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RISKY BUSINESS: RISK ASSESSMENT & OCCUPATIONAL THERAPY

Alanna Cunningham � Jessie Trenholm

Risk was defined though a literature review:u  At risk refers to a chance of suffering or injury, and harm to self or others. u  Risk is a matter of degree: the degree of harm and the probability of that

harm eventuating.

Tolerable & Intolerable Risk:u  Level of risk should be viewed on a continuum and risk within a domain

may be tolerable up to some point. 

Defining Risk Guiding Principles Ethics & Practice

Standards

DecisionMaking

Capacity

Patient &Family

Centred Care

Therapist Perspectives

PersonEnvironmentOccupation

Model

Reviewed the legal and ethical standards that guide therapists in the

assessment of risk.

AcuteCareFunctionalRiskAssessmentFrameworkOccupationalTherapy

Therapistsignature:____________________________________[initials:_______]Date:____________________

AdaptedfromPatientRiskAssessmentFramework,developedbyDr.K.Fruetel,geriatrician

Patientname&IDnumberorDemographicsticker

Additionalpagesmaybeaddedifrequired.

Family/TeamMeetingDate:DischargePlanDecisionMakingCapacity

Whataretheactualcurrentrisks?

Pre-existing/New? ☐Pre-Existing☐New☐Worse☐Aware/insight

☐Pre-Existing☐New☐Worse☐Aware/insight

☐Pre-Existing☐New☐Worse☐Aware/insight

☐Pre-Existing☐New☐Worse☐Aware/insight

Whathavebeentheconsequences?

Whathasbeentriedpreviouslytomitigatetherisk?

Wasthepreviousmitigationstrategyeffective?

Canthecurrentriskbemitigatedtosupportdischargehome?

Ifso,whataretherecommendationstomitigatethecurrentrisk?

Ifnot,isthecurrentriskintolerable?

Ifcurrentriskisintolerable,whohasdeterminedthisandwhy?

General OT screening/

assessment

Determine if risk assessment is

required

Dialogue with key stakeholders

Risk Assessment Framework

Identify risk(s)

Identify mitigation strategies/generate

recommendations

Team/Family Meeting

Review recommendations

Patient and family perspective

Create discharge plan

Consider decision-making capacity

Tension or conflict in values

Self-awareness

Tolerable vs. intolerable risk

Red flag“Ick” feeling

Yes No

DRAFTProcess for using Functional Risk

Assessment Framework

October 2014 RGH OT Community of Practice A. Cunningham & J. Trenholm

Process

Informs process

Event

Optional

Key

Decision

I n t o l e r a b l e r i s kConsiderat ions of r isk factors that have a greater potential for harm to self or others; evidence of new behaviour is unprecedented

T o l e r a b l e r i s k Individualized risk factors that require no intervention based upon strengths, suppor t sys tem, and environmental supports

Evaluation

Risk Assessment Framework Tool (RAFT) & Implementation

Background

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In Acute Care Occupational Therapy (OT) provides assessment and interventions related to patients’ functional cognitive and physical abilities to facilitate discharge planning. These functional assessments often reveal safety risks, which lead to barriers for patients to return to the community and engage in meaningful activity.

AcknowledgementsDebra Froese- OT PPL Calgary Zone

Allied Health ManagementRGH OT Community of Practice

ReferencesAlbertaCollegeofOccupa1onalTherapists.(2005)CodeofEthics.Edmonton,AB:Author.AlbertaCollegeofOccupa1onalTherapists.(2003)StandardsofPrac1ce.Edmonton,AB:Author.Associa1onofCanadianOccupa1onalTherapyRegulatoryOrganiza1ons.(2011)Essen%alcompetenciesofprac%ceforoccupa%onaltherapistsinCanada(3rdEd.).Toronto,ON:Author.CanadianAssocia1onofOccupa1onalTherapists.(2011)CAOTPosi1onStatement:Occupa1onaltherapyandclientsafety.OKawa,ON:Author.

FraserHealthAuthority–RiskAssessmentSharedWorkTeam.(2011November)ClinicalPrac%ceGuideline:RiskAssessment–Iden%fyingTolerableandIntolerableRiskFactorsandInformingDecisionMakingAbility.RetrievedfromhKp://gnabc.com/gnabcAdmin/wp-content/uploads/2014/04/RISK-Clinical-Prac1ce-Guideline-March2014.pdf.Fruetel,K.(2008)Pa1entRiskAssessmentFramework.InScoK,D.ToolkitforPrimaryCare:CapacityAssessment.(26-27).London,ON:RegionalGeriatricProgramofSWOntar1o.RetrievedfromhKp://giic.rgps.on.ca/files/1%20Capacity%20Assessment%20Toolkit%20Overview.pdf.

Gallagher,A.(2013)Riskassessment:enablerorbarrier?Bri%shJournalofOccupa%onalTherapy,76(7),337-339.Moats,G.(2007)DischargeDecision-Making,EnablingOccupa1ons,andClient-CentredPrac1ce.CanadianJournalofOccupa%onalTherapy,74(2),91-101.Moats,G.(2006)DischargePlanningwithOlderAdults:TowardaNego1atedModelofDecisionMaking.CanadianJournalofOccupa%onalTherapy,73(5),303-311.Reich,S.,Eastwood,C.,Tilling,K.,&Hopper,A.(1998)Clinicaldecisionmaking,riskandoccupa1onaltherapy.HealthandSocialCareintheCommunity,6910,47-54.

Approach

To address this gap, the role of OT in risk assessment was explored through:q Completing a literature review of the OT role and risk assessmentq Defining riskq Developing guiding principles for risk assessmentq Developing a tool for risk assessmentq Developing a process for initiating risk assessmentq Engaging stakeholders in the practice change processq Utilizing Plan Do Study Act (PDSA) cycles for evaluation

Next Stepsu  Adapt the RAFT to different clinical areas beyond the

Acute Care setting.u  Offer ongoing education on risk assessment.u  Survey therapists and holding focus groups to gather

feedback and adapt the RAFT as needed.u  Continue to promote the important role of OT in functional

risk assessment to improve patient outcomes.

The RAFT was developed to provide:u  Structure for Occupational Therapists’ clinical reasoning when

evaluating risks versus benefits to decrease subjectivity in discharge recommendations.

u  A tool to formally communicate the functional risks, potential consequences, and mitigation strategies to the interdisciplinary team, patient, and family.

u  An increase in the continuity and consistency of care, thereby achieving patient and family-centred care goals.

Implementation of the RAFT included:u  Engagement of stakeholders.u  Identification of barriers.u  Creating a process to initiate the

RAFT:

A gap was recognized by Occupational Therapists in their knowledge and skills for identifying and mitigating functional risk factors for patients being discharged from hospital.

Five Guiding Principles were established: Ethics & Practice Standards, Person-Environment-Occupation Model, Therapist Perspectives, & Decision Making Capacity.

These identify the interconnected & influencing factors that create a foundation for the emerging practice area of functional risk assessment.

Ensured the risk

assessment process upheld the tenets of patient and

family centred care.

Defined the interface between risk assessment

and decision making capacity pre-assessment

processes.Explored the impact of

personal values, biases, prior experience, &

practice setting on how therapists approach risk.

Grounded the risk assessment process in a

holistic OT model of functional performance.

Typical OT Role in a Patient’s Flow Through Acute Care

LogicModelComponents Screen RiskAssessment DischargePlan Documenta;on

Objec;ves Todetermineifpa.entsareappropriateforriskassessment.

Toiden.fyrisks,strengths,andrecommenda.onsfordischarge.Toiden.fytolerableversusintolerablerisk.

Tocommunicaterecommenda.onstopt,family,andteam.Toimplementrecommenda.ons.

Tosupportclinicalreasoning.Tocommunicatetointer-disciplinaryteamover.me.

Outputs • Numberofptsappropriateforriskax• Listofreasonsforini.a.ngriskax• Current/previousconsults• Numberof.mesreasonforadmissionwastheini.a.ngfactorforriskax• Numberof.mesriskhadbeeniden.fiedonprevioushospitaladmissions

• Listoftypesofrisk• Numberofrisks/pt• Numberofintolerablerisks/pt• Presenceorabsenceofsupportnetwork• Presenceorabsenceofhomecarepriortoadmission

• Numberofptsreturningtopriortoadmitenvironment• Numberofptswhothenneededcapacityassessment(DMCA/Psychiatry)• Newrecommenda.onsY/N• Numberofdayssincescreen

• Timetocompleteriskax• Numberofworksheetsfiledonchart(vs.keptasnon-formal/internalworksheets)

Shorttermoutcomes

Increasedunderstandingbetweenteamandpa.ent/familyaboutrisksandconsequencestomakeaninformeddecisionaboutdischargeplan.

Morepa.entsdischargedtopriortoadmitenvironment.

Cohesiveunderstandingofrisk/OTroleinriskassessment.Understandingofdecisionmakingprocesstoini.ateriskassessment.

Formalevidencetocommunicateassessmentandrecommenda.onstointer-disciplinaryteam.

Longtermoutcomes

Increasedcon.nuityandconsistencyofcare.Decreasedsubjec.vityofriskvs.benefit.

Increasedunderstandingbetweenteammemberstosupportaleast-intrusivedischargeplan.Promo.onofaginginplaceprinciples.

A logic model and PDSA cycles were used to evaluate and adapt the tool as needed.