Improving Quality & Safety of Mental Healthcare in Singapore

Transcription

1 Improving Quality & Safety of Mental Healthcare in Singapore

2 S/N Presenters Topics A/Prof Chua Hong Choon Chief Executive Officer Ms Samantha Ong Bee Cheng Chief Nurse Presentation topics Introduction of Institute of Mental Health (IMH) & Mental Healthcare in Singapore Managing & Improving Quality & Safety - Falls and Use of Restraints A/Prof Daniel Fung Shuen Sheng Chairman Medical Board A/Prof Swapna Kamal Verma Senior Consultant and Chief Integrating Physical & Mental Healthcare Empanelment and Patient-Centred Care

3 Introduction: Singapore at a glance 719km million population Life Expectancy (y/o): Male (80) Female (85)

4 Introduction: Mental Healthcare in Singapore Community / Social Social + Health Healthcare Community Agencies & Outreach Schools/ Police Community Residential Institutions Community Support, Rehab National Mental Health Helpline General Practitioners and Polyclinics Nursing homes Public & Private Hospitals, IMH

5 Introduction: IMH Today Singapore s ONLY Tertiary Psychiatric Institution

6 Introduction: IMH Today Singapore s only tertiary psychiatric institution, situated on a 25-hectare campus at Buangkok Green Medical Park. Provides acute and long-term care Inpatient: 1,950 beds in service Outpatient: 41,000 patients Outpatient Rehabilitation Centres: 3 OcTAVE* centres Emergency Service: 24hr walk-in clinic and observation ward Procedures: Electroconvulsive Therapy and Repetitive Transcranial Magnetic Simulation Pls visit for more information on us. *OcTAVE - Occupational Therapy: Activities, Vocation and Empowerment

7 Introduction: Clinical services overview HOSPITAL-BASED SERVICES General Psychiatry Child & Adolescent Psychiatry Community Psychiatry Geriatric Psychiatry Forensic Psychiatry Rehabilitation Psychiatry Early Psychosis Intervention Addiction Medicine Psychotherapy Emergency Psychiatry Allied Health COMMUNITY-BASED SERVICES YOUNG Response, Early Intervention and Assessment in Community Mental Health (REACH) Provides help for students with emotional, social and behavioural issues and disorders Support for Wellness Achievement Programme (SWAP) Provides help for individuals between 16 and 30 with at-risk mental states Community Health Assessment Team (CHAT) Promotes mental health awareness among youths, and encourages them to seek help early ADULTS Community Mental Health Team (CMHT) Treats patients in the community and keeps them well there for as long as possible Job Club Assists individuals with mental illness obtain and sustain employment, or provide support as required in their work GP-Partnership Joint collaboration between IMH and GPs to manage patients with stabilised mental conditions in the community ELDERLY Aged Psychiatry Community Assessment and Treatment Service (APCATS) Provides assessment and treatment for homebound or frail elderly patients with mental disorders

8 DETECTION & MEASUREMENT Introduction: Quality & Safety Framework VALIDATION ANALYSIS Improvement GOVERNANCE & HOSPITAL LEADERSHIP Retrospective methods Just culture Reporting of actual incidents Risk identification Adverse event prevalence studies Patient feedback/surveys/foc us groups Chart reviews/clinical audits Safety walkabouts Prospective methods Failure Modes Effects and Analysis (FMEA) Near misses reporting Cross institution Learning Serious Reportable Events Prevalent Adverse Events Near Misses/ Identified Risks Re-checking Re-collecting data Serious reportable event review Root cause analysis FMEA Review by Quality Assurance/Peer review committees (e.g. Mortality & Morbidity, Clinical Risk and Patient Safety Committee etc) Data/ Benchmarking for continuous improvement Clinical Practice Improvement Programme Process Improvement (e.g. 6s, Lean etc) Breakthrough collaborative (through National Healthcare Group) Quality Assurance and Quality Improvement Programmes Report a spread Outcomes/ Feedback Tracking System TRAINING, CHANGE MANAGEMENT, SERVICE CULTURE, SAFETY CULTURE Monitor and Evaluate Change

9 Introduction: Quality Council Structure IMH QUALITY COUNCIL Improvement & Innovation Committee Operational Quality Committee Nursing Quality Improvement Committee Quality Assurance & Standards Committees Clinical Risk & Patient Safety Committee IHI-MOH Quality & Innovation Centre Environment, Health & Safety (EHS) Committee Nursing Quality Assurance MOH Healthcare Performance Office Clinical Risks/ Quality & Patient Safety Indicators Improvement Methods - Clinical Microsystems - CPIP Committee - FMEA - LEAN Tools Clinical Risk & Patient Safety Quality Improvement MOH Hospital Re-licensure JCI Re-accreditation Infection Control Medication Safety Presentations and Publications Research & Evidence Based Nursing Medical Record Audit Committee Adverse Events Surveillance Improvement & Innovation Grant Applications Nursing Clinical Practice & Standards Clinical Pathways Safety Walkabouts Mental Health Trigger Tool Development Medical Accreditation & Credentialing Patient Safety Culture/Training

10 Introduction: Challenges Top and how we addressed them Challenges

11 Introduction: Challenges Challenge patients have higher expectations of care; adverse events are still happening in the hospital Managing & improving quality & patient safety for our patients

12 Introduction: Challenges Challenge Many mental health patients have multiple comorbidities and medical problems as well Integrating physical & mental health

13 Introduction: Challenges Lack of integrated care; non-patientcentric healthcare system Challenge Empanelment: One-patient, oneclinician team

14 Managing and Improving Quality and Safety - Falls and Use of Restraints Ms Samantha Ong Bee Cheng Department of Nursing Administration, Institute of Mental Health, Chief Nurse SINGAPORE

15 Challenge: High Falls Rates of Patients Falls with injuries are on the rise Aging population more prone to falls Ambulatory patients non compliant to fall risk advices Long term patient with osteoporotic conditions

16 Inpatient fall rate Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Inpatient Falls Rate (3 year trend) Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec Apr 2014 Reviewed and revised fall risk assessment tool and care plan Inpatient fall rate (number of inpatient falls per 1000 patient days) May 2014 Fall prevention educational brochures Apr 2015 Fall clinics and monthly meetings with block reps Jul 2015 New guidelines for post-fall management Dec 2015 Project for replacing ward flooring with non-slip tiles (ongoing) Feb 2016 Started developing post-fall management guidelines Mar 2016 Osteoporosis prevention project led by APNs Sep 2016 Worked with MMD to make size 3 & 4 slippers avail for patients Jun 2016 Reviewed fall trends and interventions to seek areas for improvement Oct 2016 Revised WI incorporating MDT role and post-fall management Dec % of hospitals beds were replaced by cot beds Inpatient fall rate UCL (+3σ) Mean LCL (-3σ) Target = 0.45 Outcomes: Since 2015, falls in acute wards have been reduced with hourly safety monitoring. Falls in long stay wards have increased slightly due to aging patients.

17 Falls Prevention Strategies Falls prevention workgroup Analyze data Develop strategies Safety Nurse Conduct hourly safety rounds Physical activities for patients ROM exercise Muscle strengthening exercises Environment Night lights Non-slip tiles Non-slip floor mats Falls Clinic for Nurses Case discussions Sharing of best practices Post falls management and ROM training Using video and role play Patient and caregiver education on falls Use of technology in falls prevention and detection E.g. Falls Alert System

18 Challenge: Frequent Use of Restraints Patients with challenging behavior Risk of DVT and other complications Restraint for safety reasons Lack of confidence amongst Nurses

19 Restraint rate Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Restraint Rate (3 year trend) Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Restraint rate (number of 4-5 point restraint episode per 1000 patient days) Aug 2015 Start of PROMISE Workgroup, in collaboration with UK PROMISE Global Dec 2015 Reduced restrainer par level in wards to encourage nurses to explore nonrestraint practice. Aug 2016 Restraints clinic for Block 3 Nov 2016 Restraints survey on duration of restraints Jul 2015 Revised restraint workflow to be based on points of restraint, instead of indication, and to separate restraint from RT administration. Oct 2016 Restraints clinic for Block 2 Restraint rate UCL (+3σ) Mean LCL (-3σ) Target = 2.38 Outcome: The restraint rate had gradually declined over the years.

20 Restraint duration (hr) Restraint Duration (10 year trend) Average 4-5 point restraint duration per episode Restraint duration Outcome: The restraint duration had gradually declined over the years.

21 Restraint Reduction Strategies Restraint & assault reduction workgroups Analyze data Develop strategies Training of Staff Care and Response training One on one engagement sessions with staff who are assaulted Restraints Clinic for Nurses Case discussions Sharing of best practices Review restraint workflow Workflow to be based on points of restraint Risk Assessment Tools Modified Fremantle Acute Arousal Scale Broset Violence Checklist 2- Hourly potting Patients on safety restraint potted 2-hourly Reduce par level of restrainers in the ward Encourage nurses to explore nonrestraint practice

22 Integrating Physical & Mental Health A/Prof Daniel Fung Shuen Sheng Chairman Medical Board, Institute of Mental Health SINGAPORE

23 Integrating Physical and Mental Health Life Expectancy Long stay patients Acute patients Greater risk of premature death, dying as much as 25 years younger than the general population Higher than expected prevalent rates of comorbid general medical conditions, particularly metabolic and cardiovascular disease People with Mental Illness (PMI) Contributing factors to overall excess mortality are cardiovascular diseases such as high rates of cigarette smoking, obesity, diabetes, hypertension and triglyceridemia. A recent meta-analysis of quality of medical care for people with co-morbid mental illness reported that the majority of studies demonstrate significant inequalities in receipt or uptake of medical care for people with SMI

24 Problems we faced 1. About Patients with DHL 900 patients Prescribed with at least one of the conditions: Diabetes Mellitus Hypertension Lipids Almostnone received the standard care monitoring as recommended by the National Treatment Guidelines for their respective conditions. Comparison among IMH, NHG, NHGP & TTSH

25 Screening Results of Long stay inpatients Top 3 screening results from Yr 2015 to Yr % 21.9% Lipids 18.8% Hypertension Diabetes Mellitus Comparison between Yr 2013 and Yr 2016 Data taken from Yr % Lipids 47% Diabetes Mellitus 97% Hypertension Data taken from Yr2013 & 2016

26 % of Long Stay patients Age Proportion of long stay patients in each age group 24 yo yo yo 75 yo 30% 25% 20% 15% 10% 5% Obesity % of long stay obese patients in each age group Causes 26% 24% 19% 16% 17% 18% 11% 9% 10% 6% 6% 3% patients above 50 years old increased chance of contracting DHL 69% (933) Lipids 72 % (399) Hypertension 75 % (343) Diabetes Mellitus above 50 years old 0% 30 yo yo yo yo yo 65 yo Age of Long Stay patients Increased risk of developing cardiovascular diseases and diabetes Obesity associated with 51% increase in mortality 1 compared to people with a normal weight 1 Stokes, A. and Preston, S. H. (2015), Smoking and reverse causation create an obesity paradox in cardiovascular disease. Obesity, 23: doi: /oby.21239

27 Number of deaths Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Number of incidents Feb-14 Apr-14 Jun-14 Aug-14 Problems we faced Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec Oral Health Status 34% (624) of patients referred had tooth extractions 22 % (624) of patients referred had tooth fillings Increased risk of major chronic diseases Higher Number mortality of pneumonia rate deaths from pneumonia Decreases chewing efficiency, Number of choking incidents potential choking

28 Number of falls with injuries Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Problems we faced Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec Osteoporosis Average of 8long stay patients per year sustained fracture of low to moderate impacted injury due to fall Increased number of falls with injuries 30 Falls with injuries

29 Medical Care Services Specialist Outpatient & Satellite Clinics Long Stay patients DHL screening for : a. Patients prescribed with medication for at least one of the DHL conditions b. New patients age 40 & above c. Smoking Cessation Prog. ipace Annual Review Clinic to review schizophrenic patients for: a. physical comorbidities b. side effects to antipsychotic medications c. adherence to medical care for medical disorders d. screening of glycemic control and dyslipidemia, hypertension and obesity 31 Screening for : a. Diabetes Mellitus, Hypertension, Lipids (DHL) b. Breast cancer c. Weight gain & obesity d. Oral health status

30 1. Patients with DHL Qualitative Research Methods of Qualitative Data Collection Launch of Medical Service Qualitative Research involves finding out what Services Stabilize the current Semi-structured Interviewing people think, and 4 how primary they care feel - or Continues at any review rate, for patients what on cohort of DHL they say they think and how they say they feel. This patients identified Focus Groups kind of information is subjective. Proper It involves management feelings of medical Participant Observations and impressions, rather than numbers Photo-elicitation physicians How we address the problems Team Outcomes of Medical Service Bellenger, Bernhardt and Goldstucker, Qualitative Research in Marketing, Services Working with specialize units for proper medical management American CoverageMarketing Team Association Expanding to the rest of hospital, open for referrals Increased to 7 primary care physicians Goal primary care follow-ups Refers to primary care if appropriate investigations at IMH are carried out Lifestyle counseling conditions Screening of new cases 38,000 patients at outpatient clinics 21,000 patients 40 years and above 7,000 patients may need hypertension management

31 SHINe Diabetes Management Project Interventions Project Title: To reduce the percentage of diabetic patients who have blood glucose going out of protocol limits (less than 4mmol/L and greater than 20mmol/L) by 30%. Hypoglycemia & Hyperglycemia Rescue Protocol & Hypokit Diabetes Care Plan - Incorporated 1800kcal Diet Revised Blood Glucose Monitoring Form Diabetes Management Poster for Staff Sticker reminder on ipad for serving meds Story-telling Slides for Spread WI-MBD Management of Patients with Diabetes Education Brochure for Patients (3 languages)

32 Percentage of patients SHINe Diabetes Management Outcome Measure Out of range blood glucose monitoring: Percentage of patients whose blood glucose monitoring results are beyond protocol limits 120% 100% 100% 100% 100% 88% 100% 100% 100% 100% 80% 60% 75% 60% 60% 50% 67% 50% 50% 40% 20% 0% 25% 33% 21% 27% 14% 0% 0% 33% 33% 9% 29% 25% 0% 25% 0% 33% 0% 0% 0% 0% 10% 33% 11% 0% 17% 25% 25% 20% 11% 20% 9% 6% 15% 10% 0% 0% 0% 0% 0% 0% Insulin Oral Hypoglycaemic Medications PDSA 1: New form to collect data for indicators (9 July 2015) PDSA 2: Placing of glucometer and data collection form on trolley when taking hypocount (9 Jul 2015) PDSA 3: Revised Rescue Protocol (23 Nov 2015) PDSA 4: Revised Routine Protocol and DM educational brochure for patients (4 Apr 2016) PDSA 5: Merging of project form with existing hypocount monitoring form (4 July 2016) PDSA 6: Reminder sticker label on med serving device and DM poster (17 Oct 2016) PDSA 7: Changing of diabetic diet from 1500kcal to 1800kcal (21 Oct 2016)

33 How we address the problems 2. Initially Oral health Status Dental assessments were done when patients complain of teeth problems Now Dental assessments were done proactively 1. Annual screening 2. Dentists go to wards to do screening Improvement project Improving participation rate of oral hygiene activities for ID (Intellectual Disability) patients Results Before Conclusion Patients are screened before they have teeth problems Free up dental slots After Project is ongoing, with intention to spread to all ID wards

34 3. Osteoporosis How we address the problems Interventions Osteoporosis Assessment and Treatment Program were launched Target patients Higher risk patients aged 75 and above Assessment 1. Team sends a list of patients to the wards to assess patients needs for Bone Mineral Densitometry (BMD) testing using Osteoporosis Assessment form 2. Those who meet criteria will be sent for the mobile BMD test Results 83% (96) of elderly patients screened are osteoporotic and need treatment Treatment Tested positive for osteoporosis: 1. Alendronate 2. Vitamin D 3. Calcium 4. Dietary supplement 5. Physiotherapy 6. Weekly exercise sessions 7. Sunlight exposure

35 Empanelment and Patient-Centred Care A/Prof Swapna Kamal Verma Department of General Psychiatry, Institute of Mental Health, Senior Consultant and Chief SINGAPORE

36 Contents S/N Contents What is Empanelment Why Empanelment Preparing for Empanelment Beginning of Empanelment Early Achievements & Key Challenges

37 What is Empanelment act of assigning individual patients to a panel of care providers/care teams, with sensitivity to patient and family s needs and preferences basis for population health management and the key to continuity of care

38 Why Empanelment Lack of: Integration between service providers Communication between staff and patients/caregivers and within internal stakeholders Efficient documentation Clear roles and responsibilities Guidelines on information sharing

39 Vision Before: Inpatient Doctor IMH Case Manager E-room Doctor Community Partners e.g. AIC Patient Allied Health Services Outpatient teams Specialty Services Outpatient Doctor After: Preventive Care Intermediate Residential Support Emergency services Patient Acute and Specialty Care Community Support

40 Steering Committee Workshop Guiding Principles QUALITY ACCESSIBILITY RELIABILITY EMPOWERMENT EFFICIENCY EFFECTIVENESS AFFORDABILITY

41 Workshop Roadmap Workshop 1 Workshop 2 Workshop 3 Workshop 4 Patient s journey from inpatient to outpatient Individual profession s work flow Mapped the two process flows Categorize challenges Prioritized the challenges Root Cause Analysis Brainstorm for solutions

42 Beginning of Empanelment Re-organisation at hospital level to provide relationship/team-based care

43 SPOC Framework

44 ipace Programme ipace Programme Risk & Need Assessment & Stratification Case Management Framework (SPOC) Assess & stratify Risks and Needs Case Tracking Data tracking and monitoring

45 Some other key achievements

46 Some key challenges Changing from a Clinician-Centred Care to a Patient-Centred Care mind set Locating and leveraging on resources within the patient s geographic areas Creating a system for real time information with community partners.

47 Thank You Q & A