Resident-to-Resident Assaults AIM: To decrease incidents of Resident to Residents assaults by 5% in the Fiscal Year (FY) 2011-2012. MONITORING: Data is collected from all instances in which State of California 341 (SOC341) forms are submitted to the Ombudsman and from incidents that are reported to the California Department of Public Health (CDPH). SFGH STRATEGIC PLAN: Clinical Quality Service Excellence The SFBHC SNF resident population includes psychiatric and medical diagnoses, as well as cognitive impairment. Clinical presentation of the population includes the propensity for assaults which may be impulsive and unprovoked. Data collection began in October 2008 in response to the CDPH mandate to report all incidents regardless of injury. Data has been collected by monitoring of the number of incidents and related factors, i.e. environment and diagnosis. RESULTS: BHC-SNF Resident-to-Resident Assaults FY 2009-2012 60 50 40 30 20 10 0 26 11 BHC-SNF Resident-to-Resident Assaults 2009-2013 37 37 2-NORTH 2-SOUTH TOTALS * FY 12 13 = July 2012 Feb 2013; figures displayed are projected counts by end of FY 2013. ANALYSIS: BHC-SNF Resident-to-Resident Assaults FY 2009-2012 28 9 FY 09-10 FY 10-11 FY 11-12 FY 12-13* Fiscal Year (FY) 2011 2012 data displays a 38% overall increase (+33%, 2-North; +39%, 2-South) in assault rates from FY 2010 2011 (+14 incidences). 51 39 12 27 24 3 Sustaining the following initiated action plans: Culture of Safety Assault Prevention Program: A crisis management education & training program addressing workplace safety in the care setting to facilitate strategies for preventing and managing identified crisis situations. Multidisciplinary team reviewed and updated previously established curriculum in response to changing needs of programs and populations. [July 2012] BHC Interdisciplinary Team Rounds (IDT): IDT meeting and review process reexamined to maximize efficiency in reviewing pertinent resident issues and care plan efficacy. [July 2012]
ANALYSIS: BHC-SNF Resident-to-Resident Assaults FY 2009 2012 (cont.) Eleven (11) distinct residents identified as the Aggressors were involved in 46 of the 51 (90%) assault incidences. [FY 2011 2012] There were a total of 16 distinct residents identified as Aggressors out of a total of 59 residents (27%). [FY 2011 2012] Factors associated with these outcomes include: o Increased vigilance of staff awareness and knowledge of reporting requirements. o As a safety net facility, BHC-SNF has responded to the system s demand and increased admissions of clinically challenging residents with higher behavioral risks who have been declined by other facilities. o Ongoing progression of psychiatric illnesses in existing residents manifesting in inappropriate behaviors, poorer coping skills, and previously-established care plan failures. o Residents with severe progressing dementia or traumatic brain injury (TBI) have shown to be repeatedly involved in assault incidences. Assault incident characteristics: FY 2010-2011 o TRIGGERS: 54% (20/37) of incidences appeared to have been unprovoked assaults or without clear identifiable causes. o DEMENTIA: 11% (04/37) of incidences involved residents without a diagnosis of dementia. o INJURY: 100% (37/37) of incidences resulted in minor or no physical injury to involved residents. Assault incident characteristics: FY 2011-2012 o TRIGGERS: 55% (28/51) of incidences appeared to have been unprovoked assaults or without clear identifiable causes. o DEMENTIA: 14% (07/51) of incidences involved residents without a diagnosis of dementia. o INJURY: 96% (49/51) of incidences resulted in no physical injury to involved residents. Remaining 4% (02/51) if incidences have resulted in minor injuries to involved residents (e.g. bruising). BHC Activity Program Enrichment: Multidisciplinary review and development of structured setting activities to better enrich residential quality of life by fostering independence, skillbuilding, and reducing perceived boredom. Resident Discharge Planning: Multidisciplinary team initiated a review of resident discharge plans and facilitated the appropriate and successful discharge of 25 residents and reduced the program census to 34 residents (17 per unit). Reassessment of Resident Cohorting and Unit Diagnostic Mix: Interdisciplinary reviews of residential mix in unit milieu to best ensure unit safety and provision of resident care needs. [July 2012]
RESULTS: BHC-SNF Resident-to-Resident Assaults FY 2012-2013 BHC-SNF Resident-to-Resident Assaults FY 2012-2013 TO DATE 2-North 2-South TOTALS 10 9 8 7 6 4 3 2 2 2 1 1 1 1 1 0 0 0 0 0 0 0 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 California Department of Public Health (CDPH) All Facilities Letter (AFL) 12-01 & 12-50: Clarification of Statereportable assault incidences involving SNF residents based on provided criteria. [Feb 2013] ANALYSIS: BHC-SNF Resident-to-Resident Assaults FY 2012 2013 TO DATE Fiscal Year (FY) 2012 TO DATE (February 2013) data currently displays a 65% overall decrease in assault incidences from FY 2011 2012 (-33 incidences). o Projected outcome by end of FY 2013: A 47% overall decrease (-24 incidences) Five (5) distinct residents identified as the Aggressors were involved in 11 of the 18 (61%) assault incidences. [FY 2012 2013 TO DATE] There were a total of 12 distinct residents identified as Aggressors out of a total of 34 residents (35%). [FY 2012 2013 TO DATE] With an average rate down to about 2 assault incidences per month, compared to an average of about 4/month in FY 2011 2012, there is projection of at least an approximate 50% decrease of incidences by end of fiscal year, June 2013 ( 25 or less total incidences).
ANALYSIS: BHC-SNF Resident-to-Resident Assaults FY 2012 TO DATE (cont.) Absolute Rates: FY 2011 2012 vs. FY 2012 2013 TO DATE o 51 assaults / 59 total residents = 0.86 assaults/resident [FY 2011 2012] o 18 assaults / 34 total residents = 0.53 assaults/resident [FY 2012 2013 TO DATE] o 27 assaults / 34 total residents = 0.79 assaults/resident [FY 2012 2013 PROJECTED] Relative Rates: FY 2011 2012 vs. FY 2012 2013 TO DATE o 51 assaults / 16 distinct residents = 3.19 assaults/resident [FY 2011 2012] o 18 assaults / 12 distinct residents = 1.50 assaults/resident [FY 2012 2013 TO DATE] Factors associated with these outcomes include: o Resident Discharge Planning: Since August 2012: SFBHC SNF census was decreased from a total of 59 to 34 residents [17 residents per unit: 2 North & 2 South]. With only 17 residents on each unit, living space is increased. All remaining Residents now have private rooms. A notable amount of Residents diagnosed with dementia have been appropriately and successfully discharged. Remaining residents have been cohorted to different units based on reassessed assault risks. o BHC Interdisciplinary Team Rounds (IDT): More systematic assessment of assault risks, more consistent review, reporting of incidents, more comprehensive care planning, and more timely intervention. o BHC Activity Program Enrichment Decrease in perceived boredom and down time for residents, as well as providing additional means of resident distraction from inappropriate behavior. o Culture of Safety Assault Prevention Program Providing staff increased awareness of safety risks and interventional tools to manage risk factors to prevent or minimize harm to residents and themselves. Assault incident characteristics: FY 2012 TO DATE o TRIGGERS: 50% (09/18) of incidences appeared to have been unprovoked assaults or without clear identifiable causes. o DEMENTIA: 28% (05/18) of incidences involved residents without a diagnosis of dementia. o INJURY: 94% (17/18) of incidences resulted in no physical injury to involved residents. 6% (01/18) of incidences resulted in minor injury (e.g. abrasion) to the involved resident.
Resident Satisfaction Survey AIM: Resident overall positive response in SFBHC-SNF will increase by 5% in each identified survey domain from Fiscal Year (FY) 2011-2012 to FY 2012 2013. MONITORING: Data is collected from bimonthly BHC staff administered Resident Satisfaction Surveys adapted from Consumer Satisfaction in Nursing Homes: Current Practices and Resident Priorities (2004) (Robinson, J.P.; Lucas, J.A.; Castle, N.G.; Lowe, T.J.; Crystal, S.) distributed to and collected from BHC-SNF residents. The survey is distributed during resident community meetings. The survey collects data in areas of activities, environment, care and services, caregivers, meal, and wellbeing. SFGH STRATEGIC PLAN: Clinical Quality Service Excellence The San Francisco Behavioral Health Center - Skilled Nursing Facility (SFBHC-SNF) is a Distinct-Part Skilled Nursing Facility of the San Francisco General Hospital & Trauma Center. Service delivery is based on the interdisciplinary team model with the resident's personal goals and individualized needs serving as the basis for treatment planning. DESCRIPTION: Single page thirty-eight (38) item survey categorized into six domains: Activities, Environment, Care & Services, Caregivers, Meal, and Well-Being. Item questions include: Are you satisfied with the choices in activities? Is the unit home-like? Do the staff treat you with dignity and respect? Do you have enough food choices? The average percentages of satisfied and dissatisfied responses are displayed for FY 2011 2012 and FY 2012 2013 year to date data. METHODS: Administered every other month during weekly 2-North (2N) and 2-South (2S) units community meetings. Staff administers and staff facilitates resident participation. Completion of entire survey for each resident may require multiple community meeting attendance. English language version only. RESULTS: BHC-SNF Resident Satisfaction Surveys 100% 80% 60% 40% 20% 0% BHC-SNF Resident Satisfaction Survey FY 2011-2012 AVERAGE % Satisfied % Dissatisfied % No Response 34 31 27 27 20 26 12 17 17 8 17 15 54 52 56 65 63 59 Activities Environment Care & Services Caregivers Meal Well-Being Review validity/applicability of Resident Satisfaction Survey Setting/populationspecific factors Identified items & domains Standardizing survey administration Increase resident participation Incentive for anticipation Simplify survey questions Promote staff engagement with resident s participation Consider language or communication barrier issues Continue BHC Activity Program Enrichment: Multidisciplinary review and development of structured setting activities to better enrich residential quality of life by fostering independence, skillbuilding, and reducing perceived boredom.
RESULTS: BHC-SNF Resident Satisfaction Survey FY 2012 2013 TO DATE BHC-SNF Resident Satisfaction Survey FY 2012-2013 AVERAGE TO DATE* % Satisfied % Dissatisfied % No Response 100% 20 23 27 29 24 80% 34 12 20 12 8 17 60% 14 40% 20% 68 57 61 63 59 52 0% Activities Environment Care & Services Caregivers Meal Well-Being * FY 12 13 = July 2012 January 2013 Assessments obtained from activities are then discussed with the treatment team in relation to resident care planning. Ongoing review of survey data to promote positive change in setting and care Per identified domain Interdisciplinary team involvement Service Excellence & resident experience BHC-SNF Resident Satisfaction Survey FY 2011-2012 v. FY 2012-2013 POSITIVE RESPONSE AVERAGE TO DATE* 2011-2012 2012-2013 80% 60% 40% 20% 0% 68% 65% 63% 54% 52% 57% 56% 61% 63% 59% 59% 52% Activities Environment Care & Services Caregivers Meal Well-Being * FY 12 13 = July 2012 January 2013
ANALYSIS: BHC-SNF Resident Satisfaction Survey FY 2011 2012 & FY 2012 2013 TO DATE General response rate is about 51% (Ave. 30 resident participants, 2-North & 2-South; 59 total residents) Low response rate may reflect resident s impaired ability to respond or lack of willingness to participate in the survey. Some are not verbal or are too impaired cognitively to be able to respond. Some refuse to participate. Residents are overall most satisfied in the Caregiver domain (65%, FY 2011 2012). Residents are most dissatisfied in the Environment, Care & Services, and Meal domains (17% each, FY 2011 2012). Overall positive response change in satisfaction per identified domain between FY 2011 2012 and FY 2012 2013 to date: o Activities: 26% increase o Environment: 10% increase o Care & Services: 9% increase o Caregivers: 3% decrease o Meal: 6% decrease o Well-Being: 12% decrease
Reduction of Insulin-related Medication Errors AIM: Reduce Insulin related transcription and administration errors by 30% by June 30, 2012 MONITORING: Staff survey regarding insulin transcription process; audit of insulin transcription on new Insulin and Insulin-related Orders MARs, unusual occurrence reports of medication errors related to insulin transcription/administration. BACKGROUND: The American Society of Health Systems Pharmacists (ASHP) Professional Practice Recommendations for Safe Use of Insulin in Hospitals recommends the following transcription practices to reduce the risk for insulin errors: When handwritten MARs are used: 1. Minimize the number of pages used and fragmentation of insulin-related orders. In 2011, a separate MAR page(s) for transcription of insulin and insulin-related orders (glucagon, fingersticks, hold parameters) was implemented. After Introduction of the insulin-related MAR, staff was surveyed regarding its safety, efficacy and ease of use which resulted in a Likert scale average of 4.28 (favorable) response (1.0 = strongly disagree, 5.0 = strongly agree). Audit of Insulin and Insulin-related orders MARs was conducted in October of 2011 and follow-up audit was conducted in March 2013, to assess adoption of intervention. Insulin and Insulin-related orders AUDIT - BHC-SNF 2011 2013 # of Residents with Insulin Orders 5 3 # of Residents with Insulin-related 10 3 Order MAR pages # Insulin-related Order MARs with 2/5 0 Discrepancies Types of Discrepancies a) Insulin-related order MAR includes oral diabetes med b) One meal/snack order transcribed in wrong section N/A c) One FSBG order transcribed on wrong page Insulin and Insulin-related orders AUDIT - BHC-MHRC 2011 2013 # of Residents with Insulin Orders 2 2 # of Residents with Insulin-related 2 2 Order MAR pages # Insulin-related Order MARs with 0 0 Discrepancies Types of Discrepancies N/A N/A Review of Unusual Occurrence Reports for Insulin-related errors revealed a reduction in errors. Insulinrelated medication errors were reduced by 50% on the SNF for 2011 and 2012 as compared to 2009 and 2010 (average of 2 errors/year to 1 error/year). Insulin-related errors were reduced significantly with the use of the insulin and insulin-related orders MAR. Improvement was sustained from the time of adoption of intervention in 2011 through follow up audit period (2012).
2. Transcribe all insulin orders together. On the MHRC, insulin-related error rate was reduced from an average of 2 errors/year in 2009-2011 (preintervention) to zero errors in 2012. 3. Insulins to be administered together in one syringe (e.g., mixing regular and NPH prior to administration) are always transcribed together. 1 3 2 Insulin-related Medication Errors BHC-SNF Intervention 8/11 SFGH STRATEGIC PLAN: Service Excellence Clinical Quality 1 REFERENCE(S): ASHP Professional Practice Recommendations for the Safe Use of Insulin in Hospitals, http://www.ashp.org/s_ashp/ docs/files/safe_use_of_insuli n.pdf, accessed 02/06/12. 0 4 2009 2010 2011 (preintervention) 2011 (postintervention) Insulin-related Medication Errors BHC-MHRC Intervention 6/11 2012 3 2 1 0 2009 2010 2011 (preintervention) 2011 (post intervention) 2012
Antipsychotic Use and Documentation BACKGROUND: In early 2012, CMS set a goal for reduction of antipsychotic prescribing in skilled nursing facilities by 15% by December 2012. Prescribing for schizophrenia, Huntington s disease and Tourette s disorder were excluded from this goal. This goal is part of an overarching larger aim of improving dementia care in skilled nursing facilities. AIM: To improve documentation of efficacy and adverse effects of antipsychotics by 80% by January 2013. To reduce inappropriate prescribing (use for non-psychotic behaviors in demented residents) by 15% by December 2012. MONITORING: New documentation tools implemented: 1. Specific indication (implemented 11/12) 2. Target behavior for monitoring (implemented 11/12) Charts audited for a total of 19 residents who were in the facility from January through December 2012 and prescribed antipsychotics. EXCLUSIONS: Six residents admitted or discharged during the audit period One resident not prescribed an antipsychotic Indication for Antipsychotic Indicator Number Percent Residents with psychotic disorder indication 14/19 74 % Residents on antipsychotic with diagnosis of dementia Demented residents without other psychotic disorder indication 5/19 26 % 4/19 21 % Documentation Tools Indicator Number Percent Identified target behavior 19/19 100 % Count of target behaviors reported monthly to MD 19/19 100 % Template Physician s Progress Note for Antipsychotic Use Completed Adverse effects to monitor incorporated into care plan 19/19 100 % 19/19 100 % Consent Indicator Number Percent Complete consent form 11/12 7/19 37 % Complete consent form 1/13 16/19 84 % Psychotropic consent documentation continues to warrant improvement efforts. New consent documentation tools developed Begin new consent process 4/13 Follow up audit 2013 Adverse effects table developed for consent form will also be used to improve care planning tools for psychotropic adverse effect monitoring
3. Template physician s progress note (implemented in 11/12) 4. Adverse effect information incorporated into chronic psychiatric condition care plan (implemented 12/12) Gradual Dose Reduction (GDR) Indicator Number Percent Residents with attempted GDR 15/19 79 % Residents with successful GDR 15/15 100 % Demented residents with attempted GDR 5/5 100 % Demented residents with successful GDR 5/5 100 % 5. Count of target (implemented in 12/12); monthly count of target behaviors reported to physician (implemented 1/13) 6. Revision of informed consent with addition of supporting documentation regarding adverse effects (begin implementation 4/13) Audited medical records for all clients who were in the BHC-SNF from January through December 2012. Audited for: Implementation of above tools Completion of current psychotropic consent forms 20 18 16 14 12 10 8 6 4 2 0 Gradual Dose Reduction of Antipsychotics (Reported in Haloperidol Equivalents) 40% dose reduction Jan, 2012 Dec, 2012
Gradual dose reduction of antipsychotics SFGH STRATEGIC PLAN: Service Excellence Clinical Quality REFERENCE(S): 1. Bonner, A. (1/31/13). Improving Dementia Care and Reducing Unnecessary Use of Antipsychotic Medications in Nursing Homes. Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality. 2. Department of Health and Human Services, Office of Inspector General: Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents. May 2011. https://oig.hhs.gov/oei/rep orts/oei-07-08-00150.pdf. 3. Andreasen NC, et al. Antipsychotic Dose Equivalents and Dose-Years: A Standardized Method for Comparing Exposure to Different Drugs. Biol Psychiatry 2010; 67: 255-262. 30 25 20 15 10 5 0 Gradual Dose Reduction of Antipsychotics Demented Residents (Haloperidol Equivalents) 31% dose reduction Jan, 2012 Dec, 2012 ANALYSIS & CONCLUSIONS: A large majority of residents had psychotic disorder diagnoses, however, antipsychotic dosing was reduced significantly in 2012. Overall, antipsychotic dose was reduced by 40 %. This success was likely due to the following factors: Consistent efforts from medical staff to attempt gradual dose reduction of antipsychotics improved care planning and implementation of non-pharmacologic interventions reduced census in the facility Of demented residents in the facility (the CMS target population for reduction of antipsychotic use): 83% were treated with an antipsychotic 100% of residents treated with antipsychotic had successful gradual dose reduction Antipsychotic burden was reduced by 31 %
For any identified undesirable patterns or trends related to safety or quality of care: ADEQUACY OF STAFFING Was adequacy of staffing identified as contributing to possible causes? NO If yes, please describe results of analysis and any actions taken to resolve identified problems: N/A None notable. PERFORMANCE IMPROVEMENT CHALLENGES