Just Clean Your Hands in Long-Term Care Homes Coaching Project. April 26, 2011

Transcription

1 Just Clean Your Hands in Long-Term Care Homes Coaching Project April 26, 2011

2 Presentation Outline RICNs who we are and how we got here JCYHs Background What we ve done (JCYH Coaching Project) What s next (Survey Completion and Evaluation) Survey Updates Lessons Learned

3 Operation Health Protection, year plan to revitalize the public health system by preventing threats to our health and promoting a healthy Ontario.. Based on recommendations from: SARS crisis by the National Advisory Committee on SARS and Public Health chaired by Dr. David Naylor Expert Panel on SARS and Infectious Disease Control chaired by Dr. David Walker and Interim Report of Mr. Justice Archie Campbell Recommendations: Creation of a Health Protection and Promotion Agency Public Health Renewal Health Emergency Management Infection Control and Communicable Disease Capacity Health Human Resources Infrastructure for Health System Preparedness

4 Infection Control and Communicable Disease Capacity PIDAC Increasing the number of ICPs in hospitals Enhancing IPAC knowledge and practice IPAC Core Competencies Chain of Transmission, Hand Hygiene and Routine Practices (Expansion of IPAC courses and training to front line healthcare providers) Just Clean Your Hands RICNs: Regional Infection Control Networks

5 RICNs are: 14 teams across Ontario, currently aligned with the geographic LHIN boundaries Each RICN has three staff members: Network Coordinator, Infection Control Consultant, Network Assistant RICNs became part of OAHPP in July 2010, reporting in to the IDPC team Continuing to integrate RICNs into IDPC and OAHPP

6 RICNs Take Best Practice to Frontline Health Care Stakeholder contact database developed Outreach and consultation Education Communications Support for the Best Practice Core Competencies (MOHLTC) Patient Safety Indicators (MOHLTC) JCYH Evaluation in Hospitals (MOHLTC) JCYH to Long Term Care roll out

7 RICNs Are: IPAC experts situated across Ontario Backgrounds in acute care, long term care, laboratory, public health Network of networks of healthcare professionals involved in IPAC Ear to the ground Finger on the pulse

8 Just Clean Your Hands - Background MOHLTC program Enhancing IPAC knowledge and practice Ontario began its effort to find out why health care provider hand hygiene compliance was so low (Mar06) JCYH Advisory Committee Focus groups, Logic Model developed JCYH Pilot Study (Dec06-Aug07)

9 Multi-Faceted Approach

10 Toolkit ( Evidence, Information and Technical Tools Educational Tools Promotional & Reminder Tools Observer Tools & Training Program FREE!

11 PIDAC Hand Hygiene Best Practices May 2008 OHA Videoconferences RICN sent invitations to stakeholders Hospital LTCH PHU

12 JCYH LTC Roll Out LTC Focus Groups (fall) Modify JCYH for Hospitals for LTCHs (spring) RICN Roll out Strategy to LTC Pre Roll Out Survey Train The Trainer RICN Workshops Implementation of JCYH Program Auditing OAHPP Business Case to MOHLTC Coaching Visits Personal Carry ABHR Evaluation JCYH Advisory Committee

13 JCYH Status Pre roll out January % (58/69) LTC homes responded 74% responded that they have a hand hygiene program Policy for hand hygiene 86.3% Posters 94.9% Alcohol based hand rub (ABHR) at entry and other locations 98% (Information for visitors/families 86.3%, Policy and procedure for a hand care program 27.4%, Dedicated hand hygiene sinks for staff 41.0%, Hand hygiene compliance audits 52.1%, Standing item on your Infection Control Committee agenda 42.7%)

14 Elements of JCYH being used? Answer Options Response Implementation guide 24.5% Placement tool 13.2% 4 Moments poster 75.5% How to hand wash 84.9% How to hand rub 79.2% "4 moments" for HH pocket card 17.0% Prompt signs 35.8% What is a champion? 5.7% 47 % responded they use JCYH Hospitals tools Elements of JCYH used? Posters, prompts, followed by training videos (39.3%) most common Hand care program 7.5% Training Videos 39.6%

15 Have you audited Hand Hygiene compliance? 52% have audited hand hygiene compliance If you have audited hand hygiene compliance what tool did you use (please check all that apply): 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Acute care audit tool from the "Just Clean Your Hands" program Created your own audit tool CHICA Audit tool From other institution (please list below).

16 100% of LTCHs responded that they have ABHR available Where is the ABHR located? 82% responded Elevators, dining room, lounge, nursing station, kitchen, laundry room, cafeteria Answer Options Response Entrance and exits 98.2% Personal carry by health care providers 42.2% Inside resident/client rooms 30.3% Outside resident /client rooms 48.6% Various locations in hallways 85.3% On med carts 92.7% Inside tub rooms 48.6% Activity rooms hallways 68.8% On change /bathing carts 50.5% On linen carts 32.1% On waste carts 22.0% Other (please specify) 24.8%

17 Hand Hygiene Education 98% include hand hygiene in IPAC orientation for new staff 89% have mandatory hand hygiene in-services 75% offer informal hand hygiene education to residents or families

18 Room for improvement? Tools from JCYH-LTC such as Placement tool Hand care program Formalized education Pocket cards Champions Training videos

19 JCYH Roll Out Delivery Preference Jan 2010 Answer Options % Videoconference for train-the trainer session (s) 23 Teleconference for train-the-trainer session (s) 17 Training webcast (s) with archive for future reference 13 Group workshop with other facilities for face-to-face train-thetrainer session in a central location 49

20 Status November 2010 Jan 2010 Survey - 52% have audited HH compliance (10% with 4 Moments hospital tool) MOHLTC launch (Videoconference/Webcast) RICN Train the Trainer Sessions Nov 2010 Survey 72% auditing HH compliance with the 4 Moments

21 JCYH LTC Roll Out LTC Focus Groups (fall) Modify JCYH for Hospitals (spring) RICN Roll out Strategy to LTC Pre Roll Out Survey Train The Trainer RICN Workshops Implementation Auditing Standardized training across ON OAHPP Business Case to MOHLTC Coaching Visits Personal Carry ABHR Evaluation JCYH Advisory Committee

22 Why On Site Coaching Visit? Many similar issues Every LTCH at a different place in implementing the program Every LTCH is a different design/environmental issues LTC Setting challenges programs, interaction

23 Home versus hospital We have a HH program/hh education If it s that important then it s mandatory

24 Competing Priorities MOHLTC Inspectors

25 LTC Head Wear Public (Municipal) or Private (Owner) Not for Profit or For Profit Corporate Administrator Director of Care (DOC) / ADOC Unregulated Staff PSWs, Dietary, Housekeeping, Recreation Regulated Staff RNs, RPNs, Physiotherapist Other Volunteers, Contracts, Dental, Rehab, etc

26 LTCH Challenges and Opportunities LTC System Challenges and Opportunities for the City of Toronto Six key issues: (i) the changing healthcare environment; (ii) the changing healthcare workplace; (iii) the new Long-Term Care Homes Act; (iv) the growing service demand; (v) the current provincial funding for long-term care; and (vi) the provincial long-term care homes capital renewal strategy. (2008, LTC System Challenges and Opportunities for the City of Toronto, Staff Report, Action Required)

27 Long-Term Care Settings Many buildings are old and design obsolete Residents are mostly elderly with compromised immune systems In hospitals we do things to people, in the LTCH we do things with people..linda Fletcher, Ontario Shores LTC facilities are a home environment (must promote physical, mental, social health) group activities that can provide increased opportunities for person-to-person transmission Occupational, Rehabilitation and Physical therapies are in demand and also increase risk of transmission (person-to-person to environment.to staff)

28 Prediction of institutionalization in the elderly. A systematic review Ageing Jan;39(1):31-8. Luppa M, Luck T, Weyerer S, König HH, Brähler E, Riedel-Heller SG. Department of Psychiatry and Psychotherapy, University of Leipzig, Germany. Abstract OBJECTIVE: in the past decades, many studies have examined predictors of nursing home placement (NHP) in the elderly. This study provides a systematic review of predictors of NHP in the general population of developed countries. DESIGN: relevant articles were identified by searching the databases MEDLINE, Web of Science, Cochrane Library and PSYNDEXplus. Studies based on population-based samples with prospective study design and identification of predictors by multivariate analyses were included. Quality of studies and evidence of predictors were determined. RESULTS: thirty-six studies were identified; one-third of the studies were of high quality. Predictors with strong evidence were increased age, low self-rated health status, functional and cognitive impairment, dementia, prior NHP and a high number of prescriptions. Predictors with inconsistent results were male gender, low education status, low income, stroke, hypertension, incontinence, depression and prior hospital use. CONCLUSIONS: findings suggested that predictors of Nursing Home Placement are mainly based on underlying cognitive and/or functional impairment, and associated lack of support and assistance in daily living. However, the methodical quality of studies needs improvement. More theoretical embedding of risk models of NHP would help to establish more clarity in complex relationships in using nursing homes.

29 Long Term Care Settings More than one-half of all people living in long-term care homes have Alzheimer s disease or other dementias (Canadian Study of Health and Aging, 1994). Host factors immune system, malnutrition, hygiene, functional impairments Length of stay is in years Multiple complex underlying diagnoses Complex physical & psychosocial needs Increased use of antimicrobials / polypharmacy Increased device utilization (feeds, lines, trachs, dialysis, etc.)

30 Long Term Care Settings continued Increased intensity of nursing care and skills required Staffing levels Majority of staff are unregulated (ie. 5:1) Nurse turnover and attracting and retaining skilled professionals Design of rooms overcrowding, shared toilets, few dedicated hand washing sinks Family visitation rates and external providers in the home

31 Barriers to Implementing JCYH in LTCHs 1. Financial Cost of supplies, education, dedicated IPAC time 2. Resources Time to roll out and implement program, Time to educate, Time to audit compliance Staffing challenges for daily activities is already challenged 3. Attitudes/Perception/Culture Why change, we do a good job 4. Competing Priorities Corporate projects, Resident Assessment Instrument (RAI), Environmental Cleaning, Accreditation, RNAO CoP, Resident safety, Quality Health Initiatives, and so on 5. Duplication we already have a hand hygiene program in place 6. Maintaining Home Environment this is our home not a hospital 7. Disruption in business if we have to be re-educated, that must mean we are not doing our job right and all of this disruptive, I have work to finish.

32 Barriers to Opportunity On Site Coaching Sharing ideas and solutions that meet the unique needs of each LTCH Demonstrating importance of JCYH program Sharing successes of other LTCHs to motivate, inspire and advance their program

33 A COACH is someone who partners with others in a commitment to making the other person better based on their individual strengths and goals. A coach helps others find their opportunities and show unwavering faith that every person has the ability to be or do their best. A coach knows when to ask, when to listen, when encourage, when to praise and how to positively challenge procrastination and barriers to the end result. They are masters in the conversations of Facilitating, Teaching, Mentoring and Confronting.

34 JCYHs for LTCHs Coaching Project Building on the roll-out work completed last year, RICNs proposed the JCYHs Coaching Project to support LTCHs in their implementation of JCYHs using one-on-one coaching to reinforce the messages of the program

35 JCYH Coaching Goals Coach JCYH Leaders and Hand Hygiene auditors in implementing the JCYH program Motivate the JCYH Lead and Senior Management to advance the JCYH program Improve understanding and application of the 4 Moments for hand hygiene in LTCH Improve auditor/ JCYH Lead confidence in auditing accuracy Support each LTCH in Ontario with a JCYH expert Learn from the successes of our LTCHs

36 What We Did develop a work plan! Materials Development Human Resources, Orientation and Training ABHR Procurement Program Delivery Reporting Communications Program Coordination Logistics Evaluation

37 Materials Development Pre-funding 2 day work camp! Teleconference meetings and coordination of revisions Tool development for JCYHs Coaching binder Post-funding Compile and distribute the Coaching binders Develop/share other tools as indicated Database development and training Update based on feedback

38 HR + Orientation + Training Developed the JCYHs database 25 coaches hired 6 assistant coaches hired Two, 2-day training sessions offered first 2 weeks of Feb Weekly coach teleconferences to continue learning/sharing SharePoint site set-up for information sharing

39 Support and Leadership Departments impacted in addition to the RICNs: HR: onboarding and offboarding, consultation Finance: pay, expenses, Tcards IT: computers, database, SharePoint Communications: teleconferences, newsletters, translation Cathy, Louis and Melissa! This support was crucial

40 Program Delivery JCYH Coaching Program summary Review program components with RICN staff JCYH coaches to visit LTCH Workshops - Implementation, Audit, and both combined Our current status report indicates that we are now at

41 Reporting Pre-Visit Survey Status (94%) On-Site Survey Status (71%) Readiness Survey Education 173 sessions in last year

42 Communications Initial communications to stakeholders and partners Coach FAQs RICN JCYH Update/Status Reports 2 - LTCH/ partner JCYH Flyers one more planned RICN newsletter article Website updates News bulletin updates

43 Program Co-ordination Logistics JCYHs database Training for JCYH coaches Weekly check-in teleconferences Incorporating feedback Weekly data collection and reporting Finance Budget Tcards Expenses Internet access addresses What can we reasonably get done?

44 Evaluation Short timelines = decrease chance of completing surveys and, therefore, unable to complete evaluation by end of project period. Solution: Hire someone to develop a Framework Review existing data sources Review analysis options including survey analysis, interviews, case studies, etc.

45 JCYH-LTC Evaluation Train the Trainer Workshop Evaluation Summary By Overall and Agenda Type (Implementation, Auditing, Combined) Barriers and Enablers for Implementation of JCYH In LTCHs in Ontario JCYH-LTC Evaluation Pre Visit Phone Survey % completed On Site Coaching % Completed Train the Trainer Workshops % Completed Pre Roll Out Survey Jan/Feb 2010 Summary of Results RFS Procurement Framework for Uptake and Behaviour Change Evaluation Pre Visit Phone Survey Analysis of Results On Site Coaching Analysis of Results On Site Coach Experience Evaluation Summary Financial Report Travel Expenses Overall and by Region

46 Evaluation will address: The implementation of the coaching supports by the RICNs, including an assessment of the quality, accessibility and utility of the training services to the LTCHs; The satisfaction of the LTCHs with the coaching supports; and The impact of the coaching supports on the implementation of JCYH in the LTCHs and on the knowledge of LTCH staff.

47 Evaluation Approach Ethical: informed consent Consultative and Informative: provide updates and seek feedback Realistic: maximizes available resources Accessible to our French participants and partners Adaptable: Approach and Methodology generic enough to apply to other programs delivered in a similar manner

48 Figure 1: JCYH Coaching Project in LTCHs Logic Model Coaching Project Logic Model

49 Data Collection and Analysis Methods Table 3: Existing and Additional Data Sources Existing data Documentation and records Pre-visit phone survey Coach evaluation form On-site coaching and debriefing tool Additional data Key informant interviews (with RICN staff, LTCH administrators) Post-visit phone survey Coach exit survey Coach discussion group JCYH working group discussion group Show Case Facilities

50 Data Collection Documentation and Records Background (JCYHs Working group, Advisory Committee, etc.) Business case JCYHs Coaching Tools Financial documents Notes, minutes, success stories Pre and Post Visit Survey administer the same survey; easier to administer than inperson surveys; ensures that the survey is administered the same way for the pre and post-visit; help ensure comparable results

51 Data Collection Coach evaluation forms Developed as part of the Coaching tools Left at LTCH after visit (approach may have varied by RICN) Data entered into RICNAC LTCH Feedback On-Site Coaching and Debriefing Tool Information collected and entered into RICNAC Qualitative and quantitative data

52 Additional data Key informant interviews (with RICN staff and LTCH administrators) Coach exit survey Coach discussion group responses (20 minutes) Coach discussion group responses (20 minutes) JCYH working group discussion group Show Case Facilities 1 per region with focus on learning what works

53 Highlights of what we ve seen JCYH Program Coaching Implementation status - perception differs from the observed status for LTCHs ABHR availability Observations and Monitoring in LTCH Preparation Coach experience feedback LTCH feedback

54 JCYH Program: Senior Management Support 99% of facilities surveyed (559/567) indicate they have appointed a JCYHs lead - on-site surveys indicate 86% (382/443) of Sr managers are aware of the JCYHs program 64% pre-visit survey interviewees indicate that resources have been allocated for JCYHs - further probing by coaches during on-site visit indicates that new resources are not being provided work is to be carried out using existing resources How does this discrepancy affect implementation status?

55 JCYH Program: Environmental changes Pre-visit survey 100% of ABHR is alcohol based 70% (394/563) previsit, 69% (302/438) on-site - indicate placement in resident s room On-site visits so far indicate 20% (85/435) have ABHR at resident s bedside (or at point of care) On-site visits confirm that 87% have ABHR in shared area (379/437)

56 JCYH Program: Education Previsit surveys - 87% (492/564) staff attended initial implementation TTT; 76% (420/560) had staff who attended the Observation and Monitoring TTT On-site surveys: 55% (242/441) direct care staff trained, 62% (248/403) all shifts, 45% (197/440) all non-direct care On-site survey: 66% (285/434) have a person designated to deal with hand care; 23% (102/435) have intact skin policy

57 JCYH Program: Resident and Family Engagement 63% (352/562 in pre-visit survey) share information with residents; on-site visit - 53% (233/436) educate residents 33% (183/560) include Resident Council in JCYH implementation; on-site - 52% (228/442) educate Resident Council 58% (323/561) shared information with family; on-site - 54% (237/441) educate family 26% (144/560) include Family Councils in JCYH program; onsite - 49% (216/441) present to Family Council

58 JCYH Program: Hand Hygiene Champions Pre-visit - 64% (317/496) of LTCH are using JCYH Champions On-site - 59% (260/440) have JCYH champions 82% indicate that champions are trained Only 46% have been using the JCYHs tools

59 JCYH Program: Ongoing Monitoring and Observation Previsit Survey On-Site Survey Trained in the 4 Moments - 64% (358/559) of observers 59% (290/488) are using the JCYHs audit tool to document compliance 51% (147/290) who use the JCYHs tools, analyze data Trained in the 4 Moments - 70% (306/440) 33% of those who analyze their data (48/147) are using the MOHLTC analysis tools 20% use a facility spreadsheet and 28% use other tools

60 Ongoing Monitoring and Observation, cont. 23% (66/290) of those who use the JCYHs audit tools are using the onthe-spot feedback form 47% (66/141) respondents in pre-visit 49% (119/245) respondents on-site

61 The Coaching Experience: We began this project with many questions: How would we recruit the coaches? How would we prepare the coaches for this task? How would they be received? How might the coaching experience affect them and the LTCH staff they encountered?

62 Coaching Exit Survey results Based on 31 responses 32% had more than 10 years experience as an ICP 65% had previous acute care experience 19% had experience in LTCH After Coach Training: 19% felt very well prepared after training 42% felt well prepared 39% felt adequately prepared No respondents indicated they felt unprepared

63 Coach Preparation How helpful were each of the following in preparing you to fulfill your role? JCYH Coach Exit Survey Essential Very helpful Somewhat helpful A little bit helpful 5 0 Your past experience or qualifications Coach orientation JCYH materials Coaching binder Weekly coaches teleconferences RICN staff guidance SharePoint website Not at all helpful Not applicable/did not receive that support

64 Coaching Visits Visits ranged from 2.5 to 7 hours Average time was around 4 hours Top 3 Things that made it easier to Coach: 1.Having the support of the local RICN 2.Having the JCYH program tools and coach orientation tools 3.Carrying out the pre-visit phone survey

65 Challenges: Top thing that made it more difficult to coach: 1.Time, time and time! i. the time it took to contact the right person at the home to get the information needed, ii. the time it took to get to these homes, iii. the time of year for travel considering weather, outbreaks, year-end

66 How satisfied were you (coach) with each of the following supports/resources provided to you?

67 How were LTCHs affected? Coaches said 26/30 thought they helped improve understanding the 4 moments, 21 thought much better 27/30 felt that an impact was made getting environmental changes in place to support JCYH 83% of coaches felt they helped advance implementation of JCYH LTCH said: 154/164 (94%) thought that the visits helped them advance their implementation of the JCYH program

68 LTCH Responses to Coaching Overall score for all coaches was 4.8 out of 5 including professional, organized, clear, effective, encouraged questions provided positive feedback LTCH scored Coaches at a 4.7 out of 5 in helping them improve their skills 155/164 (95%) - coaching visit was a good use of their time

69 Lessons learned coach training need for reinforcement of the 4 Moments for HH in LTCHs reports in RICNAC pilot whenever you can! Surveys Reports Evaluation ensure supplies are secured Ran out of some JCYH product stock

70 Lessons learned Timing: Visits Jan Mar in Ontario can be challenging! Reaching the LTCH s phone call attempts reception to coaches Many competing priorities in LTCHs When is important!

71 Lessons learned LTCH scenarios were really needed to help LTCH understand application of 4 moments Data management tools are needed ASAP Many factors affecting full implementation In many homes, coaching helped re-energize the JCYHs lead Lack of understanding of 4 moments will impact results of any auditing already carried out Champions are not utilized to their full extent spread responsibility around Challenge in how to make JCYH a priority Many coaches felt RICN follow up was advisable

72 Successes Hand Hygiene Tips in the monthly calendar

73 It s in your hands Thank You