Listowel Memorial Hospital Wingham and District Hospital. Operating as: Listowel Wingham Hospitals Alliance. March 21, 2011

Transcription

1 Operating as: Listowel Wingham Hospitals Alliance March 21, 2011 This document is intended to provide public hospitals with guidance as to how they can satisfy the requirements related to quality improvement plans in the Excellent Care for All Act, 2010 (ECFAA). While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and hospitals should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, hospitals are free to design their own public quality improvement plans using alternative formats and contents, provided that they comply with the relevant requirements in ECFAA, and provided that they submit a version of their quality improvement plan to the OHQC in the format described herein. 1

2 Part A: Overview of Our Hospital s Quality Improvement Plan Purpose of this section: Quality Improvement Plans (QIPs) are, as the name suggests, all about improvement. They are an opportunity for organizations to focus on how and what to improve, in the name of better patient-focused care. As such, they will be unique documents, designed by, and for, each individual organization. Overall, a QIP should be seen as a tool, providing a structured format and common language that focuses an organization on change. The QIP will drive change by formalizing a plan and facilitating shared dialogue to support continuous quality improvement processes. This introductory section should highlight the main points of your hospital s plan and describe how it aligns overall with other planning processes within your organization. In addition, this section provides you with an opportunity to describe your priorities and change plan for the next year. Please refer to Appendix D in the QIP Guidance Document for more information on completing this section. 1. Overview of our quality improvement plan for [A general statement (100 words maximum) that is inspiring and situates the objectives within the Vision, Mission and Values of your organization The and operate together as the Listowel Wingham Hospitals Alliance (LWHA). The and share a joint mission to provide the best possible care for the people we serve. This simple statement describes what we collectively strive for and the inaugural Quality Improvement Plan for the LWHA reflects that mission. In light of this mission, the Alliance will focus on achieving improvements in a number of key areas that are essential to overall quality improvements. 2. What we will be focusing on and how these objectives will be achieved Safety 1. Reduce Clostridium difficile (C-Diff) infection rates Performance Goal: Reduce C Diff infection rate to zero incidents per 1000 patient days. 1. Additional and ongoing staff education (inservice, memos, intranet, digital message signs etc); 2. Implement staff and physician alerts to patients with symptoms including taking additional samples for analysis and earlier isolation and cohorting of patients; 3. Additional environmental cleaning and improved education for housekeeping staff to ensure that appropriate environmental cleaning protocols are followed; 4. Engage Pharmacist, Nursing, Pharmacy Technicians, and Physicians to enhance the monitoring and evaluation of antibiotic use as part of a more robust Antibiotic Stewardship program. 5. Reduce turnaround time for laboratory sampling on weekends to help identify positive C. Diff patients. 2. Improve Hand Hygiene Compliance Performance Goal: 80% compliance rate on staff hand hygiene practices prior to first patient contact. 1. Additional and ongoing staff education (inservices, memos, intranet, digital message signs etc); 2

3 2. Improved communication strategy and efforts to establish and maintain cultural shift regarding hand hygiene practices; 3. Continued hand hygiene auditing including additional feedback regarding results; 4. Improved location and quantity of hand hygiene products within patient care areas based on staff and physician feedback 3. Avoid Hospital Acquired Pressure Ulcers Performance Goal: Zero Complex Continuing Care Patients acquiring a new pressure ulcer while in Hospital. 1. Revise current Hospital policy to reflect Registered Nurses Association of Ontario (RNAO) Best Practice Guideline Risk Assessment and Prevention of Pressure Ulcers 2005; 2. Additional education for all nursing staff with respect to screening, early identification & prompt interdisciplinary referrals for patients at risk ; 3. Braden Skin Assessment tool to be used as a standardized measure of risk and associated interventions; 4. Monthly auditing to take place to ensure screening and reflective care planning measures are in place; 5. Capital and operation planning to ensure that appropriate pressure relief equipment and supplies are available. 4. Avoid Patient Falls within Hospital Performance Goal: Zero Complex Continuing Care Patients, who do not have a history of a fall, falling while in Hospital 1. Revised policy to reflect Registered Nurses Association of Ontario (RNAO) Best Practice Guideline Prevention of Falls and Fall Injuries in the Older Adult 2005; 2. Additional education to all nursing staff with respect to screening, early identification & prompt interdisciplinary referrals for patients at risk for falls; 3. Morse Fall Scale will be used as a standardized measure of risk and will include LWHA basic and advanced interventions; 4. Monthly auditing to ensure that screening and reflective care planning measures are in place and effective; 5. Capital and operations planning to ensure that appropriate equipment and supplies are available. 5. Reduce the Number of Duplicate Electronic Patient Files Performance Goal: Decrease the percentage of duplicate patient charts when creating new charts from 5% to less than 4%. 1. Additional education for registration staff on the importance and technique of doing proper patient searches; 2. Review the process with health record staff on identifying and correcting duplicates in a timely manner; 3. Continued monthly audits with feedback to all users. Effectiveness 1. Reduce Patient Readmission Rates for Select Diagnosis Performance Goal: Decrease 30 day rate of readmission to Hospital on the following diagnosis stroke, lung disease, heart failure, pneumonia, diabetes and gastro intestinal illness from 18.8% to less than 14%. 3

4 1. Implement the use of Standard Order Sets for care planning, patient safety, and prevention of re admissions; 2. Ensure patient linkages and access to appropriate community resources are available at discharge including Diabetes Education, Registered Dietitian, Family Health Team, Stratford Stroke Centre, Community Care Access Centre (CCAC) etc; 3. Review continuity of care and transition plans to community upon patient discharge (e.g. schedule appointments with physician offices, review instructions to resume normal activities etc); 4. Review patient education activities at discharge to ensure patients are receiving the necessary information regarding their post acute care. 2. Reduce Percentage of Patients in Alternative Level of Care Performance Goal: Reduce the percentage Alternative Level of Care (ALC) or patients awaiting placement or care elsewhere to 8.8% 1. Continued efforts with Community Care Access Centre regarding improving discharge from Hospital practices; 2. Promote the selection of 3 Long term care homes for in patients awaiting placement; 3. Establish improved communication and processes with physicians regarding ALC identified patients; 4. Review community resources and CCAC programs to ensure LWHA is taking advantage of existing community services and South West Local Health Integration Network (SW LHIN) Aging at Home strategies. 5. Re establish Hospital utilization processes to address Complex Continuing Care utilization and transition plans to long term care facilities. 3. Improve Organizational Financial Health Performance Goal: Achieve a total margin of 0% for both organizations. This achievement effectively results in a balanced budget at year end. 1. Carefully monitor financial performance against budget each month and make corrective action where necessary; 2. Explore creative solutions that would create financial efficiencies or drive new revenue sources; 3. Hold staff accountable for controlling costs and adopting financial efficiencies; 4. Adopt Standard Order Sets to address safe patient care, appropriate tests and procedures, standardized medications etc. 4. Best Possible Medication History (Medication Reconciliation) 4 Performance Goal: Complete the best possible medication history for 66% of admitted patients. 1. Improve staff education on method and reasons for obtaining best possible medication history; 2. Additional Policy development required to support process changes.; 3. Improve patient understanding of medication history through community and patient engagement including community forum, newspaper articles; 4. Improve Physician role in obtaining best possible medication history through use of community primary care health record (Purkinje) and improved reconciliation practices;

5 5. Identification and implementation of electronic capabilities to support obtaining best possible medication history; 6. Improve systems and process for communication between staff, physicians, community pharmacies, inter agencies and hospitals etc; 7. Quarterly evaluation and reporting of progress. 5. Improve Diagnostic Imaging Reporting Turnaround times Performance Goal: Improve the turnaround time from dictation to typed and available for diagnostic imaging reports. 1. Review current diagnostic imaging reporting process and determine the source of delays and backlogs;. 2. Establish appropriate turnaround times and acceptable standards of practice at each applicable stage of process to ensure timely reporting of Diagnostic Imaging reports; 3. Implement speech recognition program and provide ongoing support and education to its users (decrease turnaround time and volume of dictation using reporting template); 4. Provide education to Radiologist to improve reporting times by self editing of final reports; 5. Implement use of predefined text for normal reports; 6. Evaluate health records staff roles and workflow. Access 1. Maintain Emergency Department Wait Times Performance Goal: Length of Stay in the Emergency Room for admitted patients to be less than 25 hours. Performance Goal: Length of Stay in the Emergency Room for complex conditions to be less than 6.3 hours. 1. Monitor utilization data and make rapid cycle improvements where necessary; 2. Communicate current wait time information with patients using electronic signage in Emergency Department waiting room; 3. Ensure beds are available for admissions through the Emergency Department (ED) by carefully managing inpatient utilization. Wingham 1. Evaluate/redesign work area to allow for improved patient flow. 2. Achieve Timely Patient Repatriation from other Hospitals Performance Goal: Clinically appropriate patients to be repatriated to Listowel Wingham Hospitals Alliance within 48 hours of request. 1. Any patient repatriation request to Wingham or Listowel sites needs to be requested using the South West Local Health Integration Network (SW LHIN) Patient Access and Flow Repatriation Form; 2. Completed forms will be faxed to the Clinical Resource Nurse of the respective site who will assess appropriate bed allocation and review request with physician; 5

6 3. If patient is deemed to be clinically inappropriate for management within our sites, this will be documented on the form and communicated with the requesting facility; 4. Forms will be on each site for evaluation purposes; 5. Evaluation of requests and repatriation decisions to be reviewed monthly 3. Increase Staff Accessibility Awareness Training Performance Goal: 100% of newly hired employees to have completed the accessibility training within 1 month of hire 1. Improve education processes and tracking with e learning system for all employees; 2. Ensure present employees have completed accessibility training; 3. Use e learning and Human Resources staff to develop consistent approach to training in the future. Patient Centred Care 1. Patient Satisfaction Improve Percentage of Positive responses to Hospital recommendation Performance Goal: Greater than 80% of patients surveyed through the NRC Picker Inpatient satisfaction survey would recommend this Hospital to their family and friends. 1. Improve transition of care for patients (e.g. appointments with physician post discharge, calls after surgery etc); 2. Implement efforts to improve communication post discharge care (e.g. handouts, who to call if problems, calls after surgery etc); 3. Create actions plans for improving 5 related questions on NRC Picker Survey; 4. Identify strategies to improve patient satisfaction responses. 2. Improve Patient Satisfaction Survey Response Rates Performance Goal: Increase the response rate on the NRC Picker inpatient satisfaction survey to 50% of surveys sent. 1. At time of discharge, Hospital staff will advise patients of the potential for receiving a satisfaction survey and conveying its importance; 2. Community and patient engagement (media, community forums); 3. Review the current cover letter to ensure wording stresses the importance of response including an expression of gratitude for completion; 4. Review patient selection process and data compilation and submission processes are appropriate. 6

7 3. How the plan aligns with the other planning processes [An explanation of how this document links to the other planning documents developed by your organization (such as H-SAA) and key external partners such as the LHIN and CCACs.] The Quality Improvement Plan for the Listowel Wingham Hospitals Alliance was not developed in isolation of the H-SAA, operating budget, capital budget, senior friendly hospital audit, Accreditation Canada survey or other health care planning initiatives. The reality of the QIP process for the April 1, 2011 deadline was the need to focus on ensuring the QIP: Met the legislated requirements. Included quality improvement initiatives that were identified as part of Accreditation Canada survey, internal improvement initiatives or system wide improvement requirements. Included measures and improvement targets where existing data, systems and processes supported identifying and improving an objective. Was completed within the required timeframe with limited timely guidance and direction. Future Quality Improvement Plans will have the benefit of; Experience Incorporation into the Hospitals annual planning cycle Information and insight from other similar organizations. Sufficient time to compile, prepare and publish the QIP document following an appropriate consultation process. 4. Challenges, risks and mitigation strategies [This section describes the relative risks that may inhibit the accomplishment of the objectives and the mitigating strategies that have been identified to lower those risks.] The Listowel Wingham Hospitals Alliance is very similar to other small Hospital organizations with respect to having systems and processes in place to capture and report the required data to meet all mandatory reporting requirements. There are limited resources, systems and processes available to capture data which has not previously been required reporting. Compiling this data is therefore often a labour intensive, manual process. In addition, finding relevant, comparable performance targets and references can be difficult for small organizations. Where possible, this challenge has been mitigated by some creative information technology. In other instances, manual processes and scarce resources must be utilized. Small Hospitals are often challenged by significant variability in data quality and relevance as a result of small populations and sample sizes. This risk has been mitigated by measuring performance indicators and selecting improvement goals based on annual targets. Physician practice can significantly impact the success of an initiative. While the Listowel Wingham Hospitals Alliance generally has excellent relationships with physicians, there are very few levers of change or incentives that can be utilized by the Hospital to change physician practice. This challenge has typically been addressed through long standing relationships and goodwill. 7

8 Part B: Our Improvement Targets and Initiatives Please complete the Improvement Targets and Initiatives Part B spreadsheet (Excel file). Please remember to include the spreadsheet (Excel file) as part of the QIP Short Form package for submission to the OHQC (QIP@ohqc.ca), and to include a link to this material on your hospital s website. Part C: The Link to Performance-based Compensation of Our Executives Purpose of Performance-based compensation: 1. To drive performance and improve quality care 2. To establish clear performance expectations 3. To create clarity about expected outcomes 4. To ensure consistency in application of the performance incentive 5. To drive transparency in the performance incentive process 6. To drive accountability of the team to deliver on the Quality Improvement Plan 7. To enable team work and a shared purpose Please refer to Appendix E in the QIP Guidance Document for more information on completing this section of the QIP Short Form. Manner in and extent to which compensation of our executives is tied to achievement of targets [Compensation should be linked to targets for those members of the senior management group who report directly to the CEO, including the chief of staff (where there is one) and the chief nursing executive. Please refer to the regulation (Ontario Regulation 444/10)] Our executives' compensation is linked to performance in the following way: Chief Executive Officer - $7,500 of incentive compensation for the CEO is linked to achieving the targets set out in the QIP on the following indicators: Performance Goal Safety Hand Hygiene compliance 80% Access Patient Repatriation from other Hospitals 95% Effectiveness Best Possible Medication History 66% Patient Centred Patient Satisfaction Positive Response to Recommend Hospital 80% Vice President of Operations, CFO - $3,600 of base salary for the Vice President of Operations is linked to achieving the targets set out in the QIP on the following indicators: Performance Goal Safety - Hand Hygiene compliance 80% Effectiveness Best Possible Medication History 66% Patient Centred Patient Satisfaction Positive Response to Recommend Hospital 80% 8

9 Vice President of Clinical Services, CNE - $3,600 of base salary for the Vice President of Clinical Services, CNE is linked to achieving the targets set out in the QIP on the following indicators: Performance Goal Safety - Hand Hygiene compliance 80% Access Patient Repatriation from other Hospitals 95% Patient Centred Patient Satisfaction Positive Response to Recommend Hospital 80% Chief Human Resources Officer - $3,000 of base salary for the Chief Human Resources Officer is linked to achieving the targets set out in the QIP on the following indicators: Performance Goal Safety - Hand Hygiene compliance 80% Patient Centred Patient Satisfaction Positive Response to Recommend Hospital 80% Chief of Staff - $1,250 of base salary for the Chief of Staff is linked to achieving the targets set out in the QIP on the following indicators: Performance Goal Access Patient Repatriation from other Hospitals 95% Effectiveness Best Possible Medication History 66% The following table outlines the at risk compensation that would be paid for meeting each progress step towards the Quality Improvement Performance goals. Levels of Achievement towards Target At Risk Compensation Paid Threshold Step 1 Step 2 Target Threshold Step 1 Step 2 Target Safety 66% 70% 75% 80% 40% 60% 80% 100% Access 50% 75% 90% 95% 40% 60% 80% 100% Effectiveness 40% 50% 60% 66% 40% 60% 80% 100% Patient Centred 70% 75% 78% 80% 40% 60% 80% 100% 9

10 Part D: Accountability Sign-off [Please see the QIP Guidance Document for more information on completing this section.] I have reviewed and approved our hospital's Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan: 1. Was developed with consideration of data from the patient relations process, patient and employee/provider surveys, aggregated critical incident data, and patient safety indicators; 2. Contains annual performance improvement targets, and justification for these targets; 3. Describes the manner in and extent to which, executive compensation is tied to achievement of QIP targets; and 4. Was reviewed as part of the planning submission process and is aligned with the organization's operational planning. Kris Dekker Board Chair Mary Kerr Quality Committee Chair Karl Ellis Chief Executive Officer Margaret Stapleton Board Chair Diane Thomson Quality Committee Chair Karl Ellis Chief Executive Officer 10