care planning. The project team attended the care huddles, providing clinical support and expertise.
Describe your results and greatest successes to date. How have patients benefited from your work? What does this project mean to the residents and families who are impacted?
As of April 30, 2015, 28 of the 38 residents’ antipsychotic medication has been discontinued and five of the 38 residents are on the reduction pathway. The feedback from the family varies from neutral to positive. Most are very appreciative of having been informed along the way.
How have you been using interRAI data for your project?
Capturing and examining interRAI data was essential in order to establish the baseline at the beginning of this project. The quarter following collection of baseline data was the pre-implementation phase. Best practice in medication reduction is to go slow and re-assess with each reduction. The MDS information for the following quarter showed minimal changes. We are currently preparing to review CFHI’s quarter 2 report information and compare it to the baseline information.
What have been your biggest challenges and obstacles?
There has been significant change in facility leadership at both the unit and senior level. The project team has been consistent in providing leadership and direction to both unit staff and facility managers and senior leaders. With recruitment into the vacant manager positions, the team is looking forward to active involvement and dedication from facility leadership. The focus has also been on empowering the staff to take ownership of this initiative and to make the practices that are related to reducing the use of antipsychotic medications an integral part of their daily work.
One very important observation has surfaced: with the reductions in their antipsychotic medications, residents are beginning to verbalize boredom. This has led the team and facility leadership to consider the changes that must be made to the current routines and to support the unit staff to be flexible and creative in such things as altering the care plans and developing tool kits to make it easier for staff to engage residents in meaningful activities and conversations.
How engaged are the staff? Do some resist the initiative, concerned that less medication means more work for them?
The key to staff engagement is to have visible commitment from senior management and a strong leader on the unit. There were some struggles initially when staff, which had previously been identified as having the ability to lead this initiative, was unable to fulfill the expectations. Staff involvement improved with the installation of a new Resident Care Coordinator on the unit, and her active participation on the team. Recognition by the team and physicians and families of the remarkable progress that has been made in reducing the use of antipsychotic medications has imbued staff with a sense of pride and accomplishment.
What about physicians? Are they on board and staying actively involved?
Santa Maria (SM) management recently met with the core team of physicians. Two physicians openly applauded the results and continue to support the initiative. In addition, SM developed a policy where, prior to new antipsychotic medication commencing on evening or night shifts, or on weekends, the on-call administration must be contacted to further discuss the resident’s situation. This policy was endorsed by the physicians. Team members recently met with the Department of Psychiatry to share results of the project. Since its inception, two geriatric psychiatrists have joined the department and we’re all interested in working more collaboratively.
Is your senior leadership supportive? How have you been keeping senior leadership engaged?
Yes, following many discussions, we are confident that senior leadership is very supportive. The Interim Report was provided to CFHI and senior leadership simultaneously. It has been widely recognized that the results have been very successful and positive.
Are families and friends generally supportive? What has been their reaction to seeing loved ones suddenly become more alert?
Near the inception of the project, team members attended a Resident Council meeting to explain the project. An inherent step in our process is for the primary family contact to be notified prior to the resident commencing the medication reduction pathway. With each medication change, the family contact is again called and provided with an update and asked for feedback.
What has been the value of the Collaborative? How is CFHI funding and support helping you to reach your goals?
CFHI provided the initial seed money to get started, and continue to provide support in the form of tools and suggestions shared by other jurisdictions that have experienced some successes in their implementation of reducing the use of antipsychotic medications. Participation in the collaborative has also helped us to stay on track via webinars and required reporting. The opportunities, provided by CFHI, to learn from other similar initiatives in the collaborative have been invaluable.
How do you plan to sustain the staff training and improvements for these residents?
The Continuing Care Consultants and the Clinical Nurse Educator, who have been part of the team, will continue to be involved as regional resources to the long term care facilities. They will have ongoing opportunities to observe and influence how care is delivered to the residents. To check sustainability, the region will continuously monitor the Quality Improvement Indicator that is reported quarterly, and require Santa Maria to develop a Corrective Action Plan if the facility is not meeting the provincial benchmark.
What are your plans to spread the initiative to other units? What strategies will you use? What support will you provide?
We plan to spread this initiative to the 3rd and 4th Floors in Santa Maria, and ultimately to all long term care facilities in the region. A Driver Diagram exercise is scheduled to facilitate discussion with staff from the 2nd Floor, which will help us to understand, from those on the front line, what has worked well and what could be improved. Staff from the 3rd and 4th Floors in Santa Maria will also be attending the Driver Diagram exercise, as we believe that the discussions will facilitate engagement of staff from the 3rd and 4th Floors and contribute to a successful spread to those floors.
Continuing Care Consultants and Clinical Nurse Educators will continue to provide education. The Long Term Care Kaizen Team Lead will continue to assist staff with monitoring and measuring. Processes will be replicated, for example assessment tools and care huddles. The Resident Care Coordinator, who is the 2nd floor unit champion, will coach the Resident Care Coordinators for 3rd and 4th floors to become champions on their units. The Nurse Manager will coach/mentor the recently-hired Nurse Manager.
The project team will continue to meet regularly to support facility management and staff, as well as continue to monitor and measure successes. The team will continue to attend Care huddles to facilitate communication and foster critical thinking.
What is the top piece of advice you would provide to other teams considering implementing this initiative?
The pre-implementation phase is the most critical. It is important to engage ALL key stakeholders at the beginning and to plan each step including plan to support unit staff. A standardized process for communicating with staff is key to the implementation.