Activity Lead: Dr. Paul Carey
Update: June 2020
Dr. Carey leads a dynamic group of physicians at the Vernon Jubilee Hospital to protect the vulnerable.
The ability of physicians and staff within Interior Health to provide high quality, effective and safe care to patients in volatile emergency and inpatient psychiatric settings depends in part on an accessible and clear framework within which to work. In British Columbia, this framework includes the Mental Health Act. Front line physicians are responsible for balancing multiple sources of information to formulate a diagnosis and treatment plan for patients. It may also include admitting patients with mental health disorders on an involuntary basis. Involuntary admission presents inherent and profound curtailment of individual rights with significant risks to patients and medico-legal risk to physicians and the Health Authority. Recent reports suggest we have fallen short of the legal requirements set out in the Mental Health Guide (2005) by failing to demonstrate standards of care that are shown through the use of standardized documentation. This situation substantially compounds inherent risks and collectively fails to demonstrate our delivery of quality of care to some of our most vulnerable patients.
In BC, training in the utilization of the Mental Health Act is neither widely available, nor is it mandated by either contracting Health Authorities or the College of Physicians and Surgeons of BC. Consequently, there is considerable variation in the appreciation, by physicians and staff, of the specific requirements of the act as well as their mandatory obligations in its practical application.
In 2017 the Office of the Ombudsperson did a province-wide review on the use of the Mental Health Act and the forms mandated by the Mental Health Regulation. Despite two previous reviews by IHA’s internal Audit team and two brief education sessions provided in 2012 & 2014, Interior Health had below-average adherence to mandatory completion of forms and patient education. Unfortunately, the Ombudsperson report (2019) showed IH had had little improvement in the areas mentioned above, since the last internal report. Mandatory forms outlined in the Mental Health Regulation document (Mental Health Act) are not being filled in a timely and accurate way if indeed at all.
We speculate that numerous factors contributed to this disappointing finding and include:
• Staff turn over
• Lack of consistent mandatory education for Mental Health workers
• Lack of physician participation in the education sessions
• High turnover of patients allows little time for clinical supervision and review of charts
For education to impact and (1) improve compliance with standards and (2) to endure within the Health
Authority, strategies to revise and mandate education, and to monitor and provide feedback to staff and
physicians need to be embedded within the daily frontline application of the mental health act.
Among this group of dedicated physicians working on his activity are Dr. Susan Wiseman, Department of Emergency Medicine, the co-developer of education material, simulation organizer and education event coordinator; Dr. Janus Steyn, Department of Psychiatry, developer and editor of education audiovisual material; Sandy da Silva, MHSU Director – Family Standards – PQI Project Partner and co-developer of education material/PPO development and revisions/Cognitive aid development.
The project to date also has involved members of the departments of psychiatry, emergency medicine, and VJH clerical and clinical staff in the development and roll-out of the preliminary work.
Substantial work has been completed in the first few months of 2020 before COVID-19 hit with a vengeance.
February produced team meeting ERP’s, Psychiatry, VJH staff – QI exercise.
March 2020 – The preparation and recording of education material, development of cognitive aids for ED, and revision of admission order set for Psychiatry, along with amending Mental Health act for packages to promote completion in nursing staff. Also, an education event with ERP’s (VJH Department Emergency Medicine), Education event with Psychiatry (abridged), and an Education event using ECHO platform to rural and remote GPS (16).
What were the significant successes achieved?
1. The development of collaborative relationships with ED and Psychiatry.
2. Co-development of the first version of Education modules to supplement IH I-learns.
3. A first-time focus in education on quality of form completion.
4. Audit of form completion data before and currently reviewing post-education completion data.
5. Identification of places to make improvements in education modules and engagement as the work moves forward to regionalize implementation.
Did you have a primary objective?
One of the main objectives- physicians at VJH (designated facility) will complete 100% of the Forms 4 and 5 for involuntary admission within 24 hrs of admission, by March 30, 2020.
How did you validate your success?
Data source to validate success was achieved through interviews and a survey.
What conclusion can you share?
The project has achieved most of the secondary goals set out in this preliminary project stage. We have learned and will continue to learn from this work to promote a culture of patient-centered care for involuntarily admitted patients. This project has highlighted the importance of collaboration and engagement of all who will be impacted or are going to need to continue to lead improvement work moving forward.
While we do not anticipate 100% completion rates in the post-implementation survey, the results will be used to inform further adjustments to our education and auditing process moving forward regionally.
What has been the overall impact of the activity?
• Improved the building of connections, trust and collaboration within the MSA and with the health system managers.
• Enhanced the communication of ideas and beliefs consistent with the changes we hoped to see.
• Established formalized roles, rules and policies that support the changes we want to see.
• Concrete initiatives and actions were implemented that will advance or protect the desired changes.
What areas were impacted by your outcomes?
• Increasing physician engagement
• Enhancing communication with Interior Health and/or improving patient care
Did you experience any challenges?
The process of engaging all members of the relevant teams in the necessary changes to practice is a work in progress.
Given the tight timelines, offering only one education session inevitably meant some were not given the opportunity to be engaged.
Have these challenges affected the workplace, your likely outcomes, or your expected end date? If so, how?
The timelines before March 30 were always ambitious. COVID-19 related delays did not help. It has delayed reporting on findings, but these are anticipated in a more finalized form by the end of June 2020.
How did you revise your activities to remove these barriers?
We will likely make further changes to education material to improve messaging and important areas identified in the first post-implementation survey. Given the move to the next fiscal year and lack of ongoing funding, we will find ways to promote on-line, practitioner-driven access to education materials on-line. Further quality audits are planned – the timeline to be determined.
What meetings, research reports and communications are planned?
PQI poster presentation.
Who will be involved?
ER and Psychiatry co-leads.