Examining Safety Within An
Acute Mental Health Setting:
Building On Lessons Learned
2nd Annual International
Patient Safety Symposium
Sonja Grbevski, PhD
Director Mental Health
Robert Moroz, MSW
Mental Health Manager
Definition- Safety & Mental Health
Program Overview
Identified Challenges
Safety & Mental Health
Program Changes
Future Direction
Canadian Patient Safety Dictionary (Davies, Hebert, &
Hoffman, 2003) developed in response to an identified need
for a common language of patient safety, recommends
“that patient safety be defined as the reduction and mitigation of
unsafe acts within the health care system, as well as through
the use of best practices shown to lead to optimal patient
A Patient safety incident is defined as “ an event or
circumstance which could have resulted, or did result, in
unnecessary harm to a patient, and has a more constrained
meaning than the term incident which, when used in a
general context, has a wider meaning as an event or
circumstance which could have resulted, or did result, in
harm to any person and/or a complaint, loss or damage
(WHO, 2007, p.7)
What Does Patient Safety Mean for
Acute Mental Health Services?
Creating and ensuring safety within acute adult
inpatient units presents a range of challenges:
Medication adverse events
Slips and Falls
Violence & Aggression
Patient Risk for Injury
Staff Risk for Injury
Physical Environment
Risk Assessments-Suicide and Self Harm
Clinical Advancements
What Does Patient Safety Mean for
Acute Mental Health Services? Continued
Creating and ensuring safety within acute adult
inpatient units presents a range of challenges:
Absconding and Missing patients
Seclusion and Restraint
Other Areas for Consideration:
Privacy Violations
Infectious Disease
Human Resource
Mixed-sex environments, limited physical space, and the
acuity of patients’ illnesses are just some of the difficulties
Program Overview
Hotel Dieu Grace Hospital Mental
Health services:
68 Inpatient Acute Beds
Partial Hospital Program
Injection Clinic
Psychiatric Assessment Nurse Team–ED
Community Crisis Program
Inpatient Psychiatric Liaison
Outpatient Urgent Assessment Clinics
Mental Health Hospitalists
Hotel Dieu Grace Hospital
Mental Health Program- continued
HDGH Mental Health services is dedicated to providing
services for all individuals in the Windsor-Essex County
area in a safe and dignified manner.
The Mental Health program continues to identify
opportunities for improvement:
– Physical layout of units- Environmental Assessment
» Safety practice
– Clinical Practice enhancements & education- 5 year plan
Cohesive/Comprehensive Interdisciplinary Patient Care
Model for Mental Health-Recovery focus
Improve Patient/Family Involvement with Patient Safety
Improve Work-life and job satisfaction
Fiscal Stability
Deliverables of Mental Health
Evaluate admission criteria-manage increased
volumes /divert patients to appropriate level of
Decrease ER wait times (enhancement of the PATeampsychiatric assessment nursing team)
Time for patient-staff interaction
Monitor length of stay
Patient safety & security
Strengthening partnerships within HDGH and
the community
Model of care-defined and standardized
Charting process and plans of care
Safety Measures
Medication Errors
Critical Incidents
Suicide Risk Assessment
Code White/AOB
Therapeutic Milieu
Environmental Risk Assessment Tool
Safety Measures
Establish model of care to ensure patient safety and
measure treatment outcomes:
Seclusion and Restraints
Recovery Model and Approach to Treatment
Suicide Risk Assessment
Risk of Elopement Assessment
MH operational manual- revised September 2011
Coordinate psychiatric practice with MH clinicians and
community partners in providing team approach to
mental health treatment:
Community partnerships: (transfer of care to community)
– Mental Health Connections
– Maryvale
– Crisis Program and ED
– Windsor Police Services
– Integrated MH Emergency Clinic (Urgent Response)
Safety Measures
Enhancing the security of the units
Access to unit
Enhanced security features on doors- alarm
Over bed light fixtures
Weekly safety walk rounds
Daily safety rounds» Elopement risk assessment
» Falls
» AOB (acting out behaviour)
Formal standardized clinical structure
» Standardize & enhance practice between 3 N & 3 S
Enhanced utilization of RAI-MH Tool
» Residential Assessment Instrument for Mental Health)
Program Development:
Exploring The Last 5 years
Value stream mapping was conducted in 2007, and
considered the current and future state of the entire
mental health stream.
From that mapping, completed 3 A3s focusing on:
Emergency Department/Inpatient flow,
Inpatient flow, and
Handoffs to outpatient areas.
(Development has also been reflective of MoHLTC,
the LHIN and HDGH requirements)
Value stream mapping and A3s considered
structural changes in three main areas:
inpatient units
outpatient services.
Updated roles and responsibilities for all mental
health positions
Integrated Mental Health Services into HDGH’s
admission process, in order to improve
transparency in bed availability.
Developed document describing mental health
flow from admission to discharge
Adapted SBAR communication tool to meet
specific needs of Mental Health Services, and
implemented tool to facilitate flow
Introduced Clinical Liaison position, which
provides reliable and regular psychiatric services
to medical/surgical inpatient areas
Emergency Department/Community
Crisis Centre/Psychiatric Assessment
Introduced enhanced PAN coverage in Jan
2010 (24 hours- 7 days per week)
CCC enhanced staffing in ED after hours in
order to meet demand (identified peek times)
Mobile Crisis Response implemented in
COAST services started in partnership with
Windsor Police Services (currently under review)
Developed protocol enabling PANs to
facilitate pull system from ED to inpatient
areas (reduction in LOS in ED)
Developed and distributed staff orientation
guide for new employees
Local mental health services providers
describe crisis services on after hours
telephone messages
Inpatient Units
PICU (Psychiatric Intensive Care Unit)
reduced in size to current 8 bed format in
2007. This balanced 3N and 3S, and so
reduced bottlenecks. Also, it created more
acute care beds to meet demand
PICU layout was modified in 2010 to facilitate
improved patient care and safety
“Quiet Rooms” added to 3N and 3S to assist
patients in skill development to reduce AOB
(acting out behaviour)
Inpatient Units-continued
Implemented daily flow meetings, utilizing
multidisciplinary team that includes
community partners.
Allows for improved direction of flow and early
identification of barriers to discharge
Unit security/accessibility has been
extensively reviewed in May 2010, and Jan
Currently this has resulted in major revision in
inpatient pass and smoking policies, and in more
controlled access to inpatient units
Patient/family handbooks have been updated
Inpatient Units-continued
Inpatient group programming has been
extensively revised, with a highlight being the
development of improved module materials
regarding patient education and coping
Inpatient staff has participated in three revisions
to inpatient charting- ongoing
Safety and security rounds are regularly
conducted, and lessons learned applied
Pass policies have been streamlined with
pharmacy requirements in order to reduce
Outpatient Services
Former OT services restructured in 2007,
largely to create a Partial Hospital
The PHP is designed to be an active bridge in the
patient’s journey from inpatient to community care, or to
provide acute care for patient’s not requiring inpatient
This support offers psychiatrists the opportunity to
confidently discharge at the earliest opportunity, or to
avoid unnecessary psychiatric admissions
In partnership with physicians developed a
crisis clinic for patients requiring psychiatric
care. This has facilitated the diversion of
those appropriate patients away from ED
Outpatient Services-continued
Utilized HDGH e-mail system to establish
timely referral process to outpatient services
time for referrals went from several weeks to next
business day
Dedicated crisis worker assigned to PHP to
support patients in crisis, and when
appropriate to divert those patients from ED
PHP programming extensively revised to
reflect new mandate
PHP resources improved to allow for access
to supporting psychiatrist and a RN
Staff Education
Dimensions of Suicide.
Essential Skills for Health Care Professionals
Psychiatric Refresher Day
Borderline Personality Disorder
Long Acting Injectables
Mood Disorders
Threat- Ready – Violence Prevention
Community Partnerships
Developed working arrangement to have two CMHA
(Canadian mental Health Association) workers based
at HDGH to ensure appropriate handoffs during
discharge (2006).
An additional CMHA worker was based at HDGH in
2010; this worker is dedicated to working with ED
patients to ensure smooth transition to community care
A CMHA manager was also based at HDGH in late
2010. In addition to other duties, this manager
administers Community Treatment Orders (CTOs).
– Maryvale (Child/Adolescent Services)
– City Centre Heath Care
– Alive Canada and Distress Centre of WindsorEssex County
Mental Health Services Community
Committee Participation
Human Services and Justice Coordination
Difficult to Serve Committee - ACCESS
Elder Abuse Committee
Dual Diagnosis Committee
LHIN working groups as requested &
Work continues to address improvements in handoffs
in care for long acting injectables.
With the recent resolution of technical issues,
videoconferencing services in support of psychiatric
care at WRH ED will be available in a few weeks
Improved care planning utilizing the Resident
Assessment Instrument – Mental Health (RAI-MH) is a
departmental priority
Means of improving access to hand washing/sanitizing
equipment are being investigated
Reviewing changes to physical layout of outpatient
waiting area, in order to reduce chronic flow issues
Liaise with local Police Services regarding potential for
further active partnerships in programme delivery
Visioning Exercise scheduled for November 15, 2011
Future Direction
Good morale among staff on inpatient psychiatric
units is an important requirement for the
maintenance of strong therapeutic alliances and
positive patient experiences, and for the
successful implementation of initiatives to improve
Increase employee voice, design roles to
maximize autonomy within clear and wellstructured operational protocols, promoting greater
staff-patient contact and improving responses to
violence may contribute more to inpatient staff
morale than formal support mechanisms
Start a Community Advisory Panel- November
Monitor and develop diversion plan for individuals
that have more than 2 emergency department visit
within a 30 day timeframe
Thank you
Contact Information
Sonja Grbevski, PhD
Director, Mental Health Services
Hotel Dieu Grace Hospital
Windsor, Ontario
Robert Moroz, MSW
Manager, Mental Health
Hotel Dieu Grace Hospital
Windsor, Ontario

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