DRAFT. Current performance Target. Target justification. process and. phone calls from hospital staff. # of patients who about what to do if

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Prudence Newman
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1 2017/18 Quality Improvement Plan "Improvement s and Initiatives" DRAFT Carleton Place and District Memorial Hospital 211 Lake Avenue East Effective Effective transitions Did you receive % / Survey CIHI CPES / April CB 5% above CB Evaluate the # of completed enough information respondents June 2016 (Q1 FY baseline process and phone calls from hospital staff 2016/17) effectiveness of the # of patients who about what to do if post discharge responded yes/no as you were worried phone calls to to whether they about your condition discharged received enough or treatment after inpatients and day information. you left the hospital? surgery patients. Review current tools and ensure there is are questions which align with indicator. Develop audit process. Review quarterly results at Patient Care Team and the Patient and Family Advisory Committee. Identify opportunities for imrpovement. updated Mar 16, 2017RdK for process 100% of patients discharged to home/retirement home from day surgery and the inpt unit will receive a post discharge phone call by March 31st, % of patients will respond positively to receiving enough information by March 31st, 2018

2 Effective transitions Risk adjusted 30 day Rate / CHF QBP CIHI DAD / Prov target Theoretical 1)Evaluation and # CHF order sets all cause readmission Cohort January 2015 best use of current CHF used/#charts rate for patients with December 2015 pre printed order audited # QBP CHF (QBP cohort) set to ensure standards omitted # alignment with clinicians who Provincial QBP. received education Ensure follow up # Patients requiring with patients Family physician follow up physician within 7 appointments within days of discharge. 7 days of discharge. Audit charts of patients admitted with a diagnosis of CHF to evaluate pre printed order set use. Develop evaluation tool to review CHF order set and QBP. Identify areas for and alignment with QBP. Revise order sets as required. Education on changes for clinicians Develop a process to ensure patient has an appointment with the family physician within 7 days of discharge. for process The CHF order set will be aligned with the Provincial CHF QBP by Dec 31st, % of clinicians who use the CHF order set will receive education on any changes by Feb 28th, % of patients discharged btw Oct Mar 31st, 2018 with CHF will have a follow up appointment with their family physician within 7 days.

3 Efficient Access to right level 25 Theoretical of care best 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 WTIS, CCO, BCS, MOHLTC / July September 2016 (Q2 FY 2016/17 report) Ensure all eligible patients are designated ALC appropriately. Review current state process for ALC designation. Review MOHLTC definitions for ALC. Connect with Cancer Care Ontario to ensure process aligns with definitions. Investigate other area hospitals and their processes. Identify areas of and incorporate into future state process. Provide education to physicians and nursing. # eligible patients designated ALC. %ALC rate for process 100% of eligible patients will be designated ALC appropriately by March 31st, Effectiveness Improve organizational financial health Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total %/n/a corporate (consolidated) expenses, excluding the impact of facility amortization in a given year. OHRS, MOH/Q3 FY Greater than or equal to 0% Hospital Service Accountabilit y Agreement (HSAA) requirement. Review of processes to look for opportunities for reduction of costs

4 Patient centred Palliative care Percent of palliative % / Palliative CIHI DAD / April Theoretical 1)Palliative patients care patients patients 2015 March best with Palliative discharged from 2016 Performance Scale hospital with the (PPS) score of 60% discharge status or less will receive "Home with referrals for Support". appropriate community supports 1) Referral to CCAC initiated in hospital for personal care and symptom management, as appropriate 2) Information provided to patient/family re: community services eg. Hub Hospice, friendly visitors 3) Develop and Implement post discharge phone calls for palliative patients 1) # patient with PPS score of 60% or less 2) # CCAC referrals for Patients discharged from hospital with DC status "Home with Support" 3) # completed post discharge phone calls for process By March 31st, 2018, 80% of palliative patients discharged home will receive a post discharge phone call and a CCAC referral for appropriate community supports.

5 Palliative care performance 2)Complete the development and implementation of The Goals for Care Framework with North Lanark Palliative Care Network (NLPCN) Advance Care Planning Work Group. (carried over from QIP) Seek feedback from Patient and Family Advisory Committee. Develop education plan for staff (including active physicians. Implement Goals of Care framework. Evaluate effectiveness. # staff and physicians (active) who received education # staff and physicians (active) who have completed evaluation tool. for process 80% of staff will receive education by Feb 28th, % of physicians (active) will receive education by Feb 28th, 2018.Hospital Goals of Care Framework will be implemented by March 31st, % of staff and physicians (active) will have completed an evaluation tool by May 31st, 2018.

6 for process Person experience "Would you % / Survey EDPEC / April 52% 60% Theoretical Implement the Educate leadership 1) # of staff 1) Patient recommend this respondents June 2016 (Q1 FY best AIDET group on AIDET (including satisfaction results emergency 2016/17) communication communication leadership) who for the question department to your framework in the framework, develop have received AIDET "Would you friends and family?" emergency education plan for staff, education by Dec recommend this department. implement tool, 31st, ) # of hospital for ED A=Acknowledge evaluate effectiveness staff (including services" will be I=Introduce of education and leadership) who maintained above D=Duration implementation. have successfully average for fiscal E=Explanation completed a post T=Thank You education test by 2) 90% of staff Feb 28, wpassed the post education test..

7 for process "Would you % / Survey CIHI CPES / April 85% Maintain Theoretical Implement the Educate leadership 1) # of staff 1) Patient recommend this respondents June 2016 (Q1 FY above best AIDET group on AIDET (including satisfaction results hospital to your 2016/17) benchmark communication communication leadership) who for the question friends and family?" framework in the framework, develop have received AIDET "Would you (Inpatient care) inpatine education plan for staff, education by Dec recommend this department. implement tool, 31st, ) # of hospital for ED A=Acknowledge evaluate effectiveness staff (including services" will be I=Introduce of education and leadership) who maintained above D=Duration implementation. have successfully average for fiscal E=Explanation completed a post T=Thank You education test by 2) 90% of staff will Feb 28, have passed the post education test..

8 Safe Medication safety Medication Rate per total Hospital collected Percentage of reconciliation at number of data / Most staff/physcians admission: The total admitted patients recent 3 month (active staff) number of patients / Hospital period educated/trained. with medications Admitted reconciled as a patients proportion of the total number of patients admitted to the hospital. 92% maintain 1) Investigate options for alignment and collaboration with other partners related to Medication Reconciliation on Admission (June 30, 2017). 2) Review and revise Medication Reconciliation P&P, incorporating changes required related Accreditation Canada Standards (Sept 30, 2017). 3) Roll out revised P&P and process (Education and training for all Nursing, Pharmacy and Medical Staff) accross all units (Dec 31, 2017) Review of current P&P and Accreditaiton Canada Standards. Revise P&P based on standards and opportunities for change. Distribute to stakeholders for review. Modify P&P based on stakeholder input. Review at Care Team/MAC approval. Develop and roll out education for all clinicians involved in the process. for process 80% of staff/physicians (active staff) educated/trained prior to implementation

9 Safe Medication safety Medication Rate per total Hospital collected CB 10% Percentage of data / Most improveme staff/physicians recent quarter nt over (active staff) available baseline educated/trained. 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. number of discharged patients / Discharged patients. 1) Investigate options for alignment and collaboration with other partners, particularly the local family physicians, related to Medication Reconciliation on discharge (June 30, 2017). 2) Review and revise Medication Reconciliation P&P, incorporating changes required related Accreditation Canada Standards (Sept 30, 2017). 3) Roll out revised P&P and process (Education and training for all Nursing, Pharmacy and Medical Staff) accross all units (Dec 31, 2017) Review of current P&P and Accreditation Canada Standards. Revise P&P based on standards and opportunities for change. Distribute to stakeholders for review. Modify P&P based on stakeholder input. Review at Care Team/MAC approval. Develop and roll out education of all clinicians involved in the process. for process 80% of staff/physicians (active staff) educated/trained prior to implementation

10 Timely Timely access to care/services 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 CIHI NACRS / January 2016 December 2016 performance Maintain for process Focus for this year is on the patient experince indicator for ED Delirium Evaluate compliance % / All inpatients Health records / of Delirium Screening Tool(CAM)completio n and implementation of associated interventions (for CAM positive) for patients age 70 years and older on the inpt unit. CAM (Confusion Assessment Method) CB CB Theoretical best 1)Ensure completion of CAM tool and associated interventions for patients age 70 years and older on the med/surg unite unit. (Supports Senior Friendly Hospital Plan to reduce delirium incidence) Develop a chart audit tool aligning with the EMR documentation screens in Meditech. Complete chart audits Review results, identify gaps and identify areas of Develop and action plan for any opportunities to ensure successful CAM completion and implementation of associated interventions # chart audits completed # initiatives identified 100% of charts of patients age 70 years and older on the med/surg unit will be audited for completion of the CAM tool and associated interventions by Feb 28th, Senior Friendly Hospital Plan

11 Reduce functional % / All inpatients EMR/Chart CB CB Theoretical # patients who decline amongst Review / best received the seniors in hospital brochure Functional Decline Implement and ensure all patients on the med/surg unit, who are 65 years of age or older, receive a copy of the "Keep your Mind and Body Active" brochure. (Supports Senior Friendly Hospital Plan to reduce functional decline) Contact Trillium Health for permission to use the brochure. Develop a process for distribution to eligible patients. Review brochure and process with Patient and Family Advisory Committee. Education to staff. for process 100% of patients on the med/surg unit, aged 65 yrs or older, will have received a copy of the "Keep your mind and body active" brochure by Mar 31st, 2018.

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

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