Evidence-Based Practice Proposal – Final Paper

Learning What is Important: A Quality Improvement Initiative to Enhance Patient-Centred Care in Home Care

Patricia Millera, Caroline Gillb, Kathy Mazzab, C�elynne Pilonb, and Melissa Hillb

aIAHS Room 403, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada; bCBI Health Group West Tower, Toronto, Ontario, Canada

ABSTRACT Aim: A quality improvement initiative was undertaken to increase the utilization of a new tool designed to facilitate the provision of patient-centred care in the homecare setting. Methods: The tool, entitled Life Through My Eyes (LTME), is completed voluntarily by the patient or a family member. In order to personalize the patient’s care, it captures information about what is important to the patient and ways to make the patient feel comfortable. Patients and families played an inte- gral role in the Plan, Do, Study, Act cycle used to introduce the tool into practice. Results: Patients and family members (n¼ 19) and personnel (n¼ 7) offered feedback that directed revisions to the tool’s format, and additional strategies were implemented to increase personnel’s familiarity with the tool. Conclusion: Improvements in the format and in the implemen- tation process for the LTME tool were identified through a QI initiative, and the revised tool has now been distrib- uted broadly.

ARTICLE HISTORY Received 23 August 2018 Accepted 2 January 2019

KEYWORDS Quality improvement; home care services; communication

Introduction

Patient-centred care, which may also be referred to as client-centred care, is endorsed by numerous international health organizations and associa- tions, and ensures that the patients’ interests are integrated into the care provided and into the healthcare decisions made in partnership with the healthcare provider.1,2 Across the various definitions for a patient-centred approach to care, there is “a strong emphasis on a collaborative approach or partnership, respect for the client, facilitating choice and involving the client in determining the occupational goals that emerge from his or her

CONTACT Pat Miller pmiller@mcmaster.ca IAHS Room 403, School of Rehabilitation Science, McMaster University, 1400 Main Street West, Hamilton, Ontario, Canada L8S 1C7 �C�elynne Pilon was an employee at CBI Health Group at the time the quality improvement initiative was con- ducted. She has recently moved to a new job at MD Financial Management, 1870 Alta Vista Drive, Ottawa, Ontario, Canada K1G 6R7. This material was presented in part as a poster at Hospice Palliative Care Ontario (HPCO) in April 2017, and as a presentation at the Health Shared Services Ontario conference in June 2017, and at the Canadian Hospice Palliative Care Association Conference (CHPCA) in September 2017. � 2019 Taylor & Francis Group, LLC

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2019, VOL. 37, NO. 1, 3–15 https://doi.org/10.1080/02703181.2019.1567643

choices”.3 The provision of patient-centred care has been shown to posi- tively influence clinical outcomes, including patient satisfaction and self- management.4 Furthermore, patient-centred care is becoming a recognized quality indicator on which organizations should be evaluated.4

Many authors have noted the importance of getting to know your patient, and making an effort to understand what things are important to them. In a recent concept mapping exercise undertaken in Australia to identify the requirements of patient-centred care, involving stakeholders including patients, carers, health professionals, and managers, “knowing and valuing the patient” was one of the clusters identified. It fell under the domain of “Humanity and partnership”.5 Similarly, when Sumsion and Law undertook a critical review of the literature to identify the key elements of client-centred practice, they identified the overarching theme of power, along with the additional themes of listening and communicating, partner- ship, choice, and hope.3 One of the practice questions provided by Sumsion and Law to consider when offering patient-centred care is “Do I facilitate a process of ensuring my client’s voice is heard?”3 Thus, it is incumbent upon both individuals and organizations to employ strategies to better understand the wishes of the patient which can, in turn, facilitate the provision of patient-centred care regardless of where the person receives care along the continuum of care. There is an increasing number of individuals receiving care in their

home which enables them to receive the care they need while living with independence and dignity.6 Home care is defined as “an array of services for people of all ages, provided in the home and community setting, that encompasses health promotion and teaching, rehabilitation, support and maintenance, social adaptation and integration, end-of-life care, and sup- port for family caregivers”.7 Home care services, based on individual need, are provided to individuals of all ages with both acute and chronic condi- tions, including adults with disabilities and the frail elderly.6 Indeed, the majority of patients (63%) receiving home care services in the province of Ontario, Canada, in 2015/2016 were 65 years of age or older.8 In keeping with the trend towards patient-centred care across the healthcare con- tinuum, it is not surprising that one of the six principles of the Harmonized Principles of Home Care of the Canadian Home Care Association, designed to support consistency and equity among those receiving home care services, is “Client- and Family- Centred Care”.9

The Ontario division of CBI Home Health (CBI Home Health-Ontario) provides a range of health care services, including personal care, nursing and therapy services to persons living at home, in long-term care facilities, hospi- tals, and other settings.10 Personnel providing direct care includes both regu- lated healthcare providers (e.g., registered nurses, physical and occupational

4 P. MILLER ET AL.

therapists) and unregulated healthcare providers (e.g., personal support workers) who are supervised by registered nurses. As a Registered Nurses’ Association of Ontario Best Practice Spotlight OrganizationTM,11 CBI Home Health- Ontario has implemented the person- and family-centred care best practice guideline, among others.12 Recently, the Life Through My Eyes (LTME) tool was developed and introduced as a strategy to improve patient- centred care within the homecare setting. It was anticipated that the use of this tool could enhance the provision of more personalized care across per- sonnel, services, and regions by increasing CBI personnel’s awareness of what was important to the patient. The purpose of this quality improvement (QI) initiative, using Plan-Do-Study-Act (PDSA) cycle,13 was to increase the utilization of the new LTME tool. Below we describe the iterative process of developing and testing the new tool through the four stages of the PSDA cycle, and we outline the changes made in response to feedback from patients, family, and CBI personnel. The results of the QI initiative directed changes to the format of the tool and to the process by which the LTME tool was introduced to patients, families, and personnel in one province prior to being distributed more broadly.

Methods

The PDSA cycle is one the most commonly methodologies used in health- care.13 It engages a small-scale, iterative approach to test interventions and build confidence for change on a larger scale.14 Because it occurs on a small scale, there is minimal risk to the patient and the organization, and the process offers flexibility to respond to feedback while developing solu- tions.14 In the Plan stage, the new LTME tool was developed by an inter- disciplinary committee that also included a patient advisor. In the Do stage, the tool was pilot-tested with a small number of patients, and revised prior to being introduced into practice with selected patients and families (i.e., a small group of volunteers) in several regions in one province. In the Study stage, feedback was solicited from those patients and their families and the respective CBI personnel using short surveys. In the Act stage, both the content and processes regarding the use of the LTME tool were modified, prior to it being introduced provincially. The Hamilton Integrated Research Ethics Board confirmed that we did not require formal ethical approval because this was a QI project.

Plan Stage (2015–March 2016)

The LTME tool is a short questionnaire completed voluntarily by the patient and/or their family. It was developed by the national

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 5

interdisciplinary CBI Patient- and Family-Centred Care (PFCC) Committee that included organizational leaders, direct care personnel and a patient advisor. The patient advisor was a parent of a patient who had been receiv- ing care for several years. The role of the committee is to promote and monitor activities related to PFCC. Integrating PFCC as a tenet of care aligns with CBI values of ‘We Really Care, We Make It Happen, We Aim Higher and We Do Great Work Together’.15 The LTME tool was derived from similar tools, including one by Janes.16

The tool provides an opportunity for the patient or their family to pro- vide a short summary about people or things that are important to them, and activities that can be done by CBI personnel in order to provide indi- vidualized care and comfort. Family members were included because for many older individuals, the family plays a critical role in the patient’s care in the homecare setting. Indeed, in many instances, the CBI personnel sup- plement the care the family provides to their family member. The input of the family is especially critical when the patient’s cognitive or physical sta- tus limits their ability to make their own needs known, and/or to complete the tool. The tool includes five questions/items intended to gather import- ant personal information from the patient used to direct individualized care provided by CBI personnel. They are: “I would like to share with you the most important connections and relationships in my life (e.g., people, pets, beliefs, traditions, places)”, “I will enjoy my day if I am comfortable, so please don’t forget (glasses, lotion, hearing aids, etc.)”, “If I become frightened or upset, these things may help me:”, “Some of the favourite things I enjoy are (e.g., music, movies, TV shows, books, magazines, food or drinks, activities)”, and “Here are a few more things I’d like you to know” (Appendix 1). The patient or their family member writes the answers to these five questions/items on the form, or alternatively they may request the assistance of the CBI personnel to record their answers. The completed LTME tool then becomes part of the care documents that remain in the home with the patient and are available for review by every care provider.

Do Stage (April 2016–February 2017)

The initial version of the LTME tool developed by the PFCC Committee was introduced in one location in Ontario in April 2016 where CBI person- nel provided nursing and personal support services. After several months, members of the PFCC committee recognized that utilization of the tool was limited and they identified the need to initiate a QI initiative to iden- tify the barriers facing patients and personnel which had resulted in the lower than expected acceptance of the LTME tool.

6 P. MILLER ET AL.

By using a structured QI methodology, the PDSA cycle,13 the time and effort of a smaller working group of the PFCC committee, namely the LTME Quality Team which included three organizational leaders (CG, KM, CP), brought additional rigour and focus to the initiative. They designed a series of questions to use to seek feedback from both patients and their families, and CBI personnel, in a small number of selected jurisdictions. Commencing in September 2016, CBI personnel shared the tool with inter- ested patients and/or their family members who were receiving nursing, therapy, and personal support services in four jurisdictions in southwestern Ontario. Following approval from the funders (i.e., Community Care Access Centres), CBI personnel obtained consent from patients or their family member to be contacted by a member of the LTME Quality Team approximately two weeks after the new tool had been introduced as part of the patient’s care.

Study Stage (September 2016–February 2017)

The LTME tool was shared with 49 patients of all ages over a seven month period. All patients or their family members agreed to complete the tool as part of their care, and to subsequently answer a series of short questions about the new tool over the phone. Three members of the LTME Quality Team (CG, KM, CP) conducted the short telephone survey (approximately 20minutes in length) using a semi-structured interview format, seeking feed- back about the tool and capturing verbatim responses from the patient or family member when possible. The survey included questions regarding the time it took to complete the form, and questions about the tool’s content, format and usefulness. Examples of questions were: “What did you think about the length of time it took to complete the document?” “Were you comfortable sharing information to all of the questions?” “Do you feel there was anything missing from the document?” Additionally, a short online sur- vey was circulated by email to CBI personnel who had distributed the tool to their patients (e.g., personal support workers, supervisors, nurses and therapists). This survey included questions about its content, format, and usefulness. Examples of questions were: “Based on your impressions, how much ease or difficulty did you perceive the client had when filling out the document?” “Did the use of this tool affect your practice?” “What has been the biggest surprise in the use of this tool?” The responses of patient, family members, and personnel were anonymized and analyzed by the evaluation team (PM, CC, KM, CP, MH) using qualitative content analysis.17

After the tool had been made available for several months, the LTME Quality Team recognized that the number of patient respondents was lower than expected. In keeping with iterative PDSA methodology, strategies were

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 7

introduced to address this deficiency. The LTME Quality Team developed resources to highlight the role and key features of the LTME tool. This included the distribution of a summary sheet for personal support workers which highlighted the intent and the value of using the tool, and a coach- ing session conducted via teleconference for the supervisors to encourage greater uptake of the tool among their staff. Twenty patients or family members, of the 49 patients who received the

LTME tool, completed the telephone survey over seven months (i.e., 41% response rate). Feedback was not received from the other 29 patients who received the tool because they did not complete the tool, or they were unavailable to answer the survey questions (e.g., admitted to hospital, reported that they could not remember the tool well enough), or they were unable to be contacted despite repeated attempts. The results associated with 19 patients of the 20 patients who were in middle or late adulthood are reported, and the results from the family member of one younger patient were excluded. The sample included 12 female and 7 male patients, com- prised of patients, and spouses and adult children of the patients (Table 1) with patients’ mean age of 78 years (range 53–93). Five patients were in mid- dle adulthood, the 14 others were in late adulthood (Table 2). Patients in middle and late adulthood were considered together because they were receiving similar care and therapy, including assistance with personal care (e.g., bathing, feeding) or requiring therapy or social work services following discharge from hospital (e.g., exercise prescription, safety and support in the home). Fifty-eight percent (n¼ 11) of patients had been receiving care for more than a month, the others were considered to be “new” to the service. Respondents reported 16minutes as the average time to complete the

form, (range 3 to 60minutes). Seventeen of the respondents (90%) reported that the amount of time to complete the form was acceptable. There was a unanimous positive response (n¼ 17/19), with responses missing from two patients, to the question “Do you feel that CBI Home Health should con- tinue asking clients to complete the document?”

Feedback from patients and their families

Seventeen of the 19 respondents (89%) either “agreed” or “strongly agreed” that they were comfortable answering the questions on the tool. Both

Table 1. Relationship of questionnaire respondents to patient (n¼ 19). Respondent

Patient him/herself 10 Son/daughter of patient 4 Spouse of patient 3 Other relative 1 Caregiver 1

8 P. MILLER ET AL.

patient and family members indicated they appreciated the importance of sharing personal information so that care providers were able to provide more personalized care.

� “I’m fine with sharing, [the information] helps people coming in to care for me to know me better.” (58 year old female client)

� “I would share anything with someone who came here. It’s all for helping me." (62 year old male client)

� “I think it is essential to share the information. I have no problem with sharing. It’s a disease, and we’re living with it, and anything that can help us, we’re game to try.” (wife of 82 year old male client)

Various benefits of the LTME tool were noted by the respondents. The use of the tool was noted to prevent the unnecessary repetition of key personal information including preferences with changing personnel. Some respondents noted they appreciated the opportunity to discuss comfort measures.

� “They’re [questions] all good, and what is not covered in the questions can be covered in the last one about anything they would like to share.” (Wife of 76 year old male client)

� “I’m dependent on my family, so that question [about important relation- ships] was the most important.” (93 year old female client)

� “ … [the form] increases your comfort level and makes you believe that CBI is concerned about your well-being.” (81 year old male client)

Some respondents had suggestions about how to improve the tool or its implementation. While most felt the questions were sufficient, one noted there was no way to know if the care providers read the document. Another noted this was an important tool to use with new personnel. Others requested more space to include additional information.

“I think it will [be useful] but I want to add more about how she expresses herself- in other words, ‘Treat me with respect, I’m still in here.’” (Daughter of 88 year old female client)

Feedback from personnel

Responses, including both benefits and challenges, were received from seven CBI personnel: two personal support workers, two supervisors, two

Table 2. Ages of patients (n¼ 19). n Mean (range)

Middle adulthood 5 59 (53–63) Late adulthood 14 84 (74–93)

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 9

therapists and one nurse. Most identified the tool’s value for new patients, and there were several specific examples of how information in the tool had unexpectedly enhanced care for longstanding patients.

� “It reinforces what I know about the client, and adds details like “favourites” that I can reinforce.” (Registered Practical Nurse (RPN))

� “[The] client got hearing aides and for three weeks we didn’t know about it, until we introduced this tool and the family wrote “Please don’t forget to use the hearing aids.” It was really surprising because for so long, we didn’t know the hearing aides were present.” (RPN in a Supervisor role)

Act stage (March–October 2017)

Based on the feedback from patients, their families, and personnel, the PFCC Committee made further changes to the content of the LTME tool and the process for its integration into practice. The changes made were as follows. The purpose of the LTME tool was explicitly stated on the form: “We would like to get to know you and learn what is most important to you.” New sections were added so that patients could provide additional information about past events as well as their current situation. Greater space was made for additional personal details. To increase accountability, each CBI personnel who provides care is required to sign and date the form to indicate they have reviewed it in order to become more familiar with the preferences and needs of the patient. This is also to ensure that the patient or their family member does not have to provide their story more than once (Appendix 1).

New cycle- plan stage (November 2017 onwards)

Building on the results of the first PDSA cycle, a second PDSA cycle has been implemented with the introduction of the LTME tool throughout the province. A ‘train the trainer’ webinar was developed and delivered to all provincial PFCC leaders. Coaching techniques include an explanation of the benefits of LTME, the ‘why’ of PFCC and emphasizing the ‘win-win’ for patients and personnel. Members of the PFCC Committee also recog- nized the need for additional training to optimize the successful integration of the new tool into the homecare setting. A specific training program was developed for supervisors to use when coaching frontline personnel. It includes information on the use of PFCC principles and outlines strategies for optimizing patient-centred care that includes the LTME tool. Furthermore, the tool and the results of the PDSA cycle have been

shared with the clinical leaders in all provinces. The long term goal is to

10 P. MILLER ET AL.

formally evaluate the use of the LTME tool using a larger sample of patients and families, including different services across a range of locations throughout the country.

Discussion

Feedback from patients, their families and CBI personnel through the PDSA cycle has lead to changes in both the format and implementation of the LTME tool. The PSDA methodology, with its iterative cycles, was well suited to this QI initiative. Members of the LTME Quality Team had the opportunity to respond quickly to implement strategies within a limited number of jurisdictions in order to increase uptake of the tool, and to develop short surveys to use to gather feedback about its acceptability and usage. The results of these surveys then guided changes and improvements to the tool and its implementation. The LTME tool, which is a concrete strategy by which personnel can

ensure that the patient’s preferences are known, would fall under the “Listening and Communicating” domain identified by Sumsion and Law.3

While the sample size was small, the patient and family members who offered feedback validated the importance of sharing these personal details with the care providers, and CBI personnel shared a number of specific examples of how the use of the LTME tool improved the care or comfort of patients. Indeed, physical comfort, a dimension of patient-centred care, has been shown to be strongly correlated with the patients’ overall ratings of the quality of care they received.4 While our results may be based on the feedback of only those who agreed to use the tool and liked it, this initia- tive has indicated that there is a sample of patients for whom CBI person- nel will be able to use the LTME tool to gain personal information about the client which can, in turn, facilitate the provision of patient-cen- tred care. Patients and their families played an integral role in design and revision

of the LTME tool. A patient advisor was part of the CBI PFCC Committee that created the initial form and directed this QI initiative. Feedback from patients and their family members was a critical source of feedback that directed the revision of the LTME tool, which, in turn, can enhance the ability of CBI personnel to provide personalized care and comfort for patients. Baker and colleagues identify that patient engagement in QI initia- tives can yield many benefits, including their role here to problem-solve and co-design improvements to care.18 They suggest that involvement of patients in such quality improvement may help establish a platform for broader engagement in patient care and organizational decision-making.18

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 11

Conclusion

The LTME tool, designed to enhance patient-centred care in the homecare setting, was developed and implemented under the direction of the CBI PFCC Committee with patient engagement being an integral aspect of the process. Guided by a PDSA cycle, and based on feedback from patients, their families, and personnel, changes were made to the tool to improve it ability to capture information about what is important to the patient and ways to for personnel to make the patient feel comfortable. The results of this QI initiative, introduced in selected regions in one province, directed changes to the tool’s format and to the processes related to its use, prior to its introduction provincially, with national distribution planned.

Acknowledgements

Members of the LTME Quality Team sincerely thank the patients, their families, and per- sonnel who shared their feedback.

Disclosure Statement

Patricia Miller received payment as a consultant from CBI regarding the implementation of this quality improvement initiative and for assistance in the preparation of material for presentation and this manuscript. Caroline Gill, Kathy Mazza, C�elynne Pilon, and Melissa Hill were employees of CBI Health at the time of the quality improvement initiative. Caroline Gill and Kathy Mazza received funds reimbursing them for attending a profes- sional conference to present this material in part.

References

1. Montague T, Gogovor A, Aylen J, et al. Patient-centred care in Canada: key compo- nents and the path forward. Healthc Q. 2017;20(1):50–56.

2. McCormack B, Borg M, Cardiff S. et al. Person-centredness - the ’state’ of the art. Int Pract Dev J. 2015;5 (Suppl.1):1–15.

3. Sumsion T, Law M. A review of evidence on the conceptual elements informing cli- ent-centred practice. Can J Occup Ther. 2006;73(3):153–162.

4. Rathert C, Wyrwich M, Boren S. Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev. 2013;70(4):351–379. doi.org/10.1177/ 1077558712465774

5. Ogden K, Barr J, Greenfield D. Determining requirements for patient-centred care: a participatory concept mapping study. BMC Health Serv Res. 2017;17:780. http://doi. org/10.1186/s12913-017-2741-y

6. Yakerson A. Home care in Ontario: perspectives on equity. Int J Health Serv. 2018; 49(2):260–272. doi.org/10.1177/0020731418804403

7. Home care in Canada: Advancing quality improvement and integrated care. Canadian Home Care Association. Published May 2015. http://www.cdnhomecare.ca/ media.php?mid¼4328 Accessed November 21, 2018.

12 P. MILLER ET AL.

8. Facts and Figures: Publicly Funded Home Care. Home Care Ontario. https://www. homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare Accessed November 21, 2018.

9. Backgrounder: Harmonized principles for home care. Canadian Home Care Association. Published April 2016. http://www.cdnhomecare.ca/media.php?mid¼4650 Accessed November 21, 2018.

10. CBI Home Health. https://www.cbi.ca/web/home-health Accessed November 21, 2018 11. Registered Nurses’ Association of Ontario. Best Practice Spotlight Organizations.

http://rnao.ca/bpg/bpso Accessed November 21, 2018 12. Registered Nurses’ Association of Ontario. Person- and Family-Centred Care (2015).

Toronto, ON. http://rnao.ca/bpg/guidelines/person-and-family-centred-care Accessed November 21, 2018.

13. Varkey P, Reller K, Resar RK. Basics of quality improvement in health care. Mayo Clin Proc. 2007;82 (6): 735–739. doi.org/10.4065/82.6.735

14. Taylor M, McNicholas C, Nicolay C, Darzi A, Bell D, Reed J. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf. 2013;23(4): 290–298. doi.org/10.1136/bmjqs-2013-001862

15. CBI Home Health, Welcome Home. https://www.cbi.ca/web/home-health/welcome- home Accessed November 21, 2018.

16. Janes, N. “Getting to know me” In Registered Nurses Association of Ontario (2004). Caregiving Strategies for Older Adults with Delirium, Dementia and Depression. (Appendix 0, p. 156) http://rnao.ca/sites/rnao-ca/files/Caregiving_Strategies_for_ Older_Adults_with_Delirium_Dementia_and_Depression.pdf Accessed November 21, 2018.

17. Hsieh H, Shannon S. Three approaches to qualitative content analysis. Qual Health Res. 2005;15 (9):1277–1288. doi.org/10.1177/1049732305276687

18. Baker G, Fancott C, Judd M, O’Connor P. Expanding patient engagement in quality improvement and health system redesign: three Canadian case studies. Healthc Manage Forum 2016;29(5):176–182. doi.org/10.1177/0840470416645601

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 13

Appendix 1

14 P. MILLER ET AL.

PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 15

Copyright of Physical & Occupational Therapy in Geriatrics is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.