How to Get There:
A Regional Approach to
Senior Friendly Hospitals
Kathleen Graham RN MN CHE
VP Patient Care & CNO
Queensway Carleton Hospital
Ottawa
1
Genesis of the SFH Initiative
Ottawa RGAP developed “Vision for Care”
Strategic Plan
One of the initiatives arising from the plan:
“Effective & efficient treatment of the
elderly in the hospital”
2
Implementing a Strategy for SFHs
Steering Committee mandated by RGAC to:
• Improve patient outcomes
• Reduce suboptimal use of resources
• Improve patient/family satisfaction
Recruited a chairperson and a consultant to
help develop a conceptual framework
Partnered with the Council on Aging to collect
information on the broader aspects from
consumers & providers with focus groups and
a conference
3
5 Major Elements and Key Questions
1. Physical Environment
Is the physical environment sensitive to
the capacities of elderly clients and
visitors?
2. Emotional/Behavioural Environment
Do the staff interact with the elderly client
in a respectful, supportive and caring
way?
4
Major Elements (con’t)
3. Process of Care
Does the care and treatment take into
consideration research and evidence
regarding the physiology and pathology
of aging as well as the social science
research?
Is the knowledge gained through
orientation and education translated into
practice?
5
Major Elements (con’t)
4. Organizational Support
Does the organization show its support
for being a senior friendly hospital in its
organizational structures and processes?
5. Ethics in Clinical Care and Research
Do care providers, researchers and
others ensure that ethical issues are fully
addressed with elderly clients or
research subjects?
6
Senior Friendly Hospital
Major Elements
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Process of Care
Assessment and diagnosis with special emphasis on age related changes
Planning emphasis on avoiding hazards of hospitalization
Implementation-use of aids to compensate for sensory losses
Evaluation - consider response to hospitalization, impact of treatment
Emotional and Behavioural
Environment
Courtesy of staff
Respect
Information sharing and listening
Individualized approach to each patient
Culturally and gender sensitive
Organizational Support
• Relevant policies and procedures
• Inclusion into program development
• Staff recruitment, orientation,
ongoing education
• Membership and TOR for
committees dealing with patient
outcomes
Ethics in Clinical Care and Research
• Confirm patient’s understanding of
informed consent
• Use of Advanced Directives
• Thoughtful discussion of treatment
options and palliative care options
Physical Environment
• Visual aspects
• Physical space including external
surfaces/crosswalks,speed bumps,
sidewalks / grounds
• Sensory Comfort
• Furniture
7
Getting Started—
Building Organizational Commitment
Letters to CEOs introduced the Senior Friendly
Hospital concept
Extended invitation to be involved and have a
representative on the Steering Committee
Coincided with introduction of the
Accessibility Act
Provided helpful documentation
Strong endorsement received from local and
Ottawa Valley hospitals
8
Physical Environment Criteria
Overall Environment
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Lighting
Noise / Sound
Décor
Orientation / Wayfinding
Safe Mobility
Specific Functional Areas
• Bedrooms
• Flooring
• Telephone
• Doors
• Light Switches
• Hallways, Waiting Rooms,
Washrooms
Furniture
Other Factors
• Tables
• Large print on written materials
• Beds, and bedside tables
• Hearing amplifiers for all staff
• Chairs
• Consider nutrition needs
9
From Theory to Practice…
(Embedding the Environment Work)
Joanne O’Keefe O.T. developed senior friendly
guidelines for physical environment (Geriatrics Today,
www.rgapottawa.com)
“Free” expert consultation for building plans
St. Joseph’s Buying Group
Algonquin College Design Program
10
Emotional & Behavioural Environment
Patients and their families report a need to improve the
way we communicate and demonstrate respect
Respect/dignity is an illusive element to measure
Clustered around questions in the NRC Hospital
Patient Satisfaction Survey
Patient Satisfaction Survey Reports will inform quality
improvement
Built on Accreditation Standards
Is there a correlation between the hospital’s patient
satisfaction score and the checklist score
11
Merging SFH with Quality
OHA Patient Satisfaction Survey
Accreditation Standards
Hospital specific indicators/balanced score
cards
Best Practice Guidelines
12
Building on NRC Patient Satisfaction
Process of Care
• Access
• Continuity and Transition
• Coordination of Care
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Emotional and Behavioural Environment
Emotional support
Information and education
Respect for Patient Preferences
Involvement of Family
Overall Impressions
Organizational Support
• Additional questions
• Physical Comfort
• Overall Impressions
• Additional Items
Ethics in Clinical Care and Research
Item not included in NRC(Picker/Smaller
World ) Patient Survey
Physical Environment
• Amenities
13
Evaluation Strategies:
Building on Existing Tools
Process for Comparative Analysis using OHA Patient
Satisfaction Survey
Cluster items that are most senior sensitive
Analysis
Dr S. Amos-RGP and Dr. A. Brown, University of
Toronto
Expected Outcomes
Senior Specific Hospital Report Card
Comparison of SFH achievement across the region
and provincial hospitals
14
Comparison of Hospital Patient Satisfaction Survey
with SFH Guidelines
Patient Satisfaction Questions
Respect
1. Rate the courtesy of staff
2. Treated with respect and
dignity
3. Staff discussed
anxieties/fears about
treatment/conditions
4. Staff spoke in front of you as
if you were not there
5. Enough to say about your
treatment
Senior Friendly Guidelines
Did staff demonstrate respect and
dignity in interactions with patients
and families?
1. Introduce themselves, their roles,
proposed intervention
2. Avoid exposing patient, properly
covered/pull curtains, speak in a
discrete voice
3. Time is available for emotional
support
4. Speak directly to patient when
asking for and giving information
5. Information about tests/treatments
so patient/family are fully
informed/involved in decisions
15
Comparison of Hospital Patient Satisfaction Survey
with SFH Guidelines
Patient Satisfaction Questions
Information Sharing/Listening
1. Staff answered important questions
Senior Friendly Guidelines
Are staff’s communications
senior friendly?
1. Inform patients/ family what to
expect.
2. Staff explained results of test in a
way you could understand
2. Use common spoken/written
language.
3. Information was given to family
about your condition/treatment
3. Family participate in care and
discharge planning
16
NRC Results
Respect for Patient’s Preferences
54.2% Had enough to say about their treatment
80.1% Treated with respect/dignity
Emotional Support
62.5% All Dimensions combined
47% Nurse discussed anxieties/fears
57.9% Ease of finding someone to talk to
Information & Education
64.8% All Dimensions combined
Continuity & Transition
58.2% When to resume normal activities
Involvement with Family
60.9% Amount of information given to family
62.3% Family had enough recovery information
17
SFH Dimensions of Quality
Process of Care
• Access
• Continuity and Transition
• Coordination of Care
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•
•
•
•
Emotional and Behavioural Environment
Emotional support
Information and education
Respect for Patient Preferences
Involvement of Family
Overall Impressions
Organizational Support
• Additional questions
• Physical Comfort
• Overall Impressions
• Additional Items
Ethics in Clinical Care and Research
Item not included in NRC(Picker/Smaller
World ) Patient Survey
Physical Environment
• Amenities
18
Other Quality Initiatives/Measures
Process of Care
• Develop and implement Senior Sensitive Protocols Falls, Restraints, Delirium, etc
• Adverse Events ( Encon)
• Patient / Family Comment Cards, Complaints/Compliments
• Utilization: readmission, discharge disposition etc.
Emotional and Behavioural
Environment
• Comment Cards,
Complaints/Compliments
• Focus Groups
Organizational Support
• Audits of Policies and Procedures to
ensure sensitivity to seniors’ needs
Ethics in Clinical Care and Research
• Audits for informed consents
• Proportion of seniors enrolled in
Research projects
Physical Environment
• Adherence to Senior Friendly
Guidelines
• Accessibility Working groups
• Focus Groups
• Audits
19
More Evaluation Building on Existing Tools
Use other data collection tools and stratify
by age
Prevalence reports : Falls,
Restraints, Pressure
Incidence reports: Adverse
Incidents,
Patient/Family Comment Cards
20
Other Quality Indicators-Skin
Pressure Ulcer Prevalence (PUP) 2002
83% of patients are “at risk”
Of these, 65% have a deficit in nutrition
18% prevalence rate in ulcers
Seniors represent 77% of ulcer population
37% of ulcers develop within first 7 days
after admission
Average LOS 31 days vs 21 days patients
with intact skin
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Other IndicatorsFalls and Restraints
Falls – 2003/04
Of the ~2200 falls, those > 71 yrs. experienced
41% of all falls
Those >71 yrs. had 64% of population with
moderate degree of injury Those >71 yrs. had 74%
of serious degree of injury
Use of Restraints 2002/2003
Those >70 yrs. represent 39.4% of population
using restraints
Those >70 yrs. 26.4% with both physical and
chemical restraints
22
Care Processes
First steps:
Expert Panel convened Oct 03
Possible foci for care processes collated,
debated, clustered, and priorized
Each member exploring topic e.g. 3D’s
Possible next steps:
Use Steering Committee as focus group
Find champion(s) and support them
Vision: a checklist for best processes for
senior friendly hospital care
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Where to Go From Here?
Continue work on Conceptual Framework Elements
1. Physical Environment-Completed
2. Emotional/Behavioural Environment Nov03
3. Care Processes-June 04
4. Organizational Support- tbd
5. Ethics in Clinical Care and Research-tbd
Continue Dialogue and Education
•
OHA- Toronto Nov 03
•
Publication of Guidelines
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Benefits of Being Senior Friendly
W.H.O. recommends senior friendly health-care
centers
Patients receive targeted approaches and best
practice care
Care providers note increased job satisfaction
and morale
Impacts on patient safety and functional level
(quality and risk)
Decreases LOS and cost- in human and financial
terms
25
The Pitch To Boards and Administration
Seniors are 1/3 of hospital admissions but 2/3 of days
ER Readmission rates are 42% in patients >75 years
Frail elderly experience further functional decline not
related to acute episode but to hospital practices (even
when adjusted for age/co morbidity)
Frailest elderly ~3% of population use 30% of healthcare resources
Supports Accreditation Process
Seniors are the largest group of foundation donors
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In Closing….
“Best Practice” depends upon an environment where
choices are guided by clinical expertise, developed
through education, based on research, and
incorporating the wishes of seniors
Success requires building on the strengths of our
communities, leaders, care receivers and providers
We are just beginning, and would welcome other
partners
27
Other Initiatives
Vancouver Island Health Authority- “Elder Friendly
Hospital” adopted the gerontology perspective for all
programs/services
System-wide approach-all levels and types of staff
High-risk screen at admission on all patients
Objectives:
Predict and prevent adverse consequences of
hospitalization
Preserve functional ability
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Early discharge planning and return to the community
Other Initiatives
Edmonton-”Senior Friendly” Toolkit
Sponsored by the Alberta Council on Aging
Targeted the community (retail sector) to
direct changes in facilities & services
Guide book, Workshops/seminars, Presenters
Kit, Tee shirts, Stickers
Senior Friendly Checkup with manual,
checklist & rating scale
29
Senior Friendly Hospital
Major Elements
•
•
•
•
•
•
•
•
•
Process of Care
Assessment and diagnosis with special emphasis on age related changes
Planning emphasis on avoiding hazards of hospitalization
Implementation-use of aids to compensate for sensory losses
Evaluation - consider response to hospitalization, impact of treatment
Emotional and Behavioural
Environment
Courtesy of staff
Respect
Information sharing and listening
Individualized approach to each patient
Culturally and gender sensitive
Organizational Support
• Relevant policies and procedures
• Inclusion into program development
• Staff recruitment, orientation,
ongoing education
• Membership and TOR for
committees dealing with patient
outcomes
Ethics in Clinical Care and Research
• Confirm patient’s understanding of
informed consent
• Use of Advanced Directives
• Thoughtful discussion of treatment
options and palliative care options
Physical Environment
• Visual aspects
• Physical space including external
surfaces/crosswalks,speed bumps,
sidewalks / grounds
• Sensory Comfort
• Furniture
30
Remember…A Senior Friendly Hospital…
• maintains and/or improves functional abilities
• has a safe and comfortable physical and emotional
environment
• provides respectful and responsive care and
services
• has staff who ask questions and listen for responses
without making assumptions
• encourages and supports patients and families
having input into decisions
31
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