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Forensic Psychiatric Hospital Improvements

We are implementing a comprehensive 18-month action plan to improve safety, operations and patient care at the Forensic Psychiatric Hospital in Coquitlam, the only facility of its kind in British Columbia.

External review of Forensic Psychiatric Hospital leads to action plan

All Forensic Psychiatric Hospital patients and clients are referred to us by the courts or BC Corrections, and we provide them with psychiatric assessment, treatment and rehabilitation. Our goal is to restore their fitness to stand trial or reintegrate them into their communities while ensuring public safety.

Our clients and patients are the most severely mentally ill people in the province. All live with complex mental health issues, most often a psychotic disorder such as schizophrenia. For many patients, this is combined with a mood disorder such as post-traumatic stress disorder, or a personality disorder that makes them anxious, paranoid or fearful. Most have also experienced trauma.

All of these factors can make our patients and clients prone to disruptive behaviour. Providing them with the most effective care and treatment while ensuring everyone's safety and security requires a highly specialized and trained interdisciplinary team of staff and physicians.

To address our unique challenges and improve the effectiveness of our services, our vice-president, Lynn Pelletier, commissioned a comprehensive external review in the spring of 2018. This led to the establishment of a new hospital leadership team and the development of our 2018-2020 Forensic Psychiatric Hospital Action Plan.

Forensic Psychiatric Hospital Action Plan highlights

The goals of the action plan are as follows:

  • Improve patient, staff and public safety
  • Improve clinical service delivery and patient-centred care
  • Strengthen and integrate leadership, inter-disciplinary teamwork and professional development

Five safety actions:

We announced five immediate actions in September 2018 as part of the action plan:

  • Hire additional security officers and enhance their training.
  • Establish new teams of clinical-security staff who specialize in safety at secure hospitals.
  • Expand orientation and training for all staff in emergency response as well as therapeutic and relational security, which teaches staff to be acutely aware of their surroundings and build a deep rapport with and understanding of patients in order to anticipate, de-escalate and prevent aggression.
  • Increase 24/7 supervision and leadership.
  • Hire additional staff for better patient care.

Other action plan highlights:

  • Further invest in staff training and safety and security procedures
  • Improve reporting systems
  • Reduce environmental risks
  • Facilitate improved facility maintenance
  • Conduct patient-needs assessments    
  • Evaluate and review our current care model and align it with patient needs
  • Expand trauma-informed practice
  • Improve reporting to the BC Review Board
  • Maximize resources and efficiency related to patient assessment, communication and flow
  • Develop and implement provincial forensic mental-health guidelines and standards
  • Improve documentation and records
  • Clarify leadership roles and responsibilities and improve committee effectiveness
  • Improve employee engagement
  • Generate staff core competencies and invest in professional development

Forensic Psychiatric Hospital 2018-2020 Action Plan Completion Report - Summary

Overview

In spring 2018, the Vice President, Mental Health and Substance Use Services (BCMHSUS) commissioned an international expert panel to provide advice and recommendations to further improve the effectiveness of Forensic Psychiatric Services (FPS), specifically the Forensic Psychiatric Hospital (FPH). The resulting 2018-2020 Action Plan was initiated to plan and implement the recommendations over an 18-month period (Sept. 2018 to March 2020) with three primary goals:

  1. Improve patient, staff and public safety;
  2. Improve clinical service delivery and patient-centred care; and
  3. Strengthen leadership, interdisciplinary teamwork and professional development.
The scope of work touched upon virtually all FPH functions, including governance, clinical and administrative services and was managed to incorporate related quality review priorities and risk mitigation strategies.

Phasing - Safety first

The highest priority work for FPH was addressing immediate safety and security issues, which was initiated in summer 2018 prior to the action plan project being activated. This initial work included hiring and training additional Forensic Security Officers (FSO) to be dedicated to high security units as other safety improvements were addressed. A new site leadership structure was designed, with directors hired into the positions starting in summer 2018 and all director positions filled by January 2019.

Outcomes & Achievements

The action plan project focused its achievements under three primary goals including:

  • Reduced safety incidents - significant reductions in time loss for staff have occurred from 2018 to 2019 with a 19% drop in incidents and a 43.3% reduction in total days lost from 2,175 days (2018) to 1,234 days (2019).
  • Improve integrated safety and security training - by enhancing existing training, formalizing learning structures, increasing completion rates and developing specialized training and origination for key positions.
  • Hire specialized clinical-security roles - creating eight Clinical Security Liaison Nurse positions.
  • Update and increase awareness of safety and security procedures - revising and approving a wide range of policies and Code White education and training plans.
  • Improved reporting systems - with a new reporting resource manual for managers and completion of a PSLS/WHITE systems audit.
  • Increased the expertise and presence of Forensic Services Officers (FSOs) - through increased hiring, enhanced training and incident reporting as well as a revised job description for FSOs.
  • Reduced environmental risks - after completing an environmental risk assessment, a number of facility improvements have been carried out including improved lighting, a new camera system and renovations in nursing stations and bathrooms. 
  • Facilitated improved facility maintenance - streamlining the repair/maintenance process and preparing a priority list of future work.
 
  • Align service delivery with patient needs - through the following work streams:
    • Model of Care analysis and development - using research and staff and physician involvement to identify improvements to the existing Model of Care to align better with care and core principles.
    • Early Model of Care and Clinical Services Delivery Plan implemented - by bridging staffing gaps, creating new positions and improving integration and communication processes within the teams.
    • Improved patient flow and communication - using a patient-led process to map the patient journey, which was then validated by staff and physicians prior to being adopted.
    • Patient Needs Assessment (PNA) to support aligning service delivery to patient needs - with PNA methodology and data collection used to inform the Model of Care refresh.
    • Expanded and strengthened roles of psychologists and clinical counsellors - by integrating psychology into one clinical program, establishing Practice Leaders for Psychology and Director of Training positions and revising work schedules and compensation where needed.
    • Increased assessments outside the hospital - with use of video fitness assessments, developing psychiatrist rotations and piloting Telehealth assessment clinics.
  • Expanded trauma-informed practice - through best-practice research and adopting an evidence-informed organizational assessment.
  • Improved BC Review Board reporting - by developing adjusted tools as well as feedback/communication loops within the interdisciplinary teams to help define a future state process and the roles and responsibilities of each team member.
  • Improved clinical documentation and implemented electronic health records - using an interdisciplinary approach to address key priorities of risk-based charting and standards as well as care planning and interdependent tools (and planning for CST).
  • Physician recruitment and retention - through a physician HR plan developed in conjunction with physician leaders.
 
  • Clarified roles and responsibilities of hospital leaders - restructuring the leadership team to increase focus on clinical and risk management, using a Town Hall meeting to introduce the team and the new roles.
  • Strengthened clinical leadership and supervision - by creating Patient Care Supervisor positions and reviewing unit-based clinical leadership roles.
  • Improved committee effectiveness - by revamping committee roles and participant lists to reflect updated mandates.
  • Improved physician and staff engagement - through a comprehensive consultation and engagement process outlined in Stakeholder Engagement and Communications below.
  • Generated core competencies in forensic mental health, and develop and implement provincial forensic mental-health standards - by researching best practices at other leading forensic centres and developing core competencies and a CAPE (Competency Assessment, Planning and Evaluation) tool.
  • Invested in professional development - providing therapeutic and relational security training to staff of FPH and other facilities and collaborated with other educational institutions around customization opportunities.
  • Strengthened the psychological health and resiliency of the workforce at FPH - via partnerships with key stakeholders to plan a "Guarding Minds at Work" survey and assessment process that was completed by 220+ staff and physicians.
 

Stakeholder Engagement and Communications 

After adopting an 'engagement as a philosophy' approach, FPH leaders developed and followed a detailed stakeholder communications plan, working hard to connect with all of the groups that would be affected by the action plan including:

  • Patients and families
  • Staff
  • Physicians

Remaining Activity

While a great deal of the recommendations and activities have been completed during the 18 months of the project, there are a number of items still in progress as a result of a number of factors, including the interdependency of some activities on the timing of others as well as the onset of the COVID-19 pandemic. These activities each have a scheduled completion date in 2021/22 and are itemized in a table on pages 26 - 27 of the full report.

Sustainment Plan

Being able to sustain this kind of transformational change is important to this process, with changes such as therapeutic and relational security, workflows and procedures, clinical leadership roles and practice, shifts in Review Board processes, and engagement practices potentially taking years to embed in the FPH culture.

Evaluation

An action plan Evaluation Working Group was assembled in March 2019 to determine measurable impacts related to the action plan's goals and whether progress has been made towards the intended outcomes. The group has taken the following steps:

  • Confirmed the evaluation focus and developed the logic model (see Appendix B - Logic Model).
  • Developed the evaluation framework outlining how outputs and short-term outcomes are defined and measured (see Appendix B - Evaluation Framework).
  • Developed a stakeholder matrix and engaged stakeholders for feedback via focus groups and meetings with patients, FPH staff and physicians and other key stakeholders.
  • Identified data sources and strategies for data collection.

More information

For more information, view the following documents:

Progress updates on the Forensic Psychiatric Hospital action plan

2018

2019

2020

Questions?

If you are a staff member of BC Mental Health and Substance Use Services and have a question about the improvements at the Forensic Psychiatric Hospital, please email us.

SOURCE: Forensic Psychiatric Hospital Improvements ( )
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