A Quality Improvement Project CMHA Conference
2nd April, 2019
Presented by:Zahra Bolouk – Harm Reduction CoordinatorKimia Ghomeshi – Consultant, Research and Evaluation
Reducing Conflict Amongst Participants with Multiple Presenting Issues within a Low Barrier 24/7 Drop-in
• About Sistering• About CMHA E-QIP Project • Sistering’s E-QIP Process:
• Identifying problem and aim statement• Diagnostic tools• Change Ideas
• Discussion
Agenda
• A low-barrier, trauma-informedplace for all women
• Reaching the most marginalizedo Homelesso Complex mental health issues o Substance users and sex workerso Racialized populations
• Women-identified, non-binary, and gender expanisive peoples
About Sistering
• 24/7 Drop In o 3 Meals/Dayo Rest areao Laundry & Showerso Donations
• Harm reduction program • Case support workers• Medical clinic and counselling• Spun Studio• Peer employment program• Social and recreational activities• Advocacy
About Sistering
• Over 3200 participants have used Drop In• 80% of participants surveyed used Drop In• Over 50 participants overnight (avg), most
are living at Sistering• 400+ meals served daily
With increased homelessness and precarious housing in Toronto, the Drop In isovercapacity
24/7 Drop In
• Partnership between Addictions & Mental Health Ontario, Health Quality Ontario, and CMHA
• Promote and support quality improvement in the communitymental health and addictions sector.
• Workshops on quality improvement processes and tools• Coaching• Community of practice• Several participating organizations
About E-QIP project
Reducing participant-participant conflictin 24/7 Drop In
Sistering E-QIP Project
PART 1: PREPARING FOR QI
Sistering E-QIP Project
Identify the Problem
• Increased participant-to-participant altercations, primarily in the Drop In. Altercations include:o Physical violence o Harassment / verbal o Racism & discrimination
• Participants and staff are emotionally and physically impacted and feel unsafe –triggered, trauma
• Significant time and human resources to manage
• Since the Drop In extended its hours to 24/7, demographics have shifted and conflict perceived to increase.
PART 2: UNDERSTAND THE PROBLEM
Sistering E-QIP Project
Step 1. Understand the problem
• Analyze existing data on violent incidents • Determine times of greatest frequency • Understand nature of conflict – where, when, what
18%
13% 13%
6%
23%
28%
1am-5am 6am-9am 10am-12pm 1pm-3pm 4pm-8pm 9pm-12am
Time period of incidents
33%
28%
20%
14%
9%
5%
3% 3%1%
Dining room Outdoor infront of Drop In
Hallway byfront desk
Rest area Entrance -indoors
Other (pleasespecify)
Bathroom Upstairs Basement
Where did incident take place?
Step 2. Aim Statement
By December 31, 2019, Sistering will reduce physical violent incidents in the dining room that take place between 9pm-12am
by 10%.
Step 3. Root Causes of Violence
Diagnostic Tools:• Process Map• Fishbone• Needs assessment surveys• Pareto chart• 5 Whys
Process Map: Incident reporting
Fishbone diagram
Participants Physical Space
Policies Staff
Bullying and discrimination: racism, transphobia etc.
Lack of trusting relationships developed with each other
Fear of losing belongings Conflict over limited supplies:
phones, computers, chairs
Limited space: storage, sleeping, renovations
Lack of amenities/elements shown by research to reduce violence: natural light, bright colours, greenspace, etc.
Lack of clarity/consistency in policies and procedures to deal with incidents
Limited staff skills on de-escalation
Lack of mental health/social workers Inadequate time for self-care &
debriefing after violent incidents
Lack of staff/participant interaction & monitoring drop-in floor
Violent incidents at Sistering
5 Why’s exercise
• To dig deeper into root causes of conflict • Based on fishbone factors with greatest ‘votes’• Conducted with participants and staff• Conducted 2 rounds of 5 Whys
1. Based on general problem statement (why violence happening)2. Based on more specific problem statement (why physical, after 9pm, in dining room)
5 Why’s exercise
Participant Example: Why more conflict after 9pm in dining room?
Why? Bc women start attacking cleaners after 9 p.m.Why? Women are resistant to moving their stuff
Why? Women don’t like their space being invadedWhy: Lack of clarity on how to live in a shared space
Why: No consistency among staff
5 Why’s
Beware of: tendency for circular arguments, or lack of congruence
Example: Staff Response
Why? People who have mental health issues are triggering othersWhy: Because they are mad, and yelling
Why: Not enough space for everyone and the fact that they are living thereWhy: Staff lacking empathy
Why: Staff don’t have the same and right training
3 Root Causes of conflict
1. Lack of clarity and consistency in policies
2. Limited space
3. Lack of participant engagement and monitoring on
the Drop In floor
Part 3. Understanding Measurement Plan
Sistering E-QIP Project
Run Chart: # of violence incidents/mth
Considerations: • Consistency in
reporting• How to define conflict• Limit variations in
interpretations of data • Staff training required• How to monitor0
5
10
15
20
25
Oct Nov Dec Jan Feb March April May June July Aug Sept
Frequency of incidents (Oct '17 - Sept '18)
Part 4. Developing and Planning Solutions
WORK IN PROGRESS
Sistering E-QIP Project
• Hierarchy of Effectiveness• Idea Generation Tools • Driver Diagram• Impact/Effort Grid• Cost-benefit Grid
E-QIP Tools
Hierarchy of Effectiveness
Idea Generation
• Random Words • Mental Benchmarking • TRUZ
By December 2019 Sistering will reduce physical incidents in the dining room from 9pm-12am by 10%.
Clarity in safetyprocedures
Procedures to revaluate:
Define respite criteria
Length of respites
How to reintegrate participant coming back from respite
Repeat incidences
Violation of respite
Staff communications re:conflict
Enforcing AOAR principles
One Drop In staff on each shift to update next shift staff on incidents and respites, including representative from upstairs
Criteria for all staff emails/ develop codes
What behaviour is and is not acceptable, respite procedures , AOAR policy, and healthy relationships
Update all staff on new procedures and provide training
New staff receive specialized training
Develop safety protocols for each of these areas, through consultation with staff, participants and management
Consistency in safety procedures
# trained staff
# Town halls
Staff manual developed
Written procedures
Participant education on safety procedures
Consistency in staff practices
Consistency between upstairs
and Drop In a
Develop AOAR and safety procedures poster and mini-guides
Develop system around staff communications re: conflict and
respites (fast track emails, calls, etc)
Daily announcements in Drop In
Town Hall meetings weekly – share policies
Train peers to share new policies with participants
Conduct training AOAR and non-violent communication # participant
trainings
Communications plan
# peer trainings and # peer-led sessions
Posters posted all over building
Primary Drivers Secondary Drivers Change Ideas Process Measures
Aim and Big Dot
DRIVER DIAGRAM(DRAFT)
Next step: Impact Grid
Part 5. Measuring and Testing Ideas
Sistering E-QIP Project
Part 5. Measuring and Testing Ideas
Sistering E-QIP Project
What kind of engagement strategies could we considerin the Drop In to foster a more peaceful, non-violent
environment?
A. Individual engagement B. Group engagement
DISCUSSION
Zahra Bolouk, Harm reduction [email protected]
Kimia Ghomeshi, MKG ConsultingResearch and evaluation consultant
Excellence through Quality ImprovementProject:
THANK YOU!
https://ontario.cmha.ca/provincial-programs/e-qip-excellence-through-quality-improvement-project