Quality in Coastal: Priority, Possibilities and Pain

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Mike Nader | October 1st, 2015

I’m trying not to take it personally, but my last blog post about back-to-school craziness and the need to focus on the key issues in Coastal was met with the sound of crickets. True, more than 500 people read it but not a peep in response. I get it, people are busy and maybe there wasn’t much to say about a general overview of Coastal’s four pillars. 3d render medical illustration of the bladder pain - side view

But today’s topic is quality, our first Coastal pillar and an issue that I know many of you have great ideas and passionate opinions about so I’m hoping I’ll hear comments from at least a few people  and get a discussion started around this.

Quality in health care can be a wide-ranging discussion. But I’m suggesting that we concentrate on some key measures: in particular the Balanced Scorecard measures that we’re evaluated on regularly (and publicly) throughout the year.

Of these, Care Sensitive Adverse Events (CSAEs) are at the top of my priority lists right now. For those of you unsure about what a CSAE is, these are events such as Catheter Associated Urinary Tract Infections (CAUTI) or Hospital Associated Infections (such as C. Difficile, pneumonia, etc.) that can sometimes be caused by moments of inattention during the care process.

Within Coastal, our 2014/15 CSAEs are higher than our targets and our number of occurrences are trending in the wrong direction. For example, our C. Difficile rates appear to be the highest they have been in two years and roughly double our average rate.

An ongoing battle

Many of you will have been involved in or heard about a number of initiatives across our facilities that focus on reducing the risk of a patient acquiring a CSAE. I thank you for taking part in that work as I believe it’s vital to us reducing these in Coastal.

Will make a difference

One of our more recent activities was choosing 10 acute care units within Coastal to begin the Releasing Time to Care (RT2C) program. RT2C has been in place in units in both Squamish General and Richmond Hospital for a couple of years now and results in those units show significant improvements in a number of areas, including CSAEs.

Some units such as LGH 4E have been able to make notable strides in reducing their CSAEs over the last few months/years, by concentrating on implementing the CAUTI strategies rolled out.

Going forward, I need everyone’s assistance to help focus our attention on these types of events as, in certain cases, there appears to be some misunderstanding around what a CSAE is, how they’re tracked and how we can ensure that proper practices are followed on a daily basis.

Have an idea?

Got a good idea for how we can reduce our CSAEs or any other quality of care issue? Let me hear about it.

About the Author

Mike Nader
email iconMike.Nader@vch.ca  

As Chief Operating Officer – Coastal, Mike Nader oversees the delivery of health care on the North Shore, Sea-to-Sky, Sunshine Coast, Powell River, Bella Bella and Bella Coola. Prior to this role, Mike served as the Chief Operation Officer of Richmond. Before that, he was the Executive Director of the consolidated medical imaging service at Vancouver Coastal Health, Providence Health Care, Fraser Health, and the Provincial Health Services Authority. View all posts by Mike.

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10 comments on “Quality in Coastal: Priority, Possibilities and Pain

  • Terri Betts says:

    Lori,
    I’m just getting around to reading this now. Thank you from the bottom of my heart, for writing what you did. It certainly reflects accurately what I see in my own department, and what I see around me when I’m on the nursing units.
    Everyone in your profession is surprisingly helpful to us pharmacists when we are upstairs on our clinical assignments.
    As our department tries to balance the bottom line in our new world of consolidation, we are stretched more thinly, with less continuity of care, than we had 10 years ago when I came to Lions Gate from BC Children’s Hospital. We rely even more on the nursing staff to be our eyes & ears, and consult us when there are drug therapy issues to be addressed, and I give all of you endless credit for noticing the things that you do, despite how busy we all are, and bringing us into the discussion if we aren’t there already.
    It’s only whatever camaraderie, spirit of teamwork, and compassion we have left for each other and for our patients that holds Lions Gate Hospital together these days. If only we had a little help to get ahead, instead of being permanently stuck in crisis-management mode….

    • Mike Nader says:

      Thanks Terri for your comments.

      I appreciate how hard Pharmacy staff work with our other clinical folks to ensure our patients receive the appropriate medication at the right times.

      And I was gratified to hear you agree what I’ve seen with the LGH nursing staff – that they have camaraderie, a good spirit of teamwork and compassion in abundance.

      But I’m sorry to hear you feel you’re not able to approach things as proactively as you want to. That wasn’t the goal of consolidating services – it was done to try to eliminate duplication, improve safety, minimize delays find savings and ultimately improve patient care within a sustainable system.

      Before I was the COO here in Coastal (and prior to that in Richmond), I was the Executive Director for Medical Imaging, a consolidated service like Pharmacy. I agree that there were and are challenges. Many of our staff felt “orphaned” and not part of the care team. This was one of our many challenges as we formed our new team across the Lower Mainland. However, while there were definitely challenges in how our teams felt, there were benefits such as being able to leverage resources across the Lower Mainland (for example, our extraordinary physicist team who was able to assess and reduce the radiation dose of our equipment through their work).

      I know that our goal in the Coastal Community of Care and across VCH is to recognize and support the work of the entire team. If you’ve got ways that you think we could be addressing issues that would make it easier for you to deliver great patient care, I’d encourage you to talk to your manager or feel free to e-mail me directly.

    • Terri Betts says:

      Thanks, Mike, for your thoughtful reply to my comments. I may send you a few thoughts by e-mail, as you clearly appreciate some of the challenges faced by consolidated departments.

  • Lori baker says:

    First of all I might say that if you want folks to reply, it is tricky when this message pops up “You’re using a browser that Disqus plans to stop supporting soon”, and the other links don’t like it either as your work computer is too old. Sigh.
    One way to stop Cdiff would be to have patients in private rooms, and surgical patients not co-horting with medical patients. The infection control rate in surgical hospitals in the States is 0.02% because there are private rooms.
    CAUTI: Yup. Get the catheters out asap. I will say when I am doing my chart reviews, the majority of my patients who have UTI’s, have actually come in with them, which has been the cause of their fall.
    I agree that the budget needs to be balanced…as do all government budgets, but hospitals these days are run as a business, and I don’t know of many businesses that can thrive on cutbacks alone. They also need profits. (Surprisingly, I did graduate in Business Admin before Nursing).The most smoothly run businesses have little turnover due to job satisfaction usually promoted from positive feedback from above. Magnet organizations thrive when people in the organization feel they are doing their jobs well. Right now that’s sometimes hard to feel. I believe if we keep the patient as the centre of our focus we never stray to far from the right decision. Treat them as you would like your family members to be treated. Sometimes “Home is Best”. but sometimes it’s not. There are few supports for our elderly and infirm population trying to survive at home. Those who have contributed all their lives to society, get forgotten. Sad.
    I know it’s difficult to walk in Administrator’s shoes, but it’s also hard walking in our shoes, trying desperately to hold the ladders upright, for those on a rapid climb up. After 41 years of Nursing, I still hold my patient as my compass, and will not budge.

    • Mike Nader says:

      Thanks for your insightful comments Lori.

      You should know that your compassion and patient focus is well known throughout LGH as is your reputation for going above and beyond to help patients. Sorry for the lengthy response but In order of your comments:

      Cdiff – I agree that ideally, we’d be able to have private rooms for all of our patients. This is the Ministry of Health’s standard for all new acute care facilities but the challenge is that we wouldn’t have enough beds at LGH if we tried to put everyone in private rooms. As you may know, we’re reviewing our acute care needs through the clinical facility planning that Leanne Appleton is leading. Through that process, we’ll be able to identify our future demands and plan for a new facility but this is obviously a long-term solution.

      Catheters – re: get the catheters out. I’m aware that a number of the patients that staff see already have a UTI before they arrive in hospital for care. This is a challenge for our staff and physicians as they attempt to address the patient’s UTI as well as their other needs. However, we clearly have the ability to influence catheter-acquired UTI’s within the hospital. In the numerous Accreditation Canada surveys I’ve been involved with, I’ve seen the difference that consistently following the Required Organizational Practices can make in terms of outcomes and know that this will continue to be emphasized by our Professional Practice folks as we gear up for VCH’s survey in less than a year.
      I hope this ongoing education for staff and physicians will have an effect but want to hear from staff and our Professional Practice folks if there are ways we can improve our numbers.

      Budget & job satisfaction – I agree with your comments around the need to balance our budgets here in Coastal but not at the expense of job satisfaction nor quality of care. I don’t think these are mutually exclusive and, like you, I think we need to avoid cutbacks alone. We’ve made progress by generating revenue from our Private & Semi-Private Accommodation program and we’re continuing to look at ways to increase our revenues to minimize any cutbacks we might have to make. In some cases, we have patients in inappropriate settings (our high ALC patients). Over the last couple of years, we’ve invested $2M to ensure we create capacity in the community where these patients can be best cared for.

      Shifting resources to the best setting allows us to focus on quality, improve the patient experience and save money. Given our year to date financial performance we’re going to have to come up with more innovative ways of addressing our financials, but I completely agree that a focus on quality improve everyone’s job satisfaction and help balance the budget.

      Caring for frail elderly patients – I agree that Home is Best doesn’t apply to all people equally but I can guarantee you that our frail, elderly folks aren’t forgotten.

      We’ve expanded our care for clients in their home over the last couple of years through our Rapid Response Nurse Practitioner, Jennifer Honey, who sees patients quickly and is able to line up vital community care in a rapid fashion through a Quick Response Team. As well, we’ve hired a Palliative Nurse Practioner to work with Community staff and have actually increased our budget by $2M in home care over the last couple of years. We’re also working on further increases, as well
      as expanding the number of Adult Day Care spaces and respite spaces on the North Shore.

      But we also need to keep in mind the kind of feedback the Senior’s Advocate and caregivers who look after seniors have provided at different times. By their account, many frail elderly patients prefer to live in a situation that we would describe as “at risk” in the community. While we may feel there are better options for them, it’s their choice to live as they do and a number of people have stated that we need to respect that. At times, it seems like we (the health care professionals) are the ones resisting allowing these seniors to leave the hospital to go home
      rather than respecting their choices and supporting them wherever they choose to live.

      I’m really sorry to hear you’re having a hard time feeling you’re doing your job well these days. I try to convey my appreciation for our care teams at events like staff forums when I do walkabouts because I know that, without the efforts of staff like you, we’d be in far worse shape here in Coastal. But it’s a topic I’ll bring up with the Coastal Sr. Leadership Team to ensure we’re making recognition a priority as it sounds like our message isn’t getting through.

      Thanks again for taking the time to reach out and tell me what’s on your mind. I hope you’ll do so again in the future.

      Mike

      • Lori baker says:

        Hi Mike
        Thanks for your time and thoughtful response to my reply to your blog. First of all, I personally love my job and, like everyone these days, try hard to reduce length of stay and readmits through patient, family and staff teaching while they are in house, and definitely through the Trauma Outpatient Clinic….for those who are appropriate. I was pleasantly surprised that you knew who I was as we have never had a hallway chat…just the presentation we did on Trauma briefly at one of your “SLT” meetings. (Love all the acronyms these days!)
        More specifically what is troublesome to me is when I travel from area to area in the hospital to see patients, I sense huge frustration in staff (all levels) feeling they are not doing their jobs well enough to get patients out and running as per the expectations of the organization as a whole…not sure if that is you, or all the “COO’s”/“CEO’s. I have seen people crying…I am talking all levels Mike. They don’t share why, but rest assured they get a hug from me and I let them know they are great and I learn something from each of them.
        One day, on a Trauma Clinic day, as I was walking a patient to the elevator, I had the dubious “pleasure” of hear the tone of voices in the room where the bed meeting was taking place. Really, is that the way you were all taught to speak to each other? I would have had my mouth washed out with soap….and would have truly deserved it! This should be a respectful, caring team with the leader demonstrating to all how to speak and treat with professionalism and kindness.
        When I’m in the ED and I see 26 admitted patients, 19 in the waiting room, every nook and cranny in use and think…”What the heck…get these patients up on the wards.” Then on my patient journey I see why they can’t! The complexity of care is beyond imaginable. We have excellent teams trying to solve this. I see Managers and Directors, MD’s, PCC’s PFC’s, SW, OT, PT etc. getting exhausted and saddened by their inability to make this all work. I need to be able to explain to folks as I see them and see their anxiety, hurt and depression, what the answer is.
        Mike you have a big job to do…I get it, but as an old lady I want folks to play nicely in the sandbox. Sometimes that can only happen after we walk in someone else’s shoes. What if you enlist a staff member to follow you around for the day to help understand your needs and frustrations so they can disseminate that to the staff, and then you put on some scrubs for the day (after you sign the patient confidentiality agreement) and follow some of them around for a day? Sit in on a discharge meeting of a complex patient; follow the LPN in the waiting room trying to take care of those 19+ patients, or the new RN on the ward trying to care for 5 patients, none of whom are independent, some in Halo braces, paralyzed on one side and cannot use the bathroom.
        I am really concerned Mike with what is going on and from my perspective I am thinking we need some help from you. Making people feel good does not have to be a grandiose recognition. It can be as small as stopping someone in the hall for example and asking how their day is, randomly buying someone a coffee when you’re in the coffee lineup, going to the different areas as an individual and giving recognition and thanks for the hard work they are doing. “Reward the behaviour you want to see more of.” Be visible for the journey the staff is on right now from the ED to every floor. Recognize that the majority of the patients that we send home these days, used to be our inpatients. The inpatients used to be our ICU patients and those in ICU, sadly would have never made it there.
        We need your kind, thoughtful leadership to get through this. Teach us what you want us to do after you’ve walked with us, because it’s clear we are not doing something right.
        Figure out and role model whether we “should live to work, or work to live”? Should everybody be available 24/7 or just those on call? Help me out as I’m worried about the team. I’ll do ANYTHING I can to help turn this back to an organization that cares first about those we know, prior to taking care of those we don’t know. That’s the only way it will work Mike.
        Best
        Lori

        • Diane De Stefano says:

          Thank you Lori for being an advocate for your patients and your colleagues. Your hard work, dedication, knowledge, respectful and kind nature is why you are such a valued person at LGH. I like your idea about senior leadership putting on scrubs and joining the front line staff for a few days…it is a great way for SLT to put names to faces and get a true reality check about how difficult it is for our teams working in the trenches. It may help remind them that patients aren’t just numbers on a white board, they are complex, often elderly people with multiple co-morbitities that need our help.
          The people first strategy states that to provide the best care one of the cornerstones is developing the best workforce. I believe we have an incredible workforce. BUT they are burning out, the feel disrespected, they go above and beyond the call of duty everyday. I am describing the ward staff, nurses, managers, unit clerks, Physios, OT’s, Discharge coordinators, Social workers, Patient care coordinators, educators, ward aides, physicians. (I can go on…) We are expected to “perform” 24/7 in a facility where many services and supports are only fully available 5 days per week.
          Like you Lori. I have a vested interest in working to make LGH the best place for our patients and staff. I have been here for 24 years. It begins with leadership that respects and values the strong team , acknowledges their expertise and is genuinely appreciative.

          • Mike Nader says:

            Thanks again Lori and Diane for your input and invitation to come spend time with you and other front-line staff to get a better idea of what they’re facing.

            I used to get time with front-line staff regularly when I was COO at Richmond Hospital but have to admit that, since I’ve come to Coastal a little over a year ago, I’ve faced
            some distinct challenges in getting out to speak with as many front-line caregivers as I’d like to.

            Through my ongoing time as an Accreditation Canada surveyor, I’ve done dozens of tracers at other institutions as well as here at LGH as we prepared for our survey last summer. I know that those of us at SLT will do more of them as we ramp up to next fall’s survey as well.

            But I’m definitely interested in hearing more about how we can support our staff and physicians, both here at LGH as well as in our facilities in Coastal and our community-based programs.

            To that end, I’ve booked myself for a couple of half day
            sessions to shadow care staff here at LGH next month. I’m interested in what we’ll see and will pass along my thoughts in a blog post once I’ve done them.

            I’d also be interested in chatting in person with you both one day soon to hear a little more about your concerns. Can you drop me an e-mail and we’ll work a time out?

            Regards, Mike

          • Diane De Stefano says:

            I will contact you! Looking forward to your visit.
            Thanks!

          • Lori baker says:

            Hi Mike,
            Kudos to you for coming to our huddle, rounds etc today. I believe you’re also going to be following the process of a patient from the ED to discharge?? So terrific! I hope your eyes can see things that will make it better for our patients. It meant so much to us Mike that you would take the time to walk along side us as we try our darndest to make this whole thing work for the good of our patients, staff and system. I’m not sure there’s any one easy answer, but a fresh set of eyes never hurts.
            I really look forward to your insight and thanks for your leadership.
            Best
            Lori

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