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Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

3/5/2018

This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.


Overview St. Francis Memorial Hospital (SFMH) is a small rural hospital located in Barry's Bay, Ontario about 3 hours west of Ottawa. It services a catchment area including the township of South Algonquin, Madawaska Valley, Killaloe & Hagarty and Richards, and areas of Hastings Highlands and Bonnechere Valley. The hospital offers a wide range of services and has 20 inpatient beds which includes 10 inpatient medical/surgical beds and 10 complex continuing care beds. The emergency department see approximately 10,000 patients each year and the hospital and the hospital also has a unique partnership within the Madawaska Communities Circle of Health (MCCH) to enhance partnerships and relationships with community based partners. The MCCH which includes hospital, long-term care, hospice, community health and support services, Champlain LHIN HCC and mental health holds a collaborative mandate to enhance and support health of all residents in the Madawaska Valley. The population served by SFMH grows from 10,000 to approximately 30,000 in the summer months due to recreational attractions such as Algonquin Provincial Park. SFMH embarked on a journey in 2016 to refresh the strategic direction for the organization. Our mission "to provide quality, patient centred healthcare in collaboration with partners" and our vision "to be a leader in rural healthcare delivery" align with our QIP journey. We have been engaged in the development of a yearly quality improvement plan for many years and will continue our journey with the focus on success of the new strategic plan for the organization. The mission, vision, values, and strategic direction provides the direction for the delivery of quality health services. The quality improvement plan is aligned with the hospital's four key strategic directions below, with an emphasis on the provision of quality health care services: Quality of Care We commit to providing high quality care to improve the patient and family experience by: - Providing safe and timely care through best practices - Integrating patient and family experience into the planning and decision making - Emphasizing performance measurement and reporting: while focusing on the patient safety, quality and transparency Strength in People We commit to nurturing a healthy and safe workplace in order to: - Be a preferred employer resulting in the ability to attract and retain qualified staff - Foster an environment which encourages innovation and quality across a continuum of care - Promote a healthy work-life balance System Integration We commit to working collaboratively and creatively with partners to: - Keep a patient centred approach when coordinating timely and equitable care - Deliver effective, integrated quality care - Demonstrate leadership in collaborative plans to advance a more coordinated and consumer friendly system Financial Performance We commit to responsible financial planning to ensure sustainable financial stability in order to meet the needs of those we serve by: - Working as a resource-conscious provider of care - Continuing to actively seek improvement through efficiency and sustainability


The Quality Improvement Plan (QIP) is based on the priorities identified by the Continuous Quality Improvement Committee of the Board, Senior Management Team and Care Teams. The QIP is a tool to affirm and map the commitment of the Board of Directors and all staff in the continuous pursuit of positive clinical outcomes, positive patient experience and positive staff work-life. The plan is aligned with accreditation standards and recommendations. The balanced scorecard approach ensures key improvement initiatives in the areas of safety, effectiveness, access to care, integration and patient-centred care. CQI is a method that evaluates and continuously improves the caliber of care and service delivered from a patient perspective. CQI embraces quality by focusing on continuous process improvement, teamwork, staff and patient empowerment. Each member of the senior administration team will work with their departments to have defined improvement targets and initiatives to the strategic priorities. The model for improvement used to effectively analyze and implement change will be the "Plan, Do, Study, Act" (PDSA) model. In 2018/19 aims and measures can be viewed in the attached work plan. Below is a summary of key priorities identified for the upcoming year. SFMH underwent accreditation in December 2017……….. AIMS & MEASURES Safe Care - Increase medication reconciliation compliance on discharge to 80% Effective Transitions - Reduce functional decline amoungst seniors in hospital by completing Barthel Index on 90% of admission s and ensuring up for meals is completed for 60-80% of patients on Complex Continuing Care Unit - Implement patient orientated discharge summary for patients over 65 years of age. Person Experience - Improve patient satisfaction to >80% Timely - Reduce wait times in ER for admitted patients to 9 hours Other Quality Initiatives for 2018/19 include: - reduce unnecessary time spent in acute care - increase proportion of patients receiving medication reconciliation upon discharge - Increase number of patients identified as appropriate for health links - Ensure successful transitions from hospital to home with follow up phone calls Describe your organization's greatest QI achievements from the past year SFMH has seen significant success and maintenance of some targets that were considered high performing areas when compared to other hospitals across the province. Most areas of the work plan were successfully implemented resulting in maintenance of safe hospital care and increased communication between health care providers and patients and families admitted to the hospital. The National Research Council has changed the questionnaire for patient satisfaction which has altered the achievable targets for all hospitals. As we


continue our quality improvement journey emphasis on the home first philosophy to continue to decrease our alternative level of care rates in our hospital will continue. This indicator requires continuous emphasis to ensure we are meeting targets and benchmarks that are part of our quality improvement plan. SFMH Active Care Unit and Emergency department QI Successes included: -Celebrating our 10th anniversary as a partner of the UOHI-Smoking Cessation Program -100% of ACS patients received discharge teaching and follow-up in partnership with UOHI -Implementation of PODS (Patient orientated Discharge Summaries) -Implementation of Bullet Rounds -Prevention of Functional Decline initiative -ADU in the ED -Use of SBAR at all care transitions -Implementation for a Suicide Risk screening tool -Formalized process alerting MDs of triaged CTAS (color coded clipboards) -Program review of Obstetrics care in the ED to manage Emergency delivieries The implementation of Best Practice Guidelines through our work as a partner of a Best Practice Spotlight Organization (RVH) has resulted in significant achievements this past year. SFMH has implemented some new Best Practice Guidelines in the past two years. The guidelines include screening for delirium, dementia and depression in older adults; reducing the incidence of hospital acquired pressure ulcers; assessment and prevention of functional decline and patient and family centred care. We anticipate RVH will achieve Best Practice Spotlight Designation in April 2018. We will continue our partnership journey for the 2018/19 year. Resident, Patient, Client Engagement and relations The Patient & Family Advisory Council was established at SFMH in fall of 2015. The terms of reference/reporting structure for the hospital was developed in 2015 and the first meeting for the Patient & Family Advisory Council was held in January 2016. The PFAC continues to meet regularly and members are present for Care Team and Quality, Risk & Safety Committees. The patient and family Advisory Council advise the hospital on matters pertaining to the patient experience as one example of their role. The PFAC has been involved with a number of change initiatives implemented in 2016-17. We will continue to engage and involve this group in the 2018-19 year. SFMH uses a variety of other approaches to engage patients and families: - Charge nurses make post discharge phone calls to all patients>65 after discharge to get feedback on care at SFMH. The information is tracked and trended as well as reported back to teams and board CQI committee. - NRC Patient Satisfaction data is used to make changes in care as well. A structured process is in place for patient and family feedback at our hospital and this feedback is tracked/trended and changes are made when required. For the upcoming year SFMH will continue to work to implement further Best Practices. The key Best Practices for evaluation this coming year is person centred care so numerous strategies will be evaluated to measure success with patient and family engagement. In our recent accreditation survey of December 2017. SFMH met all standards relating to patient and family centred care and was described as a leader in this area by the surveyors.


Collaboration and Integration St. Francis Memorial Hospital understands that a strong on integration across all areas of the patient journey, beyond the care delivered in the hospital setting will help ensure patients receive safe, high quality, accessible and coordinated care. The hospital works with numerous partners including: Champlain LHIN HCC (Formerly CCAC), Assisted Living, Primary Care Physicians, Renfrew County Ambulance Service – Paramedics, and Renfrew County Health Links to plan appropriate, safe care after discharge. Such existing partnerships is creating more coordinated care and improving access for patients through the entire continuum of care. Many initiatives have started, evolved and been implemented in the last few years. Some of these integration successes include: Rural Healthcare Hub (St. Francis Health Centre): SFMH built the St. Francis Health Centre, connected to the hospital via a tunnel, to help promote integration and create the rural health care hub model. SFMH board actively encourages and supports the innovative solutions by the CEO and the leadership team to improve access and coordination of services for better health and well-being of the people in our communities. Clinical integration successes include: Primary care with 6 general practitioners, laboratory services, Champlain LHIN HCC (formerly CCAC), Dialysis, Optometry, Public Health, Geriatric Mental Health and Outpatient clinics for Internal Medicine, Audiology ad Addiction Treatment Services. Madawaska Communities Circle of Health (MCCH): SFMH was instrumental in the creation of the first full community integration working group in the Champlain representing all health service providers in Madawaska Valley to implement integration opportunities in collaboration with the LHIN. Integration of Rainbow Valley Community Health Centre (RVCHC) with the SFMH (Nov 2011): This is the first full integration of the CHC with a hospital in the province. This integration has provided sustainability and vital primary care services for the CHC through recruitment of 2 family physicians and a nurse practitioner. SFMH Board created an effective governance model for the CHC with the support of the LHIN and established a Community Advisory Committee with includes SFMH board members. Expansion of the Health Care Hub: - Co-location of Barry’s Bay and Area Seniors Home Support (community support services) with SFMH (June 2011) which improved coordination of community services. - Madawaska Valley Hospice Palliative Care – A beautiful 2 bedroom Hospice palliative care unit opened its doors in April 2015. The hospice is located within the hospital and utilized vacant space. Since beginning in Dec 2012 this program has been successful in training volunteers who provide care to hospice/palliative care clients in the facility or in their own homes. The Home First philosophy promotes seamless integration of services from hospital to home. Home First policies, protocols, joint discharge rounds, huddle boards and white boards in patient rooms ensure integration with all interdisciplinary team members and family involvement.


The implementation of Renfrew County Health Links has provided opportunity for the hospital to link complex patients with care providers that can advocate and navigate their care needs after discharge. Discharge planning follow up phone calls also provide opportunity to speak to patients right after discharge and provide additional support. Additionally, Valley Manor, the local LTCH has purchased property next door to the hospital and intends to redevelop there which will further expand the health hub vision. Engagement of Clinicians, Leadership & Staff CQI is a method that evaluates and continuously improves the caliber of care and service delivered from a patient/resident/customer perspective. CQI embraces quality by focusing on continuous process improvement, teamwork, staff and patient/resident empowerment. Quality projects are identified by departments, key committees, team members and compiled by the Director of Patient Care Services. Key projects are presented throughout the organization to appropriate committees and staff. The model for improvement follows the Plan/Do/Study/Act cycle. Key projects and quality reports are shared at the CQI committee of the board on a quarterly basis. Indicator reports are reviewed quarterly at this committee to ensure excellence in service is maintained. All indicators for the 2017-18 Quality Plan are included in this quality indicator report to the CQI Committee to ensure oversight at the board level. Each department completes the SFMH balanced scorecard for the June Annual Report to highlight accomplishments and new initiatives. Staff empowerment is one of the most important means for achieving high quality services. SFMH has embraced a philosophy of teamwork where all staff members participate on teams in key committees to enhance the quality of care provided in the hospital. Examples of staff participation include: Care Team, Nursing Practice Council, and the Quality, Risk and Safety Committee. Care Team Committee meets on a regular basis to determine quality projects for the year. Care Team monitors departmental goals and objectives in line with strategic directions and pillars of quality. Clinical staff, physicians, team leads, managers and senior management participate and provide input at the Care Team Committee. Population Health and Equity Considerations The population health data for Renfrew County catchment areas has been obtained from the Renfrew County Community Health Profile. This report was developed in March 2016 and provides a brief overview of the socio-economic and health status of residents served by the Renfrew County and District Health Unit. It is intended to inform the work of Health Unit staff, community partners, government decision makers and community members as we work to address local health issues and improve health. Population size, growth, age and fertility: Just over 105,000 people live in Renfrew County and District. The area is characterized by a large rural population (almost half) and a relatively low population density. A higher proportion of the population is over age 45 compared to Ontario. The population is aging and growing slowly. The fertility rate has increased in recent years to 50 live births per 1,000 females age 15-49, and is higher than Ontario.


Culture and Language: Prominent cultural groups are German and Polish. A small proportion of the population (2%) belong to a visible minority and only 5% are immigrants. About 2% are registered treaty Indians and almost 8% claim Aboriginal identity. The population is predominantly English speaking. Income: Median incomes are lower than Ontario as a whole. However, the prevalence of low income is lower than Ontario (12% vs 14%). Employment & Education: Employment indicators such as labour force participation rate, unemployment rate, and full-time vs part-time work are similar to those for Ontario. A smaller proportion of the population age 15 and over has a post-secondary certificate, diploma, or degree. Life Expectancy: Life expectancy for females (82.8 years) is significantly lower than Ontario. Life expectancy for males (79 years) is similar to Ontario. Availability of Physicians: There are more general family physicians per 100,000 population than Ontario, but there are fewer specialist physicians. Well-Being: The proportion of the population that perceive their health and mental health as very good or excellent is similar to Ontario. However, the proportion that perceives that most days are quite a bit or extremely successful (29%) is significantly higher than Ontario. Reportable Infectious Diseases: Incidence rates of selected reportable infectious diseases are comparable to or lower than Ontario. Health Risk Factors: Rates of high alcohol intake, smoking, and obesity among adults are higher than Ontario. Other health risk factors such as overweight, vegetable and fruit consumption 4 or fewer times per day, and physical inactivity during leisure time are comparable to Ontario. The prevalence of these risk factors is concerning in both jurisdictions. Cause of Death: The leading cause of death are cancers, circulatory diseases, respiratory diseases and injuries. Mortality rates are similar to Ontario except for circulatory diseases which is higher. EQUITY Health Equity refers to the study and causes of differences in the quality of health and healthcare across different populations. Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remedial aspects of health. SFMH embraces the opportunity to ensure quality of healthcare across different populations.


Aboriginal Cultural Safety Training was completed for senior management staff at the hospital this past year. In 2017 20 frontline staff participated in the cultural sensitivity training as well. This allowed a number of staff to better understand how to provide excellent patient care to this patient group. This remains a priority for 2018-19 and more frontline staff will be completing the training. Access to the Right Level of Care - Addressing ALC Initially announced in 2007, Aging at Home is a strategy that provides continuum of community-based services for seniors and their caregivers, allowing seniors to stay healthy and live independently at home, with dignity, for as long as possible. The program also aims to decrease the number of visits to emergency departments and reduce the number of seniors waiting for admission to long-term care homes (LTCHs), as well as reduce delays in transitions to these settings. The SFMH has been an active participant in the aging at home strategies in our Champlain and supported the implementation of an assisted living program in our community in 2010. This program continues to be successful and allows seniors in our community to remain in their own homes with the right supports. This community program works very closely with the hospital to share information related to potential clients. The Quality Improvement Plan for 2018-19 continues to focus on initiatives to address ALC pressures within our own hospital. Our focus on senior friendly hospital initiatives that will maintain or improve functional decline in the elderly will enhance probability for this patient population to return home safely. Other initiatives such as follow up phone calls from our charge nurse on the inpatient unit can provide support beyond the hospital stay. SFMH in partnership with RVH has implemented a patient orientated discharge summary to ensure elderly patients have increased knowledge and understanding of their conditions at the time of discharge. All of the above initiatives are embedded into our quality improvement plan for this year. Additionally, continuing with a focus on the Home-First Philosophy we continue to meet as a team twice weekly for detailed discharge rounds. The team includes: Champlain LHIN HCC (Formerly CCAC) Care Coordinators, Health Links, Physiotherapy, Charge Nurse and the Director of Patient Care Services. Once this meeting has taken place Family Care Team meetings are organized with the patient, family, and physicians for continuity of care. In the coming weeks the Community Paramedic Program providing visits to at risk seniors will be joining our joint discharge rounds team to help support strengthened efficient discharges. Our Restorative Care approaches also support our frail elderly and clinically complex populations to discharge destinations outside of the hospital environment. Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder In light of the National opioid epidemic SFMH has endeavored to ensure a safe environment that positively contributes to this significant issue. Interventions vary by the type of care provided. Our ER department has challenged its physicians to both minimize prescribing of opioids and not renew prescriptions. The Barry’s Bay community has typical small-town challenges including no community pharmacies that are open 24 hours. This requires policies that specifically address the dispensing of narcotics from the ER department. The policy states that narcotics may not be provided from the ER department for long term therapy unless arrangements have been made with the primary prescriber and has established strict criteria by which renewals for opiates may be made. Our inpatient interventions have focussed on proper documentation surrounding the administration of opioids.


All analgesic administration must follow a pain assessment and a newly implemented patch-4-patch program for fentanyl requires shift checks of the patch and co-signing of administration and destruction. Workplace Violence Prevention Violence in the workplace presents a risk to the well-being of SFMH staff, physicians, volunteers, patients and visitors. It is everyone's responsibility to prevent violence in the workplace. At SFMH we strive to create a positive environment with mutual respect and open communication. In response to Bill 168 (act to amend the Occupational Health and Safety Act with respect to violence and harassment in the workplace and other matters)SFMH has updated its violence and harassment policies and programs, employee reporting and incident investigation procedures, emergency response procedures for violent events and a process to deal with incidents, complaints, and threats of violence. Extensive education has taken place for all SFMH staff and staff in key areas of the hospital have received non-violent crisis intervention training, which includes gentle persuasive approach training and general education on the new policies, procedures and protocols. This is a key quality indicator for 2018-19 so can continue to support and monitor at SFMH. Performance Based Compensation Two percent of compensation for executives (defined at Chief Executive Officer, Chief of Staff, Director of Patient Care Services/CNE, Chief Operating Officer and VP Financial Services) is linked to three of the four following indicators: - Improve percentage of patients discharged using PODs - Increase reporting and awareness of Workplace violence Incidents - Medication Reconciliation on discharge - Improve patient satisfaction The senior executive team will be responsible to ensure success in the four key indicators. Refer to the QIP Workplan for specific performance targets for 2018-19. As per the above statement, two percent of executive compensation will be associated with three of four QIP indicators within the SFMH plan. Sign-off It is recommended that the following individuals review and sign-off on your organization’s Quality Improvement Plan (where applicable): I have reviewed and approved our organization’s Quality Improvement Plan Board Chair _______________ (signature) Quality Committee Chair _______________ (signature) Chief Executive Officer _______________ (signature) Other leadership as appropriate _______________ (signature)

Excellent Care for All Quality Improvement Plans (QIP): Progress Report for 2017/18 QIP The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and gain insight into how their change ideas might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality improvement activities.

Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ideas, and inform robust curriculum for future educational sessions.

ID Measure/Indicator from 2017/18

Org Id

Current Performance as

stated on QIP2017/18

Target as stated on

QIP 2017/18

Current Performance

2018 Comments

1 "Would you recommend this emergency department to your friends and family?" ( %; Survey respondents; April - June 2016 (Q1 FY 2016/17); EDPEC)

768 CB 80.00 72.30

Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help build capacity across the province.

Change Ideas from Last Years

QIP (QIP 2017/18)

Was this change idea implemented as

intended? (Y/N button)

Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an

impact? What advice would you give to others? Maintain a positive patient centered environment

Yes Lesson learned: community education about impact of overcapacity, meeting repatriation agreements, and increasing volumes in the ED. The community is not used to a very long wait as historically this has been managed well and although wait times are still good they are longer than what patients expect. Consumer expectations are increasingly high. One negative aspect of a wait can impact on overall rating regardless of meeting triage times and provided quality care.

ID Measure/Indicator from 2017/18 Org Id



Target as stated on

QIP 2017/18

Current Performance

2018 Comments

2 Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? ( %; Survey respondents; April - June 2016 (Q1 FY 2016/17); CIHI CPES)

768 90.00 90.00 96.00


Change Ideas from Last Years QIP (QIP 2017/18)

Was this change idea implemented as intended? (Y/N

button)

Lessons Learned: (Some Questions to Consider) What was your experience with

this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to

others? Continue charge nurse performing discharge phone calls within 24 hours of discharge for all patients 65+ years of age

Yes Great impact. Patients very appreciative of the calls and some resulted in good catches related to queries from patients about medications.

Implement patient oriented discharge summary for all patients over 65, GEM patients in the ED and Health Links clients for health Link 9 in the Champlain LHIN

Yes This initiative was embraced and feedback from patients and families very positive.




Target as stated on

QIP 2017/18

Current Performance

2018 Comments

3 Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital ( Rate per total number of admitted patients; Hospital admitted patients; Most recent 3 month period; Hospital collected data)

768 90.00 95.00 100.00





Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you

give to others? Strengthen knowledge of best practices for all disciplines

Yes All new hires and current staff benefit from educational review of best practices. Team approach including pharmacy staff is imperative.




Target as stated on

QIP 2017/18

Current Performance

2018 Comments

4 Medication reconciliation at discharge: Total number of discharged patients for whom a Best Possible Medication Discharge Plan was created as a proportion the total number of patients discharged. ( Rate per total number of discharged patients; Discharged patients ; Most recent quarter available; Hospital collected data)

768 75.00 80.00 94.00




button)

Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did

the change ideas make an impact? What advice would you give to others?

Re-educate nursing staff on the importance of Best Possible Medication history (BPMH) at discharge

Yes Learned that with high occupancy and admits in the ED we need to include ED staff in education about med rec on discharge. Must be discussed regularly at MAC as well.




Target as stated on

QIP 2017/18

Current Performance

2018 Comments

5 Number of times that hand hygiene was performed before initial patient contact during the reporting period, divided by the number of observed hand hygiene opportunities before initial patient contact ( %; Health providers in the entire facility; January 2016- December 2017; Publicly Reported, MOH)

768 78.00 85.00 88.00


Change Ideas from Last Years QIP (QIP

2017/18)


button)


give to others? Measurement and feedback through hand hygiene audits

Yes On the spot feedback hand a positive impact on performance


Current Performance as stated on QIP2017/18

Target as stated on

QIP 2017/18

Current Performance

2018 Comments

6 Percentage of acute hospital inpatients discharged with selected HBAM inpatient Grouper (HIG) that are readmitted to any acute inpatient hospital for non-elective patient care within 30 days of the discharge for index admission ( %; All acute patients; 2017-2018; CIHI DAD)

768 12.82 12.00 4.55





Lessons Learned: (Some Questions to Consider) What was your experience with

this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to

others? Improve use of white boards to enhance patient and family centered care through communication

Yes Ongoing and still requires support through education

Continue Home First Discharge Rounds

Yes Joint discharge rounds very effective

Improve the timing of the discharge phone calls to be completed within 48 hours of discharge

Yes Excellent results and did impact on prevention of return visits per comments made and documented

ID Measure/Indicator from 2017/18

Org Id



Target as stated on

QIP 2017/18

Current Performance

2018 Comments

7 Reduce functional decline among seniors in hospital ( %; # of patietns 75 and older; 2016-2017; In-house survey)

768 80.00 85.00 93.00


Change Ideas from Last Years QIP (QIP

2017/18)


button)


give to others? Continue full implementation of Program

Yes Restorative Practices are well embedded




Target as stated on

QIP 2017/18

Current Performance

2018 Comments

8 Total ED length of stay (defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED) where 9 out of 10 complex patients completed their visits ( Hours; Patients with complex conditions; January 2016 – December 2016; CIHI NACRS)

768 7.75 7.50 6.54


Change Ideas from Last Years

QIP (QIP 2017/18)



Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others?

Continue to monitor patient flow

Yes Many variables on this and patient flow across small hospitals is challenging, particularly in rural areas where fewer resources exist




Target as stated on

QIP 2017/18

Current Performance

2018 Comments

9 Total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed census data ( Rate per 100 inpatient days; All inpatients; July – September 2016 (Q2 FY 2016/17 report); WTIS, CCO, BCS, MOHLTC)

768 2.82 3.00 6.58





Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did

the change ideas make an impact? What advice would you give to others?

Continue with Complex Medical or Complex Restorative Designation

Yes Affordable alternate accommodations are minimal; PSS services waitlisted

Continue to integrate discharge planning with CCAC, Home First, whiteboards and bullet rounds

Yes All occurring regularly but other barriers to discharge exist: fiancés, support systems, housing and heat source, PSS services

Health Links to continue to see 200 clients per year

Yes Very effective

2018/19 Quality Improvement Plan"Improvement Targets and Initiatives"

St. Francis Memorial Hospital 7 St. Francis Memorial Drive, PO Box 129

AIM Measure

Quality dimension Issue Measure/Indicator Type Unit / Population Source / Period Organization IdCurrent performance Target

Effective transitions 96 96.00

Percentage of patients discharged from hospital for which discharge summaries are

A % / Discharged patients

Hospital collected data / most recent 3 month period

768* CB 90.00

Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital?

P % / Survey respondents

CIHI CPES / April - June 2017(Q1 FY 2017/18)

768*

M = Mandatory (all cells must be completed) P = Priority (complete ONLY the comments cell if you are not working on this indicator) A= Additional (do not select from drop dow

Percentage of patients identified with multiple conditions and complex needs (Health Link criteria) who are offered access to Health Links approach

A % / Patients meeting Health Link criteria

Hospital collected data / most recent 3 month period

768* CB CBCoordinating care Effective

Person experience 72.3 85.00"Would you recommend this emergency department to your friends and family?"


EDPEC / April - June 2017 (Q1 FY 2017/18)

768*

768* 100 100.00

Efficient

Percent of palliative care patients discharged from hospital with the discharge status

P % / Discharged patients

CIHI DAD / April 2016 - March 2017

Palliative carePatient-centred

6.58 6.00Access to right level of care

Total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed census data

P Rate per 100 inpatient days / All inpatients

WTIS, CCO, BCS, MOHLTC / July - September 2017

768*

768* X 10.00Percentage of patients receiving complex continuing care with a newly occurring Stage 2 or

A % / Complex continuing care patients

CIHI CCRS / July - September 2017

Wound Care

Safe 94 96.00Safe care/Medication safety

Medication reconciliation at discharge: Total number of discharged patients for whom a Best Possible Medication Discharge Plan was created as a proportion the total number of patients

P Rate per total number of discharged patients / Discharged patients

Hospital collected data / October – December (Q3) 2017

768*

CB 100.00

Percentage of complaints acknowledged to the individual who made a complaint within

A % / All patients Local data collection / Most recent 12 month period

768*

"Would you recommend this hospital to your friends and family?" (Inpatient care)


CIHI CPES / April - June 2017 (Q1 FY 2017/18)

768* 87 90.00

768* 6.54 6.00Total ED length of stay (defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED) where 9 out of 10 complex patients completed their visits

A Hours / Patients with complex conditions

CIHI NACRS / January - December 2017

Timely access to care/services

Timely

CB CBWorkplace Violence

Number of workplace violence incidents reported by hospital workers (as by defined by OHSA) within a 12 month period.

MANDATORY

Count / Worker

Local data collection / January - December 2017

768*

p discharged.

ChangeTarget justification

Planned improvement initiatives (Change Ideas) Methods Process measures

Target for process measure

1)Health Links Staff to attend bi-weekly Joint Discharge Rounds on Medical Unit

Support and promote Health Links Referrals for appropriate patients

Track number of referrals from Medical Unit and/or from JDR (Joint Discharge Rounds)

Percentage of Patients that re referred to health links from the hospital setting

2)Ensure Health Links Newsletters with success stories is circulated to all hospital staff and physicians

Circulate newsletter to all staff and physicians Newsletters circulated to all staff and physicians Referrals continue to be generated by hospital staff and physicians

1)Continue post discharge phone calls; completed by Primary Care nurses/Charge nurses for all patients 65 y.o. and older

Phone Calls to be completed 24 - 48 hours post discharge

Charge nurses provide Director of Patient Care Services with a summary quarterly

80% of patients indicate they had all of the information they needed at

2)Implement Patient oriented discharge summary for all patients over 65 years of age, and health links clients for the Health Link #9

SFMH is part of a provincial initiative to implement Patient Oriented Discharge Summaries (PODS)

The project will be fully implemented in 2018 with funding through the ARTIC project and evaluation of the project will take place over 2018-19

Number of PODS provided to the identified patient groups. Percentage of compliance for

1)All PODS (Patient Oriented Discharge Summaries) will be shared with the Primary Care Providers at the time of discharge from hospital

PODS document to be faxed to PCP on day of discharge Ward clerks and Charge nurses provide summary to Director of Patient Care Services

100% of patients with a PCP will have their PODS form faxed

Goal is to ensure patients are always well informed and this is reinforced through post discharge phone calls

Need to consider the increasing number of patients with no PCP post

n menu if you are not working on this indicator) C = custom (add any other indicators you are working on)

increasing needs of the community served

1)Continue to implement RNAO Best Practice Guideline for the Prevention of Pressure Ulcers

Educate Nursing Staff on best practices & have Wound Care Champions with additional training (Wounds Canada courses)

Track the number of staff who have had formal education (in-services)

80% of FT and PT nursing staff will attend training over the course of the year 2 Wound

1)1)Measure compliance with completion of Barthel Index on admission to measure functional ability; continue sharing tools to

Audit compliance with Barthel Index completion 24-48 hours post admission

Percentage of compliance with Barthel Index completion

80-100% of patients will have Barthel Index completed on admission

2)Improve on consistent use of patient white boards to enhance patient and family centered care through communication

Frequent discussion with families/patients to ensure white boards contain appropriate timely information to plan for discharge.

Quarterly audits with trending and tracking information Process followed for 100% of patients that are complex >65 and reduction of

3)3)Home First Joint Discharge Rounds (JDR) to ensure appropriate decisions to avoid long-term care and will include the use

All planned discharges will be presented at JDR to ensure discharge planning activities start on admission, supporting the home first philosophy

LOS data reviewed quarterly and aggregate data will be reviewed by care team to support required process changes

Aggregate data required for tracking/trending; aggregate data will be used to make

4)7)Implement new Home First philosophies, policies and procedures

Care Team members will lead implementation Educate all staff, physicians and Senior Management on policies

80% compliance with all new policies and processes

1)Continue to evaluate effectiveness of supporting patients and families to palliate at home

Include MVHPCS in Joint Discharge Rounds as a partner in care

Monitor number of patients discharged home for palliative care services versus choosing to remain in hospital

>90% of palliative patients will be discharged home with a status of "Home with

1)1)Conduct follow-up phone calls at discharge for patients >65 admitted through ER

Highlight ideas for change and positive scores to Emergency Dept team

Patient and Family Advisory Committee will continue to provide opportunity for patient feedback and input for change

A minimum high of 5 ideas for changes will be implemented and endorsed by this

2)2)Continue Patient and Family Advisory Committee in 2018/19 to ensure patient and family perspectives are key drivers to improve care

Evaluate effectiveness of change through recommendations and changes implemented

Continue to implement PFAC recommendations 100% of recommendations implemented by March 2019

Community is still adjusting to increasing demands on the local ED related to orphan patients and overall increasing volumes impacting on

Continue to embrace the Madawaska Valley Home and Palliative Care

Will continue to work to reduce ALC days; community resources In a rural area a challenge the hospital cannot control

Occurrence is low; volume is low

3)5)Bring patient experiences to hospital Board leadership team

Bring patient stories to at least 3 board meetings per year

Number of patient stories 100% of board members will indicate value added by the patient story

1)1)Conduct follow-up phone calls at discharge for patients >65

Highlight ideas for change and positive scores to Care Team and Patient and Family Advisory Council

Care Team will provide opportunity for patient feedback and input for change based on feedback

Continue to hold Patient and Family Advisory Council meetings and provide feedback

2)2)Patient and Family Advisory Council in 2018/19 to ensure patient/family perspectives are key drivers to improve care

Evaluate effectiveness of change through recommendations and changes implemented

Continue to implement PFAC changes 90-100% of recommendations implemented by March 2019

3)Evaluate effectiveness of new patient whiteboards

Audit usage an patient satisfaction Patients will report satisfaction with whiteboards 90% of whiteboards will have up to date relevant information

4)Evaluate effectiveness of patient oriented discharge summary (PODS)

Implement for all hospital discharges The summaries will be implemented and evaluated in 2018/19

90-100% of patients will have patient oriented discharge summary

1)1)All complaints will be acknowledged in the time frame

Alter policies/process to ensure follow-up is timely Monitor compliance and report to Board CQI 100% of concerns will be acknowledged in time frame

1)1)Measurement and feedback related to the compliance with medication reconciliation

Monthly audits will be completed on medication reconciliation. Audit will encompass the number of completed medication

Audit compliance with reports presented and get ideas for the change improvements when data presented

100% of reports will be brought forward to key stakeholders

2)2)Provide continual feedback on the compliance with medication reconciliation

Provide quarterly audit reports to Care Team, MAC and Pharmacy & Therapeutic committees

Change ideas will be communicated to key team members

100% compliance with dissemination and at least one improvement developed

Will continue to strive for improvement as it is key for patient safety

We continue to strive to meet 100 %

p g

wait times which negatively impacts on patient experienceSmall amount of inpatient unit surveys returned

3)Assign mandatory education that will be completed by all nursing staff in Learning Management System (LMS)

LMS will be used to ensure compliance 100% participation by all of staff in education 100% of staff complete education

1)1)Improve the culture of reporting workplace violence incidents

Workplace Violence Reporting Tool utilization has decreased over the past few years. Ensure that all staff are educated on the Violence Reporting Tool; Send out communication in staff newsletter; follow-up after incidents that should have form completed and provide re-education to staff involved; review current policy for ease of completion;

Number of Workplace Violence incidents reported

3 Workplace Violence reports

1)Daily informal bed meeting to facilitate transfers from the Emergency Dept

Key members of the care team (ED and MU) participate in daily bed meetings to enhance flow

100% participation by all team members To reach new target by March 31, 2019

2)4)Review length of stay data at Care Team meetings

Data reviews for all key areas of process show improvements are required 2018/19 year

Audit success 100% of minutes will reflect discussion and changes made

occupancy pressures in the Champlain LHIN may affect this metric

Current number of incidents is low. No comparison data available on the expected number of Workplace Violence

Comments

PODS are individual discharge instructions which help to Need to have understanding of the number of patients with no PCP

In this area these services and the existing model are dependent on strong volunteer

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