Each year, staff at Health Quality Ontario read the Quality Improvement Plans (QIPs) submitted by Ontario hospitals, primary care organizations, long-term care homes, and local health integration networks (which administer home care). We identified some stand-out examples from the 2017/18 QIPs showing how organizations have engaged patients or residents and their families and caregivers, and reached out to the people involved to find out more about their experiences.
Here, we spoke with a team from the Centre for Addiction and Mental Health (CAMH), including Heather Sulkers, the Director of Informatics; Carrie Clark, Advanced Practice Clinical Leader; Moshe Sakal, a Peer Support Worker; and Gillian Strudwick, a Project Scientist and Registered Nurse. This team’s project was related to safe medication administration, and they engaged their patients in this project by conducting interviews to find out their opinions and preferences.
Members of the CAMH
Team, from left to right: Heather Sulkers, Moshe Sakal, Gillian Strudwick, and
Carrie Clark.
Can you give a little bit of background on the problem you were trying to solve?
Heather: Our project was related to patient safety during medication administration. We wanted to leverage technology by using a barcode scanner to prevent medication errors. This follows the principles of the Five Rights of Medication Administration (the right patient, the right drug, the right dose, the right route, at the right time) – using a barcode scanner can help with this by ensuring that we have the right patient and the right medication. We were specifically interested in patients’ perceptions and understanding of medication administration.
Before we started this initiative, our scanning rates ranged from about 50–65%. Our goal was to improve scanning during medication administration to 95%.
We assembled a working group of clinicians to help identify what barriers they were currently facing that was preventing them from using scanners. They reported technology challenges, such as poor Wifi signal or medication barcodes not scanning properly. We did a systematic review of all these issues and challenges to remove the barriers and thus enable nurses to adhere to safe medication administration practices, leveraging technology.
In addition, many of our patients cannot or will not wear identification wristbands. So we needed to identify a technologically sound process by which we could still leverage technology and respect patients’ preferences. The evaluation identified alternate approaches which included three different ways of using technology to support safe patient identification. The patient had the choice of which to use. The first was to wear a barcoded wristband; the second was to identify the patient through a photo and demographic information on a barcoded patient demographic information sheet; and the third was to identify the patient through their barcoded patient demographic information sheet and either their health card or other government-issued photo ID.
We started actively working on interventions in June 2016; by December 2016 we had reached our goal of 95% scanning rates. This has been sustained and our scanning rates are consistently about 98.5%. The reason this is not 100% is due to special situations when the use of technology may actually impede patient safety – for example, when a Code White or Code Blue is called.
Who was involved?
Heather: We rolled out this initiative across all 24 inpatient units in the organization from day 1. Pretty much everyone was involved – professional practice, leadership, pharmacy, front-line clinicians. We identified nurse champions on each inpatient unit and provided them with refresher training, and they were tasked with providing this training to other nurses on their unit. Senior leadership were heavily engaged, and visited units regularly to distribute certificates – for example, for most improved unit, most consistent unit, etc. And of course, we had our peer support worker Moshe conduct the interviews with patients.
Can you discuss how you engaged your patients in this initiative?
Carrie: We were really interested in the patient experience of medication administration and what their concerns and preferences were. Moshe, a peer support worker with lived experience, conducted interviews with 52 patients on different units to learn their opinions and preferences about the process. We found that these patients had a lot of questions about the process, were interested in improving the service, and wanted to help.
Moshe: I think having a Peer Support Worker conduct the survey made it easier for peers to share their opinions in an open and honest way. Some people had been on a unit multiple times, but reported that this was the first time that someone had asked them for their opinion. This project was a wonderful opportunity to listen to that perspective. It gave peers the chance to share how they really felt about services, validated their experiences, and even offered them hope. From my experience the presence of someone with lived experience on a mental health unit goes a long way by creating a space where peers find hope that they too can recover. This was also an opportunity for staff to see individuals beyond their diagnosis.
Gillian: After we conducted the patient interviews, we completed a thematic analysis of the interview transcriptions. We found that people had many reasons for wanting to use other identification methods. Some wondered about how their information was stored and the privacy and security of their information, or described stigma around wearing a wristband when leaving the facility to go into the community. For others, having a wristband on was uncomfortable.
How do you plan to sustain your improvements?
Heather: We put posters up to remind patients about the options they have regarding identification. We facilitate education to ensure that patients are aware. We also continue to monitor scanning rates on a weekly basis and look for patterns on units to identify issues or challenges that staff may be facing, to ensure timely resolution. This process has been operationalized, and it is an expectation that with the exception of certain situations, scanning technology should support medication administration at all times.
The team at CAMH has published an article on their findings from their patient interviews in the International Journal of Medical Informatics: Strudwick G, Clark C, McBride B, Sakal M, Kalia K. Thank you for asking: Exploring patient perceptions of barcode medication administration identification practices in inpatient mental health settings. International Journal of Medical Informatics 2017;105:31-37.
You may also be interested in:
Quorum’s Indicators & Change Ideas page. Find more information about QIP indicators and related change ideas.