ARIN ANNUAL SPRING

CONVENTION2016

1. MEA CULPA

■ I apologize.■ Yes our discharge direction for uterine artery

embolization does include an anti-inflammatory.

2. THANKS TO ARIN

■ We were thrilled to present in Vancouver.■ Toronto looked like this.

AND VANCOUVER LOOKED LIKE THIS

NURTURING PATIENT COMPLIANCE

WHO ARE WE

■ Ann Zerdin RN.■ Russell Jones RN.■ Wendy Malachowski RN.

Where Are We From

■ Sunnybrook Health Sciences Centre■ Toronto■ Ontario■ Canada

Sunnybrook HSC

■ Academic Health Sciences Centre.■ Teaching hospital of the University of Toronto

Faculty of Medicine.■ Largest trauma program in Canada.■ K Wing…Long term care centre with a majority of

the patients being veterans.■ Specialties include Trauma, Women and Babies,

Neurosciences, Cancer, and Cardiovascular.

SUNNYBROOK HSC

■ 1275 Beds including 500 veteran beds and 74 bassinets

Sunnybrook HSC

■ 3 Sites

Bayview Campus

St John’s Rehab

SOME BACKGROUND

■ THE CANADA HEALTH ACT■ FEDERAL FUNDING■ PROVINCIAL COVERAGE■ LOCAL HEALTH INTEGRATION NETWORKS■ ONTARIO NURSING ASSOCIATION (THE UNION)

FUNDINGIN ONTARIO

CANADA HEALTH ACT

■ The provisions of the 1984 Canada Health Act define the health care delivery system as it currently operates. Under the Act, each provincial health plan is administered at the provincial level and provides comprehensive first dollar coverage of all medically necessary services.

■  Most physicians are paid on a fee for service basis. Private health insurance for covered services is illegal. Most Canadians have supplemental private insurance for uncovered services, such as prescription drugs and dental services. As a result, virtually all physicians are forced to participate.

■ The ministry of health in each province is responsible for controlling medical costs. Cost control is attempted primarily through fixed global budgets and predetermined fees for physicians. Specifically, the operating budgets of hospitals are approved and funded entirely by the ministry in each province and an annual global budget is negotiated between the ministry and each individual hospital. Capital expenditures must also be approved by the ministry, which funds the bulk of the spending.

FEDERAL GOVERNMENT FUNDING■ DIRECTLY FUNDS MILITARY HEALTH CARE■ ABORIGINAL HEALTH CARE■ FEDERAL GOVERNMENT PROVIDES FUNDING

SUPPORT TO ITS PROVINCIAL GOVERNMENTS FOR HEALTHCARE EXPENDITURES AS LONG AS THE PROVINCE IN QUESTION ABIDES BY ACCESSIBILITY GUARANTEES AS SET OUT IN THE CANADA HEALTH ACT, WHICH PROHIBITS BILLING END USERS FOR PROCEDURES THAT ARE COVERED BY THE PROVINCIAL PROGRAM.

EXAMPLES OF SERVICES ARE COVERED BY O.H.I.P■ MEDICALLY NECESSARY PHYSICIAN SERVICES.■ DENTAL SERVICES THAT ARE REQUIRED TO BE PERFORMED IN A HOSPITAL.■ SOME PRACTIONER SERVICES THAT ARE MEDICALLY NECESSARY.■ ANNUAL EYE EXAMINATIONS FOR THOSE UNDER 20 OR OVER 65.■ EYE EXAMINATIONS EVERY 12 MONTHS FOR THOSE AGED 20-64 WITH

MEDICAL CONDITIONS REQUIRING REGULAR EYE EXAMINATIONS.■ PRESCRIPTION DRUGS -WHILE IN HOSPITAL,OR IF AGED 65 OR OLDER, OR

ON SOCIAL ASSISTANCE, OR LIVING IN A LONG TERM CARER SETTING, OR RECEIVING PROFESSIONAL SERVICES AT HOME.

■ COST OF MEDICALLY NECESSARY SURGERY, PRESCRIBED MEDICATION DURING THE HOSPITAL STAY, AND COST OF A WARD ROOM.

■ PHYSIOTHERAPY PRESCRIBED AFTER AN OVERNIGHT HOSPITAL STAY, FOR THOSE UNDER 20 AND OVER 65, FOR THOSE IN LONG TERM CARE SETTINGS, OR REQUIRING SERVICES AT HOME.

EXAMPLES OF COSTS NOT COVERED BY O.H.I.P■ AMBULANCE SERVICES.■ DENTAL SERVICES NOT PERFORMED IN A HOSPITAL.■ MEDICATION PRESCRIPTIONS (WITH EXCEPTIONS).■ MEDICALLY UNECESSARY SURGERYS, PROCEDURES,

OR TREATMENTS.■ SOME ALTERNATIVE THERAPYS (NATUROPATHY,

ACCUPUNCTURE, CHIROPRACTORS, OR MASSAGE THERAPY.

LOCAL HEALTH INTEGRATION NETWORKS

LOCAL HEALTH INTEGRATION NETWORK

LOCAL HEALTH INTEGRATION NETWORK

■ The Toronto Central LHIN was designated by the Ministry of Health & Long-Term Care to plan,

integrate and fund local health services.  We fund over 170 health service providers, including a

Community Care Access Centre, community health centres,  community support services,  hospitals, 

long-term care homes and mental health and addiction services that deliver a variety of services.

ONTARIO NURSES

ASSOCIATION

ONTARIO NURSES ASSOCIATION■ THE TRADE UNION THAT REPRESENTS 60,000

REGISTERED NURSES AND ALLIED HEALTH PROFESSIONALS WORKING IN HOSPITALS, LONG-TERM CARE FACILITIES, PUBLIC HEALTH, COMMUNITY AGENCIES AND INDUSTRY THROUGHOUT THE PROVINCE OF ONTARIO.

■ NURSES IN MOST HOSPITALS ARE UNIONIZED (142).

INTERVENTIONAL RADIOLOGY

■ OUR CONCERNS

OUR CONCERN• Patient Compliance

• Portal Vein Embolization (PVE).• Done on an out patient basis.• Current protocol includes 6 weeks of daily subcutaneous

injections of Low Molecular Weight Heparin (LMWH).

Educating patients to self medicate prior to discharge.

OUR CONCERN• Patient Compliance

• Uterine Artery Embolization (UAE).• Done on an outpatient basis.• Pain management post procedure.

Educating patients to effectively manage post procedural pain.

OUR CONCERN• Patient Compliance

• Percutaneous Nephrostomy Tubes (PNT), Percutaneous Nephro-Ureterostomy Tubes (PNUT), Percutaneous Biliary Drains.

Requirement to uncap catheters if they develop new pain at site, leakage around the catheter or a fever.

HOW CAN WE ENABLE

COMPLIANCE?

COMPLIANCE…WHAT IS IT?

■ The degree to which a patient correctly follows medical advice

Compliance is impacted by…. Health Literacy (understanding of the directions for

treatment) Literacy (the ability to read, write and speak in English,

and to use mathematics at a level necessary to function at work and in society)

Age (young and elderly associated with non-adherence) Prescription Fill rates (cost, doubt of need, side effects,

lack of demonstrated benefit) Course Completion (asthma 28-70% worldwide,

hypertension 50% drop out of care in a year)

COMPLIANCE

INTERNAL FACTORS■ AGE■ CULTURE■ SOCIAL BACKGROUND■ VALUES■ ATTITUDES■ EMOTIONS CAUSED BY

THE DISEASE

EXTERNAL FACTORS■ NURSE-PATIENT

RELATIONSHIP■ PHYSICIAN-PATIENT

RELATIONSHIP■ SUPPORTS – FAMILY,

FRIENDS, HEALTH CARE PERSONNEL.

COMPLIANCE

■ Was there a way that we could improve our impact on the compliance of our patients.

■ Health Care field studies that we looked at during our research documented a correlation between satisfaction and compliance.

■ Was there a proven framework available to assist us.■ The Kano model of customer satisfaction related to their

perception of their experience seemed….interesting.■ We kept in mind the quote from George Box “All

theories are wrong, but some are useful”.

COMPLIANCE

■ At one time patients were seen as objects of medical interest. Now they are participants in care.

■ Published studies on Service Quality show three major areas.

Professional medical techniques Staff attitudes Environment

KANO

Kano

■ Created by Professor Noriaki Kano, it can be used to help teams uncover, classify, and integrate three categories of needs and attributes into their services.

KANO

■ A technique for classifying customer needs and determining appropriate levels of innovation for products and services. In certain cases, customer satisfaction may be greatly increased with minor performance improvements in product or service attributes; in other cases, customer satisfaction only increases slightly even when major performance improvements are made.

■ A set of ideas for planning a product, service or process.

KANO

■ Three core tenets

Value attracts customers.

Quality keeps customers and builds loyalty.

Innovation is necessary to compete in the market.

KANO

■ 3 core types of need

■BASIC NEEDS Expected, assumed, given.

HAND HYGIENE

Absence will cause dissatisfaction, but no amount of execution quality will cause positive satisfaction, it will only minimize dissatisfaction.

KANO

■ 3 core types of needs

■PERFORMANCE Needs that are consciously evaluated by the customer and

at the top of their minds. Less waiting time for a scheduled procedure = more

satisfaction. Longer waiting time for a procedure = less satisfaction.

Satisfaction is proportional to the way in which these are executed - dissatisfaction due slow, poor, or absent execution – high satisfaction due to quick, powerful or exquisite execution.

KANO

■EXCITEMENT Attributes/qualities that are “wow”, differentiators,

innovations, unique selling/value propositions. Presence of these will delight and increase

satisfaction, but absence will not dissatisfy.

COMPLIANCE

PATIENT■ APATHY.■ CONCERN ABOUT TAKING

DRUGS (e.g. adverse affects, addiction.)

■ DENIAL OF THE DISORDER OR ITS SIGNIFICANCE.

■ FINANCIAL CONCERNS

DRUG■ FORGETFULNESS■ MISUNDERSTANDING OF PRESCRIBING

INSTRUCTIONS.■ NO FAITH IN DRUG.■ PHYSICAL DIFFICULTIES (e.g. swallowing

tablets, opening bottles, injection).■ REDUCTION, DISAPPEARANCE OF

SYMPTOMS.■ ADVERSE EFFECTS.■ COMPLEX REGIMEN.■ INCONVENIENT/UNPLEASANT.

COMPLIANCE

■ PATIENTS ACT ON TREATMENT RECOMMENDATIONS WHEN THEY BELIEVE THAT THE BENEFITS OF TREATMENT OUTWEIGH THE TREATMENT BARRIERS.

COMPLIANCE

■ PATIENTS CANNOT CARRY OUT RECOMMENDATIONS THAT THEY DO NOT UNDERSTAND AND WILL NOT CARRY OUT RECOMMENDATIONS THAT THEY DO NOT ACCEPT.

■ PATIENT SATISFACTION IS RELATED TO A SENSE OF TRUST.

■ THE KANO MODEL SHOWS THAT THERE IS NOT A SIMPLE LINEAR RELATIONSHIP BETWEEN PERFORMANCE AND SATISFACTION.

OUR IMPACT

CAN’T IMPACT■ EQUIPMENT■ PHYSICAL FACILITIES■ TIMELY SERVICE

PROVISION

WE CAN IMPACT■ EDUCATION■ KNOWLEDGE TO ANSWER

QUESTIONS■ COMFORT■ CLEANLINESS■ INDIVIDUAL ATTENTION■ UNDERSTANDING AND REACTING

TO SPECIFIC NEEDS■ ONE VOICE/SINGLE MESSAGE■ BE SEEN AS WORKING AS A TEAM

TEACH-BACK

■ The Teach-Back Method, also called the "show-me" method, is a communication confirmation method used by healthcare providers to confirm whether a patient (or care takers) understands what is being explained to them. If a patient understands, they are able to "teach-back" the information accurately.

■ http://www.teachbacktraining.org/

WHAT IS TEACH-BACK

■ What is Teach-back? l A way to make sure you—the health care provider—explained information clearly.

■ It is not a test or quiz of patients. ■ Asking a patient (or family member) to explain in their

own words what they need to know or do, in a caring way. ■ A way to check for understanding and, if needed, re-

explain and check again. ■ A research-based health literacy intervention that

improves patient-provider communication and patient health outcomes.

■ http://www.teachbacktraining.org

TEACH-BACK

■ 1. Use a caring tone of voice and attitude■ 2. Display comfortable body language and make eye contact.■ 3. Use plain language.■ 4. Ask the patient to explain back, using their own words.■ 5. Use non-shaming, open-ended questions.■ 6. Avoid asking questions that can be answered with a simple

yes or no.■ 7. Emphasize that the responsibility to explain clearly is on you,

the provider.■ 8. If the patient is not able to teach back correctly, explain

again and re-check.

TEACH-BACK

■ 9. Use reader-friendly print materials to support learning

■ . 10. Document use of and patient response to teach-back.

TEACH-BACK

https://www.youtube.com/watch?v=pCNCqA5LqFo

THANK YOU• ANN

• RUSSELL

• WENDY

A SHORT FOLLOW UP

THANK YOU AGAINAND AGAIN