2014/2015 Quality Improvement Plan for Ontario Hospitals "Improvement Targets and Initiatives"

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2014/2015 Quality Improvement Plan for Ontario Hospitals "Improvement Targets and Initiatives" North York General Hospital 4001 Leslie Street AIM Measure Change Quality dimension Objective

1 2014/2015 Quality Improvement Plan for Ontario Hospitals "Improvement Targets and Initiatives" North York General Hospital 4001 Leslie Street AIM Measure Change Quality dimension Objective Measure/Indicator Unit / Population Source / Period Current performance Target Target justification Priority level Planned improvement initiatives (Change Ideas) Access Reduce wait times in the ED ED Wait times: 90th percentile ED length of stay for Admitted Hours / ED CCO iport 23.3 hours 20 hours NYGH continues to perform well Improve 1)Implementation of Quality-Based. Access / Q4 in reducing the number of hours Procedure (QBP) standards to 2012/13 that spend in the improve operational processes and Q3 2013/14 Emergency Department waiting communication on inpatient units. for a bed. Over two years a 15% improvement has been achieved. In 2014/15 a further 8% improvement is identified. Methods Process measures Goal for change ideas % of QBPs deployed on time. 100% of new QBP project completed on-time. The QBP committee will assess quarterly project health to determine if QBP projects are delivering their new standards on time. Hospital-wide a series of QBP projects will be deployed. Comments New care designs and improved processes as part of the QBP handbooks should improve patient lengths of stay while improving readmission rates. This will enable inpatient beds to be more readily available and will reduce ED LOS for admitted as a result. 2)Modifications and enhancements to the hospital wide bed status escalation policy. The project will improve the daily bed meeting, and communication processes with regards to bed management. A daily report will be developed to measure accuracy in predicting probable and definite discharge. % probable / definite discharge prediction 80% prediction accuracy. Documented in teletracker for accuracy (initial next day by 11am. (new process measure) target). In 2014/15, bed escalation will move towards more patient and resource specific needs instead of hospital-wide escalation. 3)Clinical areas will identify unit and program specific improvements that will decrease the inpatient length of A monthly report outlining unit-base % Conservable Days will be sent to each program. The expected improvements are the responsibility of each program to % Conservable days (by inpatient unit / ward). stay. A major focus will be to improve deliver. operational process with a target of saving one day per patient. 2% annual improvement yearover-year from each unit's performance.

2 4)A series of operational improvements are planned to improve transportation services portering times. A working team will be developed to test changes and Overall Portering Turnaround Time (for assess process improvements. Monthly reports demand requests only). Current focusing on "Portering Key Performance Indicators" will performance is 44 minutes (monthly assess the effectiveness of the improvements. average). Close the gap (target of 35 minutes on average) by 50% in Q4 2014/15 fiscal year (39.5 minutes on average by Q4). Effectiveness Improve organizational financial health Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year. % / N/a OHRS, MOH / Q3 2013/ NYGH continues to have good financial health. The target is set at continuing to achieve a balanced budget. Maintain 1)Corporate governance structure for Quality Based Procedures (QBPs). The QBP Committee will prioritize, implement and evaluate QBP initiatives. Prioritization will be done annually, reports to the QBP committee will be at a minimum quarterly. Metric(s) for each QBP will be established and reported monthly in the Business Intelligence Tool and in the regular status reports. QBPs will be implemented as scheduled and transition to sustainability phases as identified. QBPs undertaken in 2013/14 will transition to their sustainability phase by July QBPs undertaken in 2014/15 will achieve their target date of implementation. QBPs for implementation in 2015/16 will be prioritized by March 31, Integrated Reduce unnecessary time spent Percentage ALC days: Total number of acute inpatient days % / All acute Ministry of 16.95% 16% Reducing the % of ALC continues Improve in acute care designated as ALC, divided by the total number of acute inpatient days. Health Portal / Q3 2012/13 Q2 2013/14 to be a challenge and is multifactorial involving external agencies and access to care in the community. The target is set at the 2013/14 MLPA target and is an improvement over our 2013/14 performance. 1)Formation of ALC Steering Committee. 2)Complete a series of process improvements to the Joint Discharge Organizational Group (JDOG) meetings with a major focus on improving partnerships. 3)Improve discharge planning with patient and families with a focus on communication starting as early as possible after admission. The ALC Steering Committee will have a broad range of membership from both the hospital and community partners. The committee will have terms of reference and will identify and prioritize improvement activities. Regular reports on the status of deployed projects will be scheduled at the committee meetings. Incremental improvements to the JDOG meeting. Community partners will be invited to JDOG to inform team of applicable community resources. The working group will develop and deploy strategies for improvements in communication with and families on discharge planning. Project deliverables identified and implemented. Count the number of community partners that come on a monthly basis. Patient Feedback % positive scores on the daily discharge feedback cards for the questions: "Were you and your family given the opportunity to participate in your care?" and "Did staff discuss when you could resume your usual activities?" 100% deliverables completed by September visits in the next fiscal year. This will increase the utilization of community resources. 20% of the gap to 100% positive answers will be closed by Q4 across all Medicine, Cancer Care, and Surgery inpatient units. Information regarding each community partner will be put into a data repository of all community partners. 4)In partnership with the CCAC and Identify, prioritize and deploy six new quality the broader LHIN ALC Working Group, improvement initiatives to reduce ALC. deploy a series of process improvements focused on improving transitions to long-term care and home CCAC services. The number of improvement initiatives completed in 2014/15. March 31, 2015.

3 Reduce unnecessary hospital readmission Readmission to any facility within 30 days for selected CMGs for any cause: The rate of non-elective readmissions to any facility within 30 days of discharge following an admission for select CMGs. % / All acute DAD, CIHI / Q2 2012/13- Q1 2013/ % 14.00% Though NYGH performance is better than the 16.3% provincial average and the Central LHIN average of 15.67% this indicator has been identified for improvement. A 6% improvement on current performance has been identified. Improve 1)Expand the Congestive Heart Failure Clinic providing timely access to and supporting transition to the community. 2)Implement a Chronic Obstructive Pulmonary Disease (COPD) Clinic The clinic will establish robust relationships with the Number of who are referred to community based Rapid Response Nurses ensuring that the Rapid Response Nurse have timely access to resources that support them remaining at home and reducing the need to come to hospital. Establish baseline for referrals to the clinic by June 30, 2014 The Medical/Surgical Clinic will identify an operational Number of with COPD seen in the COPD Clinic 100% schedule for a COPD Clinic. The COPD Clinic will partner clinic. operational by July with HealthLinks to provide community based services for that will support the patient remaining in their home. 3)Engage physicians in quality improvement initiatives focused on reducing the number of who are readmitted. 4)Partner with Patient/Family Advisors on quality improvement initiatives for reducing re-admission rates. Physicians will be identified to co-lead and/or participate in quality improvement initiatives that have been identified for specific CMGs. Physician participation will be reviewed at the end of each initiative. Number of physicians participating in readmission improvement initiatives. Patient/Family Advisors have a unique ability to bring Number of Patient/Family Advisors on their experiences at NYGH to the table. In sharing we quality improvement initiatives focused are better able to understand how the care and on re-admissions for specific CMGs. services we provide impact them. In understanding their experience we can collaborate on the design and development of new care and services. In improving our re-admission rates Patient/Family Advisors will be partners with us on quality improvement initiatives. Each time an initiative is identified that team will ask themselves "what would be the role of a Patient/Family Advisor?" The initiatives will be ones in which decisions about patient care will be made. When a role is identified a request for an advisor(s) will be made. 100% of improvement initiatives will have a minimum of one physician participating 100% of initiatives will have a minimum of one Patient/Family Advisor Patient-centred Improve patient satisfaction From NRC Picker: "Overall, how would you rate the care and services you received at the ED?" (add together % of those who responded "Excellent, Very Good and Good"). % / ED NRC Picker / % 85% In 2013/14, the Emergency Department goal was to achieve 85% satisfaction beginning with the October NRC results. This goal was achieved. The fiscal YTD performance was 82.23%. For 2014/15 the Emergency Department goal is to sustain, on average 85%. This is an improvement over the current performance and is indicative of the focus of the Emergency Department team. An increase in patient satisfaction is incremental and improves over years. The 85% target is slightly below a 50% improvement from the provincial benchmark of 91% as identified by Health Quality Ontario. Improve 1)Engage NYGH Patient/Family Advisors in Emergency Department initiatives focused on improving the patient and family experience. 2)Just in time patient/family surveys. Establish an Emergency Department Patient/Family Advisor team with dedicated advisors. The advisors will partner with the Emergency Department on committees, working groups and ad hoc work that impacts decisions about clinical care. The advisors will be an equal partner in the work and not viewed as a consultant. Participation will be tracked by the individual advisor and reported quarterly by number of activities and number of hours. As a follow-up to the Emergency Department "Being on the Other Side: Learning from Patient Stories" program, internal just in time surveys will be conducted with and families while they are in the department. The surveys will be done by the Emergency Department team on a weekly basis. Data will be analyzed and reported quarterly to the Emergency Services Program meetings and Nursing Council. In addition, the feedback will be in real time which provides for immediate action as required. Patient/Family Advisor and Emergency Department team satisfaction with their experience partnering with advisors. The question "how would you rate the care you received in the Emergency Department" will be asked. Positive responses will be the % of those who responded excellent, very good and good. 85% positive experience on the annual evaluation. 85% of and/or families will rate their care as positive. These results will correspond with the NRC survey that is done on a monthly basis.

4 3)Develop and implement a medical directive for pain relief and management. Pain management and control is associated with patient ratings of satisfaction with their Emergency Department experience. The Emergency Department leadership team will review the appropriateness of implementing a medical directive which would provide for efficient, safe and timely administration of pain medication prior to the assessment by a physician. Medical Directive developed and implemented by January )Provide formal education on communication strategies for new staff and in the annual Triage Nurse orientation and re-orientation. Education programs for new staff and Triage Nurses will be revised to enhance communication strategies. Review and revision of both education programs. Triage revision to orientation + education of triage nurses complete by September New staff orientation to be revised and implemented for the September 2014 intake of new staff. 5)Provide information, on commonly asked questions, for and families who are waiting in the Yellow Zone and the initial waiting room. Answers to commonly asked questions should reduce anxieties, provide timely information and improve the overall patient experience. The TVs in the waiting area and the Yellow Zone will provide answers to commonly asked questions eg. how long may I have to wait; how long will it be until a doctor sees me; can I eat or drink. Identify the questions to be asked and the answers. Partner with Patient/Family Advisors on construction of the questions and answers so that they are easily understood. Engage Information Services in the integration of the questions and answers on the TVs. by March 2015.

5 Safety Increase proportion of receiving medication reconciliation upon admission Medication reconciliation at admission: The total number of with medications reconciled as a proportion of the total number of admitted to the hospital. % / All Hospital collected data / Most recent quarter available (e.g. Q2 2013/14, Q3 2013/14 etc) 84.00% 84.00% In 2013/14 NYGH exceeded their Maintain target by 5%. There is no established benchmark for this indicator, though an accepted peer identified target is 75%. The 2014/15 target is 12% above the peer target and maintains current performance. Though this indicator is identified to be maintained NYGH will continue to strive to improve. 1)Medication reconciliation data indicates that increases in Best Possible Medication History (BPMH) rates correlates with increases in medication reconciliation rates. Pharmacy will complete Best Possible Medication History for who have been admitted. The BPMH will be documented in Cerner. The % of BPMH will be available monthly on our Business Intelligence Tool. Number of who had a BPMH Maintain the documented. Data collected and reported current BPMH at on a monthly basis. 96% Reduce hospital acquired infection rates CDI rate per 1,000 patient days: Number of newly diagnosed with hospital-acquired CDI, divided by the number of patient days in that month, multiplied by 1,000 - Average for Jan-Dec. 2013, consistent with publicly reportable patient safety data. Rate per 1,000 patient days / All Publicly Reported, MOH / In 2013/14 we exceeded our target by 31%. In 2014/15 our goal is a slight improvement of 3.7% and has been recommended by Infection Protection and Control. NYGH continues to perform better than the 25th%tile for community hospitals. Maintain 1)Year 4 of our Antimicrobial Stewardship Program (ASP)with a focus on acceptance rates. 2)Year 4 implementation of the Antimicrobial Stewardship Program (ASP) The ASP team will partner with clinicians to provide audit and feedback on acceptance rates associated with a subset of ASP interventions focused on discontinuation and duration of antibiotic therapy. Utilizing 2 years of internal data, as the benchmark, assess the Critical Care Unit utilization of broadspectrum IV antibiotics. Number of audit and feedback discussions with clinicians and their acceptance of the recommendations will be collected on a monthly basis. Information will be shared on a quarterly basis with the team. Number of times a broad spectrum IV antibiotic was ordered per Critical Care Unit patient days. Monthly average of 80% acceptance rate for the recommendations. Utilization rate to be within 3 standard deviations of the mean days of therapy/1000 Critical Care Unit patient days. Utilization rate measured on a quarterly basis. The two years of internal data will be available by April 30, )Sustain environmental cleaning with infra-red spot testing of 6 patient rooms per week. Each patient room will have a minimum of 10 touch points marked and tested. The results of the audits will be shared with the Environmental Services team at their huddles. % of touch points that are identified as having been cleaned. Monthly average of 98% touch points meet the established standards for cleaning. Sustain the excellent work of the Environmental Services team, ensuring that patient rooms are appropriately terminally cleaned.

6 4)Optimize staff cleaning of mobile equipment between patient use. Monthly unit based audits of staff cleaning mobile Unit based percentage of mobile equipment between patient use. The number of audits equipment cleaned between patient use conducted per month will be increased over the four and the number of audits per month. quarters of 2014/15. Results of the audits will be shared monthly with staff. Monthly average of 88% of equipment cleaned between. Compliance with the number of audits required per month will increase from 59% to 70% in Q1, 80% by Q3 and 85% by Q4. 5)Implement the recommendations from the 2013/14 review of our Hand Hygiene Program. 1. Unit based feedback and recommendations to be provided to each Clinical Team Manager. 2. Offer weekly Hand Hygiene auditor training sessions to refresh current auditors and train additional auditors. 3. Provide corporate wide hand hygiene education to staff focused on refreshing knowledge of the 4 moments of hand hygiene. 1. Meetings scheduled with each Clinical Team Managers. 2. Auditor training sessions scheduled and completed 3. Hand hygiene education sessions scheduled and completed 1. by June 31, by June 31, by September 30, 2014 Avoid Patient falls Avoid patient falls: number of in who have a fall causing harm (the fall classified as critical, serious or moderate.) Counts / All Hospital acute collected data / 2014/ In 2012/13, NYGH achieved a Maintain 50% reduction over the 2011/12 baseline. This trend continued in 2013/14 with a further 25% reduction. In 2013/14 we exceeded our target by a further reduction of 2 who had a fall classified as critical, serious or moderate. In 2014/15 the target of 11 is set at current performance. As there is no established target for falls in acute care NYGH strives to continually reduce the number and severity of falls. 1)Provide written information on falls prevention to and families 2)Corporate Falls Prevention Steering Committee will conduct unit based Gemba Walks of falls prevention strategies in place for individual at risk for a fall. Patient/Family Advisors will partner with members of the Falls Steering Committee to develop a Falls Prevention brochure that will focus on the main areas for falls prevention as identified by the advisors. Patient/Family Advisors will be involved in all phases of the development of the written material. The written material will have the Patient- and -Family Centre Care stamp included. On inpatient units identified at risk for a fall 1. Four times per year members of the will have an audit of their falls risk documentation and a Falls Prevention Steering Committee will visual audit of strategies in place to reduce falls. visit inpatient units, review a patient who Feedback on the audit will be provided to the individual is at risk for a fall and complete a Gemba units after each Gemba Walk. Data from the audits will Walk form. 2. Number of at risk be compiled into a corporate report and presented to for falls reviewed four times per year by the Quality of Care Committee twice a year. the Corporate Falls Steering Committee. Written material available by June 30, % of scheduled audits completed 2. Biannual report to the hospital Quality of Care Committee completed Increase proportion of receiving medication reconciliation upon discharge Medication reconciliation at discharge: the total number of with medication reconciled as a proportion of the total number of discharged to the hospital. Hospital collected data, most recent quarter available. % / All acute Hospital collected data / most recent 64.50% 70% In 2013/14 NYGH exceeded their target which is indicative of the focus on medication reconciliation. The 2014/15 target is an 8.5% improvement on performance and closes the gap to the externally, peer identified target of 75%. Over 2 years NYGH will have closed the gap from a baseline of 56.6% to the target of 75%. This is an improvement of 73%. Improve 1)Continue to partner with the Surgical Program in supporting medication reconciliation at discharge. 2)Increase the number of inpatient units reporting through Cerner documentation medication reconciliation on discharge. Pharmacists will partner with individual surgeons to learn more about and to provide guidance on the medication reconciliation process at discharge. Information to be shared with the Surgical Leadership Team on a quarterly basis. Number of surgeons who partner with a pharmacist on learning. Include the inpatient Child and Teen Program in the Number of units reporting medication monthly medication reconciliation data that is reported reconciliation at discharge. through the Business Intelligence Tool March 31, 2015 May 1, )Partner with the Cardiology Unit identifying opportunities for change. Pharmacy will review with the Cardiology team and Review complete and recommendations cardiologists the current process for medication implemented. reconciliation at discharge. The review will identify opportunities for improvement and a plan of action will be developed. March 31, 2015

7 4)Improve the medication reconciliation at discharge for being transferred to another facility. The current process for medication reconciliation will be reviewed by a core team including pharmacists, nurses and physicians. Recommendations will be developed and an implementation plan identified. Review, recommendations and implementation plan complete. December 31, 2014

2016/17 Quality Improvement Plan "Improvement Targets and Initiatives"

2016/17 Quality Improvement Plan "Improvement Targets and Initiatives" Queensway-Carleton Hospital 3045 Baseline Road AIM Measure Quality dimension Objective Measure/Indicator Unit / Population Source