Towards Quality andAccountability in the BCMental Health System

Presented by:

June 3, 2003

Lynda BondManager

Policy & ResearchFPSC

Port Coquitlam, BC

Paul AndersonDirector

Education ServicesRVH

Port Coquitlam, BC

Derek WilsonConsultant

Policy & ResearchFPSC

Port Coquitlam, BC

Presentation Overview!Organizational profiles and the �Journey� to

Quality & Accountability

" Riverview Hospital

" Forensic Psychiatric Services

! Joint efforts in Quality & Accountability

!Challenges & lessons learned

!A look to the future

Our Mission

To improve the quality of life ofadults affected by persistent or

severe mental illness byproviding excellent, specializedcare for individuals with uniquetreatment challenges; and byincreasing service capability

within BC through clinicalservice, education andresearch partnerships.

Our VisionTransforming Mental Illness

Into Mental Wellness

Profile: Riverview Hospital!BC�s largest tertiary psychiatric facility

! Located in Port Coquitlam; serving all of BC

! 600 beds as at May 2003

! 3 major clinical programs" Adult Tertiary Psychiatry

" Geriatric Psychiatry

" Neuropsychiatry

! Full range of clinical & logistical support services

! 582 admissions, 683 discharges in 2002/03

Riverview - The Quality Journey! First accredited in 1979 by Canadian Council on

Health Services Accreditation (CCHSA)

!Traditional quality assurance focus up to 1980s

" Functional/departmental quality standards

" Largely a paper-based audit system

" Evaluative, problem-oriented approach

" Dilemma: How to �assure� quality ???

Riverview - The Quality Journey! Shift to CQI/TQM approach in early 1990s

" Board, CEO & senior management endorsement

" CQI Council, Department QI Plans, ad hoc QI projects

" CQI Facilitator Training

" Orientation to CQI methods for all staff

! Shift to program management structure in 1998

" Designed to reinforce high quality, inter-disciplinary,

patient-focused care

Current approach:

! CQI focus across all aspects of care & service

! QI activities integrated with organizational structures andstrategic & operational planning

! Modified balanced scorecards aligned with accreditation teams

! Committee structure provides additional QI support:" Medical Advisory Committee & sub committees

" Discipline & Inter-disciplinary Professional Practice Councils

" Program Planning/QI Teams

" Partnership committees � stakeholders, union/management, etc.

Riverview - The Quality Journey

HR Team Balanced Scorecard

Human Resources Balanced Scorecard Strategy MapMission: Improve the quality of life of adults affected by persistent or severe mental illness by providing excellent, specialized care for individuals with unique

treatment challenges; and by increasing service capability within BC through clinical service, education and research partnerships

Strategic Goals

CCHSA Quality Dimensions

Client/Community Focus • Communication • Confidentiality • Participation/Partnership • Respect & Caring • Organization Responsibility & Community

Involvement

Responsiveness • Availability • Accessibility • Timeliness • Continuity • Equity

System Competency • Appropriateness • Competence • Effectiveness • Safety • Legitimacy • Efficiency • System Alignment

Work Life • Open Communication • Role Clarity • Participation in Decision Making • Learning Environment • Well-Being

PA/May 5, 2003

Recruit, Select & Retain The Best

Manage Change Effectively

Develop A Highly Skilled Workforce

Promote staff currency in core courses to enhance skills & minimize risks

• Individual letters to staff mailed 09/01 • % of staff current in core courses

Review funding for contracted education

programming/subsidies • Benchmark ed. $ as a % of payroll • Funding increased to benchmark levels

Provide continuing/ specialty education

opportunities for HR staff• Training needs documented on appraisal • % staff taking training & avg. hrs/employee

Opportunities for continuous learning & professional growth

• % of staff current in core courses • Avg. hours/employee of learning activity

Implement a structured Management

Development Program

• PHSA L&D planning initiated • % of managers completing program

Positive employee relations

climate • Regular meetings with joint committees • % grievances resolved, withdrawn, to hearing

Promote employee wellness & work/life

balance • Wellness programs listed in ESOD calendar • STIIP/WCB attendance rates

Develop & implement effective employee retention strategies

• FPSC retention study completed • Turnover rates at FPSC/key RVH positions

Implement performance management process in tandem with HS move

• Ward leadership issue addressed • # and % of overdue appraisals by work area

Prompt, effective HR services & benefits

administration • Develop HR client survey • % of managers/staff satisfied per survey

Timely, fair labour relations services &

investigations • % investigations within time limits • % grievances resolved, w/d, to hearing

Develop/promote illness/injury prevention &

rehab. strategies • % of safety inspections completed • STIIP/WCB time loss rates

Maintain a healthy, safe, discrimination &

harassment-free workplace • % of staff current in core courses • WCB/STIIP & harassment complaint rates

Promote a balanced, healthy work culture within the

HR portfolio • Review of HR staff assignments completed • % of HR staff satisfied on survey

Install ceiling lifts on selected RVH wards &

train all users • Ceiling lifts installed on selected wards • % of users trained by 03/04

Develop transition services for employees

impacted by downsizing• Transition services in place • % of impacted staff utilizing services

Offer ERIP/VDP programs to staff

impacted by downsizing • ERIP/VDP approval from P.S. Agency • # of vacancies created

Train users in new HRIS technology as it

comes on-line • Training needs identified • % of staff trained by go-live date

Ready HR processes & systems for move

to the Health Sector

• Health Sector transition plan completed • % of objectives completed by target date

Design, test and install Peoplesoft

system for RVH/FPSC

• # of milestones achieved per plan • System implemented by go-live date

Prepare RVH/FPSC for move to the Health Sector

• # of milestones achieved per plan • Move to HS completed by target date

Support HR staff & Managers to deal

effectively with changes

• Timely communication & info resources• % of objectives achieved by target date

Upgrade RVH ROSS/Empath

system • # of milestones achieved per plan • System implemented by go-live date

Review implementation of ESP/TCT Staffing

System

• Review completed by 12/03 • Business case developed by 03/04

Riverview - The Environment! Many changes in leadership/governance since 1996

! On-again, off-again downsizing/redevelopment plans

! On-going financial constraints

! Increasing consumer/family expectations for care

! New medications & evidence-based care

! Significant information technology enhancements

! External CCHSA Accreditation visits every 3 years

Profile: Forensic Services

FPSC Mandate

Responsible for the provision of psychiatricassessment, treatment and community casemanagement to mentally disordered adultswho are in conflict with the law.

Profile: Forensic Services (cont.)

Inpatient ServicesForensic Psychiatric Hospital" 211 bed secure psychiatric

hospital in Port Coquitlam

" 460 Admissions for 2002/03

Outpatient ServicesRegional Clinics" Vancouver, Surrey/FV,

Kamloops, Prince George,Victoria, & Nanaimo

" 2279 Admissions for 2002/03

FPSC - The Quality Journey! 1970s-1990s � Strong strong tradition of providing high

quality forensic psychiatric assessment and treatmentservices to patients and to the courts

! 1990s � quality improvement & accountability not a keystrategic thrust of the organization � lack of formal QIprogram and organization not accredited

! 1997 � new Forensic Psychiatric Hospital opened

! 1998 (late) � decision to pursue accreditation � for FPH

! 1999-2000 � heavy organizational focus on preparing foraccreditation

FPSC - The Quality Journey! 2000 (early) � new CEO for FPSC

! 2000 (fall) � accreditation survey visit by CCHSA

! 2001 (early) � FPSC granted �Accreditation with FocusedVisit�" Develop Quality Improvement program

" Develop a formal Information Management plan

" Clarify committee structure for the organization

" Develop a Communications plan

! 2001 � Regional clinics joined accreditation process

! 2002 � focused visit by CCHSA � all areas addressed

! 2002 � new governing body for FPSC � PHSA

FPSC - The Environment

! Dramatic shift in the environment at FPSC � in termsof the organization�s focus and emphasis on qualityand accountability.

! This shift has been driven by a number of factors orforces, both internal and external to the organization.

FPSC - The Environment

! External Forces" Accreditation

" Change in Governing Body

" Fiscal Constraints

! Internal Forces" New Leadership

" Infrastructure Development

Committee Structure

Environment InformationManagement

HumanResources

Regional ProgramsIntegration Council

Directors(Leadership & Partnerships)

Hospital Council

RiskManagement

Regional ProgramsQuality Council

Regional ProgramsInter-ProfessionalPractice Council

Article 29

Joint Standing

Hospital CareTeam

Clinical Risk(Program &Privilege)

Patient Advisory

OccupationalHealth & Safety

Case ManagementSystem

ClinicalServices

CorporateServices

FPSC

Infection Control

Pharmacy

Credentialling

ResearchAdvisory

MedicalAdvisory

FPSC - The Environment

!Ongoing Challenges" Resource commitments

" Meaningful QI/Accountability indicators

! Positive Aspects of Current Environment" QI/Accountability framework

" QI/Accountability infrastructure

" Leadership by management

" Staff understanding and involvement

Joint Efforts in QI/Accountability

!Health System Restructuring

!Accreditation

!PHSA Reporting Requirements

!Challenges & Lessons Learned

!A Look to the Future

BC Health System Restructuring! Healthcare system restructured in December �01

! Objective: To reduce system costs & improvequality/accountability" 52 regional boards, councils & societies reduced to:

" 5 regional health authorities

" 1 Provincial Health Services Authority (PHSA)

! PHSA unique in Canada

" Unites all health services with province-wide scope

" RVH & FPSC included with other key health agencies

RVH and FPSC Integration

!RVH and FPSC began integrating in May 2002

" Common President/CEO assumed responsibility for allmental health services under the PHSA

" Integration of senior management team 1st step

" Efficiencies & resource sharing options identified

" Looming accreditation surveys for both organizations�galvanized� integration process

QI/Accountability Framework

0

20

40

60

80

100

1stQtr

2ndQtr

3rdQtr

4thQtr

East

West

NorthACCREDITATIONACCREDITATION

FPSCFPSC

RIVERVIEWRIVERVIEW

TQM QI

TQM QI

PHSAPHSA

Joint Accreditation Process! Integration of Accreditation Teams:

" Leadership & Partnerships (joint)" Human Resources (joint)" Information Management (joint)" Environment (joint)

!Clinical Service Teams:" Forensic Psychiatric Hospital (FPSC)" Forensic Psychiatric Community Services (FPSC)" Adult Tertiary Psychiatry (RVH)" Geriatric Psychiatry (RVH)" Neuropsychiatry (RVH)

Joint Accreditation: Positive Outcomes

! Joint preparation has helped to:

" build relationships & foster teamwork across both sites

" acquaint RVH/FPSC partners to relative strengths

" spur integration activities

" accelerate identification of improvement opportunities

" identify common CQI processes

PHSA Accountability Requirements

Availability and Access:

!Access: Patient/client easily obtains requiredservices in the most appropriate setting

PI: Average Number of Days onFPH Waitlist

5.1

6.6

5.24.5

5.4

4.6

8.6

5.3

8.5

6.25.7

6.1

0

1

2

3

4

5

6

7

8

9N

umbe

r of D

ays

Q1 02/03 Q2 02/03 Q3 02/03 Q4 02/03

Remand Temporary Absence Total

PI: Average Wait Times byProgram (RVH)

8 .7

1

7 .3

1

15 .2

1

9 .6

3 .5

18 .4

1 2 .6

7 5 .5

16 .7

13 .3

6 4 .3

0

10

20

30

40

50

60

70

80

Adult Tertiary ICU Geriatric Psychiatry NeuropsychiatryPrograms

No.

of D

ays

Wai

t

2001/02 Period 11 2001/02 Period 122002/03 Period 11 2002/03 Period 12

PHSA Accountability Requirements

Availability and Access:

!Access: Patient/client easily obtains requiredservices in the most appropriate setting

!Availability: Services and resources are availableto meet the needs of populations

PI: Average Number of Days toComplete PSR Assessments (FPSC)

24.1

38.6

30.4

41.2

22.7

43.4

28

36.7

0

5

10

15

20

25

30

35

40

45N

umbe

r of D

ays

Q1 02/03 Q2 02/03 Q3 02/03 Q4 02/03

In custody Out of custody

PHSA Accountability Requirements

Availability and Access:

!Access: Patient/client easily obtains requiredservices in the most appropriate setting

!Availability: Services and resources are availableto meet the needs of populations

!Diversion out of Province: Number of patientssent out of province for services normallyavailable in BC

PI: Number of Patients Admittedvs. Diverted (RVH)

6064 66

43

11 92 4

0

10

20

30

40

50

60

70

2001/02 Period 11 2001/02 Period 12 2002/03 Period 11 2002/03 Period 12

Fiscal Periods

No.

of P

atie

nts

Patients Accepted Patients Diverted

PHSA Accountability Requirements

Service Quality and Appropriateness:

! Effectiveness: Services, interventions or actionsachieve optimal results

! Safety/Harm: Potential risks and or unintendedresults are avoided or minimized

! Utilization: Resources are brought together toachieve optimal results with minimal waste, re-workor effort

PI: Utilization as % ofAvailable Beds (RVH)93.2%

91.9%

82.5% 81.7%

75.0%

80.0%

85.0%

90.0%

95.0%

2001/02 Period 11

2001/02 Period 12

2002/03 Period 11

2002/03 Period 12

Fiscal Periods% Utilization

PHSA Accountability RequirementsService Quality and Appropriateness:! Effectiveness: Services, interventions or actions achieve optimal

results

! Safety/Harm: Potential risks and or unintended results areavoided or minimized

! Utilization: Resources are brought together to achieve optimalresults with minimal waste, re-work or effort

! Critical Incidents

! Clinical Audits, Departmental or Program Reviews

! Complaints Received

! Legitimacy: Services conform to ethical principles, values,conventions, laws and regulations

PHSA Accountability RequirementsResources:

" Providers, Equipment, Space Planning

Satisfaction:

" Patient, Providers, Community

Value:

" Services: Cost per case

Innovation:

" Not Defined

QI/Accountability FrameworkOther Common Accountability Areas:

! Partnerships with key stakeholders

! Legislative/regulatory compliance/professional standards

! Evidence-based practices & policy development

! Prudent fiscal management (budgets & resources)

! Research capability (academic & program/policy)

! Thorough evaluation of organizational initiatives

! Periodic external reviews & QI recommendations

Some Challenges...

! Different approaches to QI/accountability

! Differing organizational mandates/circumstances

! Building working relationships

! Quality & accountability continues to evolve at PHSA

! Statistical reporting requirements

Lessons Learned! Clearly articulated vision & strategic priorities are key

! Demonstrated commitment by senior management isessential

! Adequate data collection/information managementsystems are required for effective decision making

! Education and training on quality managementprinciples provide staff with �tools of the trade�

A Look To The Future...!Continued efforts to merge Riverview/FPSC

" CCHSA Accreditation survey & recommendations

" Continuing to review/improve/streamline processes

" Development of common leadership & philosophy

" Integration & development of common policies

!Ongoing integration of Riverview/FPSC within PHSA" Integration with 6 other diverse health care agencies

" Use of Riverview/FPSC experience to inform corporate integration,accountability and quality improvement efforts

Towards Quality andAccountability in the BCMental Health System

Presented by:

June 3, 2003

Lynda BondManager

Policy & ResearchFPSC

Port Coquitlam, BC

Paul AndersonDirector

Education ServicesRVH

Port Coquitlam, BC

Derek WilsonConsultant

Policy & ResearchFPSC

Port Coquitlam, BC

Questions ?