AIM MEASURE CHANGE Quality Dimension Objective 2018 / 2019 Measure/ Indicator Current Performance Target Initiative Number

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1 s Process Measures Goal for change ideas Timely Reduce Wait Times in the Emergency Department (ED) -Complex patients ED LOS - CTAS 1-3 pts admitted and discharged 13.1 < Improve communication between the interdisciplinary team (physicians, nurses, allied health) and the patient/family to ensure consistency of the communication of the care plan and discharge plan as it relates to 1 Develop, trial and evaluate a process to improve daily team communication of Process developed, trialed and evaluated on 2 medicine units % patients with action plan in place when expected acute length of stay is exceeded by Q4 2 Enhance bedside handover to support communication of care plan and SBAR report process revised to focus on communication of % patients/family aware of expected length of stay 3 Establish leadership rounding model to sustain and support accountability for team communication of care plan and Leadership rounding model developed and implemented on all Medicine units % of Manager leadership rounds completed 3 x/week 80% % of Director leadership rounds completed weekly 80% Effective Reduce Unnecessary Hospital Readmissions (for one of) -Chronic Obstructive Pulmonary Disease (COPD) 30 Day Readmission Rate 20.53% <20% 2 Improve Transitions of Care 4 Evaluate effectiveness of referral process to clinics for post-discharge COPD patients. % of eligible patients referred % of referred patients interviewed 50% of referred patients 5 Create and trial a Patient Oriented Discharge Summary to support transitions at discharge. PODS Discharge Plan developed and trialed on 1 unit % of Patients who receive a PODS transition plan at discharge Complete Q2 6 Establish a multidisciplinary sub team of the COPD working group to assess repeat visits to the Emergency Department Team and review process created % Family Health Team patients reviewed and action plan developed Complete Q1 4/26/2018 1

2 s Process Measures Goal for change ideas 3 Develop and implement a sustainable model for audit and feedback 7 Create a routine process to audit ED and admitted patients with COPD exacerbations. % COPD Patients Audited Audit Feedback Shared Quarterly at COPD working group with 1 change initiative for testing selected per quarter 75% 4/26/2018 2

3 s Process Measures Goal for change ideas Equitable Total Margin Revenue/Expense 1.07 >1.1 4 Continue to generate a balanced operating budget on an annual basis Ensure that expenditures are within available cash flows for capital investments. 8 Monitor Operating budget variance Monitor Capital budget variance Monthly budget variance reports Monthly capital budget report Balanced or surplus Balanced or surplus Efficient Reduce Unnecessary time spent in acute care ALC Rate ALC Rate per 1000 patient days 0.99 <20% 5 Utilize the ALC leading practice report 9 Roll out and evaluate effectiveness of to guide work related to ALC the patient and family discharge tool. measurement and reduction % of discharge meetings where the communication tool is utilized. 10 Trial a process to identify and evaluate % of patients identified at risk for patients who are at risk of becoming ALC ALC due to change in treatment due to change in treatment protocol protocol from original admitting from original admitting diagnosis. diagnosis. % patients identified as at risk for ALC due to change in treatment protocol with revised action plan in place Patient- Centered Improve Patient Experience - Would you recommend PRHC? Would you recommend PRHC? 92.70% 92% 6 Utilize all sources of patient feedback to drive unit level improvements 12 Utilize patient-reported outcome measures to identify, plan and implement an improvement. % complete 13 Develop process and define infrastructure for hip and knee proms (bundled care initiative). % complete 14 Implement at least 1 change per unit/department based on patient feedback from any source % of units/departments that have implemented at least 1 patient experience improvement based on patient feedback 15 Roll-out the 'Hello My Name Is' initiative in Medicine and Surgery. % complete 7 Utilize all sources of patient feedback to implement corporate patient centered initiatives 16 Continue to have at least one Patient and Family Partner advise on each QIP Objective. % complete 17 Develop a patient handbook written by patients for patients % complete 4/26/2018 3

4 s Process Measures Goal for change ideas 8 Increase patient access to personal health information 18 Evaluate potential electronic patient portals and determine timing and plan % complete 4/26/2018 4

5 s Process Measures Goal for change ideas Safe Medication Reconciliation at Discharge % Medicine Patients with Med Rec upon discharge. 55% (steps 1-7) 75% (steps 1-5) >70% 9 Implement a sustainable Medication Reconciliation process for discharged inconsistent - prescriber patients in Medicine units (A3,A4,B4) initial and meditech entry 19 Rollout Medication Reconciliation at all Transitions of Care to Medicine units (A3, A4, B4) % of Medicine units with Med Rec at all transitions of care 20 Develop a sustainable audit and feedback program % of Non Compliance Issues Shared with Practitioner Leads Reduce Workplace Violence # workplace violence incidents 10 Develop a standardized approach to the reporting, review and tracking of factors associated with workplace violence to support development of effective prevention strategies and action plans. 21 Develop a process to ensure all Process Developed workplace violence incidents are tracked Complete Q1 22 Continue, Evaluate and Enhance process for regular review of all workplace violence incidents. Trial unit-level safety huddle with inclusion of process to identify risks for Workplace Violence. Establishing baseline data applied to broad definition of workplace violence. No target specified due to establishing baseline data applied to broad definition of workplace violence. 23 Develop and Introduce Workplace Violence metrics Workplace violence incidents and unit based action plans reviewed and shared as a portion of the Workplace Violence Committee agenda. Metrics Developed Complete Q2 11 Enhance Workplace Violence educational opportunities with focus on the populations we serve. 24 Provide Gentle Persuasive Approach training for all ED, Inpatient Surgery and Inpatient Medicine nursing staff. % Clinical Staff Trained 50% by end of Q4 4/26/2018 5

6 s Process Measures Goal for change ideas Reduce Hospital Acquired Infection Rate - C. Difficile CDI Infection Rate per 1000 patient days 0.31 <= Standardize environmental and equipment cleaning and disinfection 25 Standardize environmental and equipment cleaning processes and products to include the use of a sporicidal in three high risk outpatient areas (i.e. Oncology, Surgical Outpatients, Medical Outpatients) % Complete 13 Implement enhanced antimicrobial stewardship for high-risk surgical populations in conjunction with Infectious Diseases support 26 Implement enhanced antimicrobial stewardship in the vascular program in partnership with Infectious Diseases expertise Days of Therapy (DOTs) on A5 and B5 (Surgical Services) 10% reduction in DOTs Nosocomial CDI Rate on A5 and B5 (Surgical Services) 10% reduction in CDI Reduce Hospital Acquired Infection Rates - MRSA MRSA Infection Rate per 1000 patient days <= Implement new hand hygiene observation strategies to improve accuracy and validity and encourage positive change 27 Train and support peer hand hygiene auditors in clinical areas # of hand hygiene observations submitted by peer auditors 50% increase 28 Investigate an e-monitoring solution % complete complete 15 Collaborate with teams in units with the highest rate of nosocomial MRSA infections to identify and address opportunities to reduce transmission of MRSA 29 Initiate daily chlorhexidine bathing for MRSA patients (B5/SCC) Nosocomial rate of MRSA colonizations and infections on B5/SCC 25% reduction 30 Address barriers to aseptic technique (wound care, tracheostomy care) and Moment 1 hand hygiene (B5/SCC and other areas) Nosocomial rate of MRSA colonizations and infections on B5/SCC 25% reduction Reduce Inpatient Falls with Harm Falls with Harm Rate per 1000 patient days Continue to support sustainment of the Falls/Restraint/Delirium Strategy for all Adult Inpatient Units. 31 Support sustained use of the TIPS falls prevention tool through real-time case consultation for patients identified as at risk for falls, being restrained or experiencing delirium. % identified patient cases with supportive assistance. 32 Develop and implement process to identify and minimize pharmacological risks for falls, restraints and delirium. Process implemented on 1 unit. 4/26/2018 6

7 s Process Measures Goal for change ideas 17 Focused review of all fall incidents to promote learning between units and identify leading indicators for risk of falls. 33 Complete weekly review of all falls from previous week with Falls Analysis Team. % of falls reviewed weekly with documented changes to care plans 4/26/2018 7