Table 3 Summary of the 12-subproject quality improvement initiative, including the application of SEIPS 101 tools and proposed outcome measures for each subproject. For additional information on the 12 subprojects, please refer to Appendix 1
Subproject number | Subproject | Subproject description | SEIPS 101 tools utilized | Structural units responsible | Associated change implemented | Proposed outcome measure |
|---|---|---|---|---|---|---|
1 | Ongoing Literature Review of WPV-related topics | Ongoing literature reviews of current research pertaining to WPV in healthcare were performed to provide UHN Security with the most up to date information necessary to make informed decisions. | • Outcomes Matrix | • UHN Security WPV QI Team | Ongoing literature reviews on the following topics related to WPV: • WPV in healthcare settings during the pandemic • Agitation Management • De-escalation Techniques • Code White Simulation Training | • number of hot debriefs since implementation • number of cold debriefs logged since implementation • number of Code White/WPV requests for escalation |
2 | Identifying quality indicators for measuring change in quality of care related to Code White and WPV incidences | Based on a rapid review, a collated list of quality indicators will be condensed to the top relevant, impactful and feasible indicators through an anonymous modified Delphi process. This process will utilize experts from UHN and Toronto Academic Health Science Network. | • Outcomes Matrix | • UHN Security WPV QI Team | • Rapid review of quality indicators to measure WPV-related processes in healthcare • Modified Delphi process to select top indicators | • number of governance committee meetings • number of annual progress reports |
3 | Implementing quality indicators to an organization-wide WPV dashboard | A WPV dashboard with the top evidence-based quality indicators identified from the modified Delphi process will be created to measure WPV at UHN and be used to inform leadership decision making. | • Outcomes Matrix • Journey Map | • UHN Security WPV QI Team | • WPV dashboard creation | • number of hot debriefs since implementation • number of cold debriefs logged since implementation • number of Code White/WPV requests for escalation |
4 | Changing the perception of safety and support in HCPs during Code White and WPV incidences | A longitudinal qualitative approach to capture ED staff’s perception of safety, support, clinical guidance relating to managing and learning from WPV incidence, security and personal expectations for organizational change. Additionally, measuring change over time in sense of preparedness to handle WPV situations using Bandura’s self-efficacy theory. | • Systems Story | • UHN Security WPV QI Team | • Performing semi-structured qualitative interviews with all staff, learners and volunteers in the ED on an ongoing basis | • number of meetings regarding community outreach |
5 | Implementation of educational intervention I | An ad-hoc training program focused on situational and environmental awareness was implemented as a pilot training program for ED staff. The program would provide staff with additional training methods and skills for safety and self-protection while determining whether a need for additional training was evident. | • Outcomes Matrix • Systems Story | • UHN WPV Education Collaboration • UHN Safety Services • Code White Governance Committee • UHN Security WPV QI Team | • Implementation of a pilot WPV skills training session | • number of meetings regarding reporting systems |
6 | Implementation of a dedicated UHN Code White Governance Committee | A governance committee dedicated to Code Whites at UHN that will be responsible for the following tasks: • establishing a streamlined approach and response to Code White incidents • overseeing implementation of high complexity Code White simulation training that uses a trauma-informed lens • optimize Code White incident reporting, including a user-centred and trauma-informed reporting approach • optimizing of auditing statistics and quality indicators for Code White clinical care at UHN | • PETT Scan • People Map • Journey map • Interactions Diagram | • UHN WPV Prevention Advisory Committee • Code White Governance Committee | • Implementation of an interdisciplinary Code White Governance Committee | • number of hot debriefs since implementation • number of cold debriefs logged since implementation • number of Code White/WPV requests for escalation |
7 | Reviewing, updating and implementing incident reporting for WPV and Code White incidents | A working group made up of multiple functional units at UHN are reviewing the incident reporting processes and reporting systems at UHN. The working group will update UHN’s reporting system to develop a streamlined, user-centred and trauma-informed reporting approach. | • Tools and Tasks Matrix | • UHN Quality and Safety • UHN Safety Services • UHN Emergency Preparedness • Code White Governance Committee | • Development of Safety Event Reporting and Review System (SERRS) Project | • number of meetings on physical restraint systems |
8 | Implementation of educational intervention II (UHN TIDES) | The development of a trauma-informed WPV prevention education program centred around agitation management, de-escaltion techniques, physical safety, self-protection and code white simulation. The training must be specific to staff’s environment, provide the opportunity for different positions to work together and provide refresher training. | • Outcomes Matrix • Systems Story | • UHN WPV Education Collaboration • UHN Safety Services • Code White Governance Committee • UHN Security WPV QI Team • External Collaboration partner | • Implementation of UHN TIDES | • number of articles related to WPV in healthcare that were reviewed |
9 | Implementing Environmental Indicators for harm reduction and risk minimization | Environmental signage using trauma-informed language to communicate a message of mutual respect between hospital staff and visitors to create an environmental and cultural change surrounding WPV in EDs. | • Interactions Diagram | • UHN Security WPV QI Team | • Implementation and evaluation of environmental indicators for mutual respect in UHN EDs | • number of quality indicators identified from the literature • number of unique quality indicators operationalized for UHN • number of unique quality indicators selected through the Delphi Process |
10 | Code White hot and cold debriefing process and debriefing escalation algorithm | A new approach to debriefing following Code White and WPV events will be implemented using hot and cold debriefs. Additionally, an algorithm for escalating a Code White or WPV event will be developed. | • PETT Scan • People Map • Tools and Tasks Matrix • Journey Map • Interactions Diagram | • UHN Emergency Preparedness • Code White Governance Committee • UHN Security WPV QI Team | • Implementation of hot and cold debrief guidelines • Implementation of new communication strategy for entities requesting cold debriefs | • number of quality indicators implemented • number of databases used to provide data |
11 | Physical restraint systems | Currently no guidelines or policies on physical restraints are provided on a provincial or national level. A descriptive physical restraint system is required for a universal approach to applying physical restraints. | • Tools and Tasks Matrix | • Code White Governance Committee • UHN Security WPV QI Team | • Development of physical restraint system | • number of staff that completed training program • evidence of staff satisfaction with training |
12 | Patient partners and community outreach | Connecting with patients, caregivers and (chosen) family members and providing them with the opportunity to connect and talk about their experience during Code White or WPV events. | • People Map • Systems Story | • Code White Governance Committee • UHN Security WPV QI Team | • Implementing a town hall style meeting with patients, caregivers and (chosen) family members involved in Code White or WPV events | • evidence of new training program • number of trainers hired |