Improving Outcomes Through Risk Mi6ga6on
Bruce Majors Dir. of Safety & Loss Prevention Emeritus Senior Living
Ray Miller, MSOSH Dir. of Risk and Safety Direct Supply, Inc.
What Has Changed In YOUR World? Self-‐repor6ng requirements
Background and fingerprint check
1.4 m-‐ Skilled Residents 1.0 m+ AL Residents
Assisted Living vs. Hospice
Staff Training Culture
E-‐payment and E-‐records
What asn’t changed? You S2ll Chare About PEOPLE.
Acuity
Medica6ons
Threat of li6ga6on Family and Resident Expecta6ons
Media-‐Rela6ons
Regula6ons – in 2012, apprx. osha
120,000 state AL-related bills submitted nation-wide; no such number available for Skilled
Objec6ves
At the conclusion of this session, you’ll walk out of here with: 1. A few thoughts on how mitigate “risk” by using Resident and Staff Engagement 2. Some thoughts on empowerment to better achieve “Q2” 3. Renewed determinations and a few valuable insights
Disclaimer
The materials, comments and other informa6on contained in this presenta6on are intended to provide general informa6on but not advice about certain regula6ons and ini6a6ves. This informa6on is not and not intended as legal or other advice and each situa6on may vary depending on the par6cular facts and circumstances. You should not act upon this informa6on without first consul6ng with qualified legal counsel. Thank you.
David O. McKay -- 1968
“‘Words do not convey meanings; they call them forth.’ I speak out of the context of my experience, and you listen out of the context of yours, and that is why communication is difficult.” Just because we say something, does not guarantee that you know what we mean – please speak up.
© 2009-10 Direct Supply, Inc., all rights reserved
Agenda 1. 2. 3. 4. 5. 6.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A
What is “Risk Mitigation” – Risk Management: Identification, assessment, and prioritization of risks as well as identifying how to prevent and mitigate the effects of those risks – Risk Mitigation: Efforts to reduce the probability, frequency and severity of an incident Does this then imply that all risk can be eliminated if “WE” have identified it and reduced the chances of it occurring? NO – Accidents will happen!
This suggest that sometimes it is not the event that occurs, but how it is managed...
Chesley Burnett "Sully" Sullenberger ‌ ditched USA Flight 1549 in the Hudson River back in January 15, 2009 and saved 155 people.
Part of our goal today is to discuss;
– What “risks” are “over the horizon”?
– Are there some that we are perhaps we are ignoring?
Agenda 1. 2. 3. 4. 5. 6.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A
12
Agenda 1. 2. 3. 4. 5. 6.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A
FDA Dimensional Guidelines: Entrapment Zones
Zone 1
Recommended Space: Less than 4¾”
CAUTION: Openings in the rail
Zone 2
Recommended Space: Less than 4¾”
CAUTION: gap between the bo\om of rail and ma\ress
Zone 3
Recommended Space: Less than 4¾”
CAUTION: Ma\ress width
Zone 4
Recommended Space: Less than 23/8”
CAUTION: at the end of the rail
FYI: Zones 5 through 7 do not have specific dimensional guidance
Zone Zone 55
Zone Zone 66
Zone Zone 77
Zone 5
Zone 5 – two sets of rails/side
Zone 6
Zone 6 -‐-‐ rail and side of head or foot board
Zone 7
Zone 6 -‐-‐ between end of ma\ress and head/footboard CAUTION: 76” and 80” look similar
FDA Guidelines (http://www.directsupply.com/resources/) 1. Dimensional 2. Clinical a. Resident and environmental assessment programs b. Treatment programs/care plans 3. Safety Products 4. Mitigation a. Modifying unsafe beds b. Process to assess beds c. Corrective action products 5. Implementation
Agenda 1. 2. 3. 4. 5. 6.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education Q&A
Elopement Mr. Smith was here this morning – now we can’t find him! There are not too many other situations that can have such a negative effect on the whole community!
Two questions from a “Risk” & “Safety” viewpoint: 1. Can we ensure families that we prevent elopements? 2. Are we truly managing these events?
Definition of “Ensure”: To “make certain” or “sure of” Is this the same as saying, “We will prevent all resident falls.” Can we or should we promise either of these? What is the starting point in our striving to prevent “Elopements” and lower our “Risk”?
The Admission Process
Suggestions for Admissions 1. Are we evaluating the resident’s cognitive level or ability upon admission? 2. Are we explaining the “risk factors” involved with elopement? 3. Appropriate placement? AL or Memory Care?
Are we meeting the needs of our resident?
Prevention Considerations • Use of the sign-in book • Change of medications / Changes in Condition What about the “Physical Plant” • Door alarms • Patio furniture / Fencing • Electronic monitoring devices
Managing Elopement
Initial checks should be completed first to determine if a resident is “Missing”. These include: • • • •
Checking sign in / sign out book Bus transportation log Favorite places the resident like to go Checking with other employees and residents. Who saw the resident last?
If it is determined the resident is “Missing”, then what are your search procedures? What is your “Plan” to manage this?
Managing Elopement “The Plan” should include: • What areas are going to be searched and by who • How the search will be expanded “outside” the community • Designate the responsible party who will do notifications (Family, Physician, etc..)
• When to call in additional help and who is going to make this decision, (Law Enforcement, etc..) • Documenting search procedures and notifications • Who will be responsible for handling the “Media”?
Besides the above, suggest the most important activity we can do is to:
EDUCATE AND PRACTICE to prepare if an “Elopement” would occur! 1. Make “Elopement” procedures part of employee orientation, 2. Practice the procedures - At least annually! 3. Incorporate these drills into the community in-service and schedule.
Agenda 1. 2. 3. 4. 5.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a. Mentoring (Listening, Developing, Engaging, Harvesting) b. Hand-off Pneumonics c. Daily Contracting d. DRILLS 6. Q&A
VISIT & LISTEN
EDUCATE & DEVELOP
ENGAGE & HARVEST
MENTORING
VISIT ↔ LISTEN
EDUCATE ↔ DEVELOP
ENGAGE ↔ HARVEST
1. Rela6onship ques6ons 2. Round with them 3. What went well? 4. What didn’t go well? 1. Do you have the tools, training and resources to do MENTORING your job? 2. What is working well? 1. How can we “fix” “this”? 2. Who is doing a good job? 3. What systems can work be\er? HOW?
SIDEBAR: “Clues and Ques” Or “Itchy Vigilance” Which of these would YOU make note of?
– Less visible in the community – Check for changes in meds – Recent trip to the physician – Off pa\erns or habits
1. Why?
– Change in rou6nes
2. When?
– Posture change – “Color” change – New cough – Pain
3. Learned? 4. Teachable? 5. How?
Agenda 1. 2. 3. 4. 5.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a. Mentoring (Listening, Developing, Engaging, Harvesting) b. Hand-off Pneumonics c. Daily Contracting d. DRILLS 6. Q&A
Mnemonics
“Every Good Boy Does Fine” + “FACE” “ROYGBIV”
“Hand-‐off” Mnemonics 1. AIDET
9. Just Go NUTS
17. SHARED
2. ANTICipate
10. MIST13
18. SHARQ
3. ASHICE
11. PACE
19. SIGNOUT
4. CUBAN
12. PEDIATRIC
20. SOAP
5. DeMIST
13. SBAR
21. STICC
6. GRRRR
14. I-SBAR
22. 4 P’s
7. HANDOFFS
15. SBARR
23. 5P’s
8. I PASS the BATON
16. SBAR-T
"Handoff communica-on" now a JC standard, effec-ve January 2010 The JC con6nues to emphasize the need for "having a standardized approach to handoff communica2ons" which moved from a Na6onal Pa6ent Safety Goal to being scored as a standard, effec6ve 1/1/2010.
I-‐PASS the BATON •
Introduction: introduce yourself and your role
•
Patient: name, identifiers, age, sex, location
•
Assessment: presenting chief complaint, vital signs, symptoms, diagnosis
•
Situation: current status and circumstances; including codes status, eval. of certainty, recent changes, and response to treatment
•
Safety: concerns: critical lab values and reports, socioeconomic factors, allergies, alerts (e.g. falls, isolation)
•
Background: comorbidities, previous episodes, current medications, family history
•
Actions: which were taken or are required, providing brief rationale
•
Timing: level of urgency, explicit timing, and prioritization of actions
•
Ownership: who is responsible (eg, nurse, doctor, team), including patient or family responsibilities
I-PASS the BATON 1.
Introduction: introduce yourself and your role
2.
Patient: name, identifiers, age, sex, location
3.
Assessment: presenting chief complaint, vital signs, symptoms, diagnosis
4.
Situation: current status and circumstances; including codes status, eval. of certainty, recent changes, and response to treatment
5.
Safety: concerns: critical lab values and reports, socioeconomic factors, allergies, alerts (e.g. falls, isolation)
6.
Background: comorbidities, previous episodes, current medications, family history
7.
Actions: which were taken or are required, providing brief rationale
8.
Timing: level of urgency, explicit timing, and prioritization of actions
9.
Ownership: who is responsible (eg, nurse, doctor, team), including patient or family responsibilities
10. Next: what happens next (eg, any anticipated changes in condition or care, the plan, any contingency plans)
Just go NUTS
• Name of resident, diagnosis, room number • Unusual or unique; variances iden6fied on the individual care plan including cri6cal lab values, pain management, etc • Tubes such as IV, NG, catheters, drains, ostomies • Safety concerns such as falls, medica6on reconcilia6on
S-BAR Iterations • • • •
• SBAR Situation Background Assessment Recommendation
• • • • •
SBAR-T Situation Background Assessment Recommendation Thank residents (note: handoff done at bedside)
• • • • •
I-SBAR Introduction Situation Background Assessment Recommendation
• • • • •
SBAR-D Situation Background Assessment Recommendation Documentation
Agenda 1. 2. 3. 4. 5.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a. Mentoring (Listening, Developing, Engaging, Harvesting) b. Hand-off pneumonic c. Daily Contracting d. DRILLS 6. Q&A
A Life6me of Meaning • Our residents do not leave behind their treasure of knowledge and experience, dreams and aspira6ons when they come to live at Kirkhaven. • As care providers, it is our duty to find the ways to adapt equipment, rou6nes and the environment, whatever it takes, to enable our elders to con6nue lifelong ambi6ons and pleasures.
http://www.seniorsfirst.com/kirkhaven/
“Daily Contrac6ng” with Residents
SAFE from FALLS Toolkit -‐-‐ h\p://www.mnhospitals.org/index/tools-‐app/tool.362?view=detail
1. Verbal contrac6ng with Residents (each shift): • Example: “Do you understand that you are at high risk for
falling? Will you … “
2. Tips to share with Family Members: • Example: “Do you understand that your Mom is at high
risk for falling? Will you … ”
http://www.mnhospitals.org/index/tools-app/tool.362?view=detail
“Daily Contrac6ng” with Residents
Sample 2ps: 1. Ask for help! It is OK. (weak or dizzy) 2. Wear glasses or hearing aids, use them. 3. Sit at the bed side for a few minutes before you stand up. 4. Use your walker/cane/WC. 5. Wear shoes or non-‐skid slippers. 6. Make sure your pathway is clear. 7. Tell us about puddles/piles/pieces. 8. Use the handrails! 9. Keep important things within easy reach. http://www.mnhospitals.org/index/tools-app/tool.362?view=detail
“Daily Contrac6ng” with Family*
Sample 2ps: 1.
Before you leave, make sure the call light and the bed stand is within reach. (Phone, Kleenex, etc,)
2.
Some medica2ons may produce weakness or dizziness.
3. Consider staying with Mom if they are at a high risk for falling or are confused. 4.
No6fy staff before leaving if you no2ce confusion or disorienta2on in your Dad.
5. Remind Mom to ask for help when gesng up.
Agenda 1. 2. 3. 4. 5.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a. Mentoring (Listening, Developing, Engaging, Harvesting) b. Hand-off pneumonic c. Daily Contracting d. DRILLS 6. Q&A
Education - DRILLS • Everyone conducts does these, but “WHY”? • What is your goal? • Is it just to meet state requirements? • It is not a matter “IF” an event occurs that requires employees to respond properly , but “WHEN”!
Suggest there are two terms that relate to “Why” and “How” drills are conducted:
Reaction Defined as: Autonomic response to a stimulus Unfortunately, if we are not properly conducting drills, this can result in PANIC!
Response Defined as: An act of responding Let’s call this our PLAN!
Which of the above is the goal when conducting drills?
Planning vs. Panic 1. Having a realistic and functional written plan. 2. Accountability: Instill the importance of knowing the plan. 3. Assess the Response: What went right, what did not? 4. Identify the actions needed to improve and Implement them!
DOCUMENT
DOCUMENT
DOCUMENT!
Are we conducting the right “Drills”? Everyone knows their individual states requirements, but what other “drills “ should we do? • Elopement • Resident Falls • Bus accident events • Behaviors in Memory Care • Family and outside influences
The “Goal “ Of All “Drills Should Not Be The Reaction (PANIC) but the Response that follows a “PLAN” (PERFECT) Practice helps makes perfect!
Why Drills?
Pictures provided by Mel Tobias
Why Drills?
Pictures provided by Mel Tobias
Why Drills?
Pictures provided by Mel Tobias
Why Drills?
Why Drills? Why Checklists? *
BECAUSE THEY WORK
Pictures provided by Mel Tobias
Agenda 1. 2. 3. 4. 5.
Giving context to “Risk Mitigation” Aging With Choice Entrapment Elopement Education a. Mentoring (Listening, Developing, Engaging, Harvesting) b. Hand-off pneumonic c. Daily Contracting d. DRILLS 6. Q&A
A Closing Thought …
by Henry Van Dyke
We Thank You For Your Time.