Trellis MENTAL HEALTH AND DEVELOPMENTAL SERVICE Coming Full Circle With Community Client Case of Mr. Black ONPEA Conference 2010
Context – Background • Free-standing Community Mental Health and Developmental Services – all ages • Seniors @ Risk System Coordination Interface with Specialized Geriatric Services • Enterprise Quality/Risk Management Framework and its link to Trellis Mission/Vision; Strategic Plan Especially client/staff safety
Housekeeping • Sit with people you do not know • This is an interactive session • We need your voice • Review Mr. Black’s story beforehand
Quote “ Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” … Margaret Mead
Objectives • Tell Mr. Black’s story - What Happened? • Highlight key concerns – Small Group/Interactive • Get your reactions and feedback – What would you have done? • How did the system respond to Mr. Black’s story? • How do we prevent this happening again?
Part 1 - Mr. Black’s Story • Review of Scenario provided beforehand • Small Group Discussions re key concerns • Pick Small Group Recorder and Reporter • Document on Small Group Discussion Sheet • Highlight key concerns from both presenters and audience • Summary of Key issues on Flip Chart
Part 2 - What would you have done? Identify Your Community Partners • Small Group Discussions – What would you have done? • Identify who your community partners may be • Reconvene to Large Group • Summarize in Large Group Discussion - Themes
What We Did Front-line Workers Noted Risk & Multiple telephone/face-to-face interventions Multiple phone calls from family/neighbours/friends Multiple phone calls and several face-to-face discussions with SDM Seniors at Risk Coordinator Consultations Risk Manager Consultations Community Senior Management Consultations Family Physician/Specialists Consultations Several Court Support/Legal/Police Consultations ACE/PGT/CCB Consultations Multiple Conversations Documented Several Community Case Conferences Community Case Conference included Ethicist Incident Report/Review within a continuous learning process
Issues that Arose Who is our client? Who is responsible for the client? Whose job is this? Where is the client’s voice? What are her wishes? Who is speaking for the client? Is it risk?
Part 3-WW System Service ResponseQuestion: Risk Assessment – Identified Risks • Significant differences of opinion between Trellis and other service providers regarding Trellis’ role, the interpretation of legislation and the ethics of intervening. • Vastly different levels of knowledge among service providers and police regarding Health Care, Mental Health and Privacy Legislation compromised communication, care planning and the response to John. • Jane’s wishes were not documented through a living will or advanced directive leading to a unhelpful struggle for control over Jane’s care among John, family, neighbours and service providers. • Fragmented treatment response to Jane and John due to a lack of a shared person and family centered community care approach and plan for vulnerable clients served by multiple service providers. • High potential for violating Jane and John’s rights to privacy, involvement in treatment decisions, and informed consent.
Risk ReviewFindings of Investigation • Not all healthcare providers accurately understood privacy legislation. • Both Trellis Legal Counsel and Advocacy Center for the Elderly - ACE confirmed that PHIPA permits sharing of PHI information in risk situations. • Healthcare providers did not understand the legal recourse available to deal with a Substitute Decision Maker (SDM) who is not acting in the best interests of a vulnerable person. • The Health Care Consent Act allows a service provider to apply to the Consent and Capacity Board for a ruling to determine if the SDM is complying with the incapable person’s wishes or acting in their best interests. If not complying, the CCB can issue an order compelling the SDM to make decisions consistent with the person’s best interest or to have a new SDM assigned.
Risk ReviewFindings of Investigation – cont’d • Healthcare providers were not knowledgeable about the role, responsibility and authority of a SDM. • The Trellis Medical Director was not consulted early enough when questions of the competency of the SDM were raised. • Police consulted had differing opinions regarding their legal obligation to enact a Form 2 issued by a Justice of the Peace. • There was conflicting information and a lack of objective assessment and decision making leading to a strong and unhelpful split among service providers regarding John’s mental status and what action to take.
Risk Review Recommendations 1. Implement Education Plan for Trellis staff, community providers, police and families regarding relevant legislation and deficits in knowledge identified above. 2. A two-day workshop is planned for the fall of 2009 that will include lawyers specializing in healthcare law. A session for clients/families will focus on the duties and responsibilities of the SDM, privacy legislation and other relevant healthcare legislation. 3. A laminated reference sheet outlining the duties and responsibilities of a Substitute Decision Maker will be prepared for service providers (in progress) Orientation To Service Opportunity To Question Right to Be Informed
Risk Review Recommendations – continued 4. Educate/train Service Providers on providing collaborative care for clients receiving help from multiple providers. 5. Train Service Managers and Regional Coordinators in applying person centered and family centered principles and appropriate legal remedies to similar situations. 6. Develop protocol with CCAC for effectively managing crisis situations and addressing the needs, concerns and challenges of SDMs. 7. Invite all service providers to the two day workshop in Fall 2009 (to date, the learnings from this incident have been shared at three different community forums and reviewed at Trellis team meetings). 8. Continue to build awareness with staff regarding how to foster client self determination and protect personal rights.
Your Experience with Risk How many have participated in a “risk review” How many have participated in a “formal” debrief session? What did you learn?
Facts Around Client/Staff Safety Majority of adverse events involve communication errors These errors are a result of: - Human performance limitations - Interpersonal dynamics - Team functioning and the clinical environment…cpsi
Facts Around Client/Staff Safety We bring different filters to our work -- cultural differences - gender differences - disciplinary/professional differences - workload stress - hierarchical structures Need to identify differences and develop a shared structure to support effective communication. Need to create a culture that can examine errors in light of and consideration of interpersonal dynamics and communication structures Communication errors are a team and structural issue “we want everyone to be in the same movie” …patientsafetyinstitute.ca
Final Messages Client(s) Voice First Consistent Communication and Collaboration Be Risk Aware Be Aware of your own filters and those of others Client(s)/Staff Safety is possible within an effective risk management framework