Office of the Chief Coroner strategic plan: awareness of vulnerabilities in the elderly
Learn about the steps we are taking to build awareness of elder vulnerabilities and intentional harm in the health and long-term care sector.
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The Office of the Chief Coroner (OCC) is committed to building awareness of elder vulnerabilities and intentional harm by healthcare providers within the long-term care sector. This strategic plan represents our commitment to:
- deliver on this goal
- implement the recommendations set out in the public inquiry
- the safety and security of residents in the long-term care homes system
We identified five key priorities from the long-term care homes public inquiry and have established five systemic pillars to help deliver on these priorities. These pillars include:
- education, training and mentoring
- oversight and accountability
- continuous improvement
Within each pillar there are:
- intended outcomes to support the long-term care sector
- clear deliverables to ensure implementation of each pillar
- performance metrics to measure progress for each deliverable
These will guide our progress on building awareness for elder vulnerabilities and intentional harm and ensure ongoing accountability.
The public inquiry into the safety and security of residents in the long-term care homes system was established on August 1, 2017 by Order in Council. It was established after a registered nurse was convicted for offences she committed while working in three licensed long-term care homes and providing home care in Southwestern Ontario.
The Commissioner of the Inquiry, the Honourable Justice Eileen Gillese, issued her final report on July 31, 2019, citing 91 recommendations under the following key themes:
- Prevention: strengthening the long-term care system by building capacity and excellence throughout it.
- Awareness: building awareness throughout the health care system about the possibility of intentional harm by healthcare workers.
- Deterrence: deter wrongdoers from intentionally harming long-term care residents using medication.
- Detection: tailoring the death investigation process as it applies to deaths in long-term care homes.
Given that death investigations intersect across the healthcare sector, the Office of the Chief Coroner is in a unique position to play a leading role in bringing about systemic changes within the long-term care system. As a result, Justice Gillese has tasked the OCC with 26 recommendations, 10 of which are specific to awareness and 16 focused on detection. These recommendations include:
- playing a leadership role in building awareness on vulnerabilities of the elderly population
- detecting potential cases of intentional harm within long-term care homes
- ensuring coroners and the staff in the long-term care sector have the appropriate training required to enhance the death investigation process in both a community care and long-term care setting
There are five key priorities that drive the Office of the Chief Coroner’s commitments related to the long-term care homes public inquiry:
- Development of a strategic plan to build awareness of the vulnerabilities of the elderly population, including intentional harm. The purpose of the plan is to also highlight the Office of the Chief Coroner’s responsibilities in the public inquiry into long-term care homes and how these responsibilities will be addressed.
- Curricula and framework development for organizations and institutions responsible for the delivery of education and training in the healthcare system.
- Educational content development and delivery in consultation with healthcare partners, developing content that addresses the requirements of the long-term care homes public inquiry and providing an accessible platform to implement training for coroners and long-term care professionals.
- Program evaluation to ensure training and development programs reflect the needs of the healthcare sector and have the flexibility to make amendments where required.
- Building research capacity within the Office of the Chief Coroner on vulnerabilities of the elderly population including intentional harm.
To deliver on these priorities, five systemic pillars have been established:
- Education, training and mentoring to build awareness on the systemic vulnerabilities of the elderly.
- Oversight and accountability to develop and monitor systems of oversight within and across organizations.
- Communication to facilitate regular and meaningful lines of communication across the healthcare system where concerns, processes, patterns and best practices are shared to collectively reduce the potential for harm to the elderly.
- Culture to contribute towards establishing a “just culture” that encourages and prioritizes the reporting of vulnerabilities.
- Continuous Improvement to normalize the questioning and continued quality improvement efforts by the long-term care sector and death investigation system in Ontario.
Pillar 1: education, training and mentoring
- Improved access and availability to necessary training.
- Health care staff completion of initial/foundational training within two years.
- improved communication and transparency through the appointment of an Office of the Chief Coroner liaison in long-term care homes who will be mentored about death investigation in long-term care.
- Have resources and training programs on systemic vulnerabilities available, including the potential for intentionally caused harm by healthcare providers.
- Develop standardized information on vulnerabilities of the elderly (including the potential for intentional harm by healthcare providers) and provide it to organizations and institutions responsible for educating and training students, professionals and staff in the healthcare system and in allied programs and fields. This standardized information will also be shared with the retirement home sector.
- Offer resources and training in an easily accessible and shareable format to relevant organizations and institutions.
- Provide training for the Office of the Chief Coroner and the long-term care sector on how to use the redesigned resident death notice (formerly institutional patient death record) to report deaths in long-term care.
- Provide training for Home and Community Care Support Services on how to use the new resident death notice within a community care setting.
- Share resident death notice training material with the retirement home sector and provide training on a request basis.
- Create a training plan template outlining a proposed curriculum and key milestones for organizations to implement.
- Establish or improve a training budget for long-term care homes, including:
- protected time
- easier access and availability
- more coverage of topics based on need
- Make training programs available for all stakeholders in long term care and death investigation sectors that includes, but is not limited to, the expected trajectory of death and how to assess whether a resident’s death departs from that expected trajectory, and the meaning of a “sudden and unexpected” death.
- Train hospital staff and long-term care home staff during their initial professional education (BScN, MD, OT, etc.) and in continuing professional development settings (in-practice and team-based training).
- Establishment and presence of integrated networks and communities of practice for all stakeholders to share the practices of the training to identify opportunities for ongoing improvement.
- Assist employers to encourage and support ongoing participation of training for their workforce (protected time, resources, logistics, etc.).
- Establish and sustain networks and communities of practice related to educating on vulnerabilities in the elderly including the possibility that healthcare providers may intentionally harm those in their care.
- Encourage facilities and organizations involved in long-term care to appoint and maintain designated persons who act as a liaison with the Office of the Chief Coroner.
- Establish, maintain, and mentor specially trained coroners who agree to dedicate a portion of their practice to coroner work and receive specialized training on:
- long-term care homes
- their resident populations
- best practices in conducting preliminary consultations and investigations of resident deaths
- Number of trained Home and Community Care Support Services trained on the tailored resident death notice within a community care setting (train the trainer model).
- Percentage change in the frequency of training provided to organizations and institutions responsible for the delivery of education and training to students, professionals, and staff in the healthcare system and in allied programs and fields.
- Number of identified training programs and resources.
- Number of training programs and resources on systemic vulnerabilities of the elderly, including intentional harm by healthcare providers.
- Number of organizations/facilities in long-term care with a designated Office of the Chief Coroner contact.
- Number of coroners and long-term care homes that have received training on death investigations in LTC.
- Number of learners within networks/communities of practice.
Pillar 2: oversight and accountability
- Improved effectiveness and efficiencies in developing and monitoring oversight within organizations.
- Improved accountability and transparency across organizations.
- Increased number of preliminary consultations and/or death investigations of residents in long-term care homes, using information from the new resident death notice (currently known as institutional patient death record).
- Improved data collection processes.
- Enhanced monitoring, reporting and analysis of data to stakeholders.
- Increase in information sharing across organizations.
- Ensure the redesigned resident death notice incorporates the best available evidence from researchers and the field, supported by consultation with stakeholders.
- Establish a process with long-term care homes for the submission of the new resident death notice, including who is to submit the form.
- Establish and monitor accountability reporting to stakeholders, including:
- residents and families
- frontline staff
- those in management positions in long-term care homes
- individuals engaged in policy development and oversight at the Ministry of Long-Term Care
- professional regulatory bodies
- professional advocacy bodies
- the Office of the Chief Coroner
- the Ontario Forensic Pathology Service
- healthcare team
- Create a system for more comprehensive review of resident death notices including analytics to provide greater clarity on the process and patterns within long-term care and healthcare settings as pertaining to care of persons with real or potential vulnerabilities.
- Encourage organizations to develop and/or review their education and training goals pertaining to vulnerabilities in the elderly.
- Create a Centre of Excellence dedicated to collecting and analyzing the available elder vulnerability data to track progress towards goals.
- Establish and maintain monitoring systems that spans the breadth of the long-term care system.
- Establish a system of identifying and sharing high-impact practices.
- Availability of a process to ensure that those receiving a copy of the new resident death notice review it promptly.
- Number of reports analyzing aggregated data from the resident death notices to evaluate patterns and unusual trends in resident deaths in long-term care homes.
- Increased number of preliminary consultations and/or death investigations of residents in long-term care homes, using information from the resident death notice.
- Number of submissions of the new resident death notice.
- Number of new systems of oversight developed.
- Percentage of organizations that implemented new systems and methodologies.
- Percentage of organizations that are achieving their education and training goals pertaining to vulnerabilities in the elderly.
Pillar 3: communication
- Enhanced standardized approach to data-sharing with stakeholders and partner organizations.
- Enhanced transparency and communication on reporting results, concerns, processes and trends with stakeholders.
- Increased uptake of training through the development of a communication plan.
- Ensuring an evidence-based approach to delivering health care to the elderly.
- Decrease potential harms to the elderly.
- Sharing data, insights, and processes between healthcare partners and institutions, and collective review as appropriate.
- Pooled analytics and evidence aggregation available to all partners for review and analysis.
- Transparent reporting of concerns, processes and patterns with an open, reflective, lessons-learned approach rather than punitive manner.
- Centre of Excellence mobilizes data and appropriate reports for the public interest.
- Identification and sharing of high-impact and best practices in the pursuit of excellence.
- Establish a communication plan for raising awareness and promoting available training.
- Establish data sharing agreements that pool data for shared insights.
- Repository of high-impact and best practices established and accessible to all stakeholders.
- Number of publicly shared periodic reports.
- Number of communication plans developed for raising awareness and promoting available training.
- Percentage change in the number of trained staff.
- Number of reported harms to the elderly.
- Number of reports developed by the Centre of Excellence.
- Number of high impact and best practices identified and shared.
Pillar 4: culture
- Enhance transparency and communication with stakeholders.
- Improved data collection and analysis.
- Ensuring an evidence-based approach to achieve goals
- Increased accountability by organizations and institutions awareness of systemic vulnerabilities.
- Improved leadership and organizational capacity to transform the healthcare system.
- Increased effectiveness of data sharing from data analytics models.
- Increased number of vulnerabilities reported.
- Normalize the questioning and continued quality improvement efforts by organizations and institutions.
- Enable regular and ongoing sharing of information from data analytics models.
- Establish open lines of communication that encourage contacting the Office of the Chief Coroner to address concerns about the resident’s death or the accuracy of the information set out in the resident death notice.
- Act as a leader in the education and training of organizations and institutions as it relates to building awareness on systemic vulnerabilities including the possibility that healthcare providers may intentionally harm those in their care.
- Opportunities for improvement raised by stakeholders are reviewed by leadership as potential sites for investment and commitment of resources.
- Discourse used indicates awareness of systemic vulnerabilities including the possibility of intentional harm.
- Number of times the Office of the Chief Coroner/Ontario Forensic Pathology Service is contacted to address concerns about the resident’s death.
- Number of times the Office of the Chief Coroner/Ontario Forensic Pathology Service is contacted to address concerns about the accuracy of the information set out in the new resident patient death notice.
- Percentage change in the number of vulnerabilities reported.
- Number of training sessions on systemic vulnerabilities delivered.
Pillar 5: continuous improvement
- Improved accuracy of tools and resources to assist with high quality death investigations
- Ensuring continuous improvement in the delivery of death investigations in long-term care homes.
- Enhanced transparency and communication with partners and stakeholders.
- Ensure ongoing research is conducted to prevent, deter, detect and report on potential harms by healthcare professionals to those in their care.
- Gather and analyze data from the new resident death notice to ensure the tool meets the needs of long-term care homes and assists with high quality death investigations.
- Partners in long-term care establish and maintain continuous improvement committees within their organizations that track and promote continuous quality improvement.
- Conduct ongoing research on national and international developments directed at systemic vulnerabilities, including preventing, deterring, detecting and reporting healthcare professionals who may intentionally harm those in their care.
- Centre of Excellence mobilizes and evaluates education programs to ensure sustainability and continuous improvement.
- Centre of Excellence identifies and shares the high-impact and best practices within the sector amplifying excellence across the system.
- Establishment of an evaluation framework for ongoing monitoring and enhancement of:
- the new resident death notice
- developed curriculum
- strategic plan
- awareness promotion efforts
- Documenting continuous improvement by long-term care homes.
- Sharing of high-impact best practices with long-term care stakeholders on a quarterly basis
The performance metrics that will measure progress toward achieving this goal, include the number of:
- high-impact and best practices shared
- education program evaluations conducted
- working groups/committees established to track and promote continuous quality improvement
- new resources (for example, technology) to ensure quality improvement
- new quality improvement measures implemented