Quality Improvement Plan Narrative

Transcription

1 Quality Improvement Plan Narrative 12/18/2017

2 Overview is pleased to share its eighth annual Quality Improvement Plan (QIP). This plan describes the hospital s key priorities for quality improvement. Sunnybrook s four quality strategic goals that guided the selection of the QIP priorities are: 1. Improve the patient experience and outcomes through inter-professional, high quality care. 2. Focus on the highest levels of specialized care as an Academic Health Sciences Centre. 3. Work with system partners and government to build an integrated delivery system in support of our communities and our Academic Health Sciences Centre definition. 4. Achieve excellence in clinical care associated with our strategic priorities. The other key framework that informed our QIP is the hospital s inaugural hospital-wide Quality Strategic Plan. To learn more, please visit our website Sunnybrook is continuously leading and/or engaged in multiple activities that improve the quality of our services. The following are just a few areas of focus: Patient engagement remains a key area of emphasis. We have created an external website to support patients who want to work with us to improve our practices. We have also created an internal website to guide staff about how to meaningfully engage patients. Each of our twelve QIPs will engage patients and families in their implementation and/or evaluation. Another focus at Sunnybrook is to promote compassionate care which we measure in a number of ways, including patient surveys. New initiatives include guiding staff on how they can integrate compassion into daily care and a new team compassion award. Sunnybrook is pioneering the implementation of a robust hand hygiene measurement system to reduce patient and staff infections as part of a multi-centre initiative with four other Ontario hospitals (Michael Garron Hospital, Sinai Health System, Lakeridge Health and St. Michael s Hospital). This new system uses built-in motion-activated censors to improve measurement. Key Quality Improvements made in 2017/18 On the 2017/18 Quality Improvement Plan, we included work to reduce urinary tract infections associated with catheter use. We have reached our target earlier than expected. Changes that contributed to this success include: o Infection Prevention & Control staff collaborating with Laboratory staff to change a microbiology practice to avoid over-diagnosis of urinary tract infections. o Inpatient and Emergency Department staff adopting new and sustaining existing initiatives to reduce unnecessary use of urinary catheters. o After surgery, removing urinary catheters earlier and sharing new patient education materials. In order to ensure our patients primary care providers in the community receive discharge summaries from our physicians in a timely fashion, we began providing performance data more regularly. We have reached our target and will continue to monitor this closely in 2018/19. Sunnybrook needed to improve the time it takes us to transfer patients arriving via ambulance into our Emergency Department. An interprofessional team is now adjusting processes and we have already seen an improvement from the 90 minutes it took us in 2017 to move 90% of patients into our care down to 71 minutes in January 2018.

3 Engaging Patients and Residents in Quality Improvement Sunnybrook actively creates a culture of patient, resident and family engagement to support the delivery of safe, quality and person-centred care. Patients and family partners are actively engaged in improvement of care processes through their roles in Patient and Family Advisory Committees. Sunnybrook has also implemented a Person-Centred Care approach across the organization that actively supports patients and families as equal partners in their care. We recently consulted with patients, families and staff to create a Person-Centred Care Action Plan for Patient Relations The Office of the Patient Experience works in partnership with patients, residents and families to resolve any concerns they may have with their experience at Sunnybrook. Through the complaint resolution process, quality improvement opportunities are often uncovered. While we might not be able to change a poor patient experience from the past, we can reassure our patients and families that we have taken the necessary steps to prevent the same experience from happening in the future. Collaboration and Integration Sunnybrook has collaborated with Markham-Stouffville Hospital to create a shared QIP to improve repatriation making it safer, more timely, and a better experience for patients and families. This will include improving hand-over processes between care teams and improving communication with patients and families. Sunnybrook has also partnered in less formal ways with hospitals, family physicians, the Toronto Central Local Health Integration Network (LHIN), Toronto Paramedic Services in other QIPs such as Hand Hygiene, Quality of Discharge Summaries, Alternate Level of Care, and Emergency Department Length of Stay. Engagement of Clinicians, Leadership & Staff Sunnybrook has numerous strategies for engaging clinicians, leadership and staff in quality improvement planning and implementation activities. Sunnybrook has developed its own in-house Quality & Patient Safety program (the ilead Program ). The Program is made up of a repository of data from across the organization, numerous courses, stand-alone tools as well as coaching and support for staff at all levels. The focus in 2017 was on providing more current and local data thereby enabling staff to have more meaningful dialogue to drive targeted improvements. Clinical staff hold regular and structured Quality Conversations. At these Quality Conversations, the interdisciplinary team comes together to review data, share progress and generate ideas on local improvements every week. Family members and/or patients are welcome to participate if they wish. Sunnybrook also has several ways in which staff and informal and formal leaders can contribute to quality improvement, including our Nursing Council, Health Professions Leaders, and the Practicebased Research and Innovation program.

4 Population Health and Equity Considerations Health equity at Sunnybrook is about ensuring that we provide the highest quality care and create the best possible experience for our diverse patient populations and their families. In 2017, the hospital established a new role dedicated to identifying barriers to access and care, and to putting strategies in place to address them. In 2018 we will launch a three-year strategic plan, building on the many mechanisms currently supporting equity at Sunnybrook such as our Diversity statement and principles, Accessibility policy, mandatory diversity training for managers and discrimination training for all staff. A specific example of how we are increasing equity in our QIP is our plan to co-design with patients, a package of care at our Accessible Care Pregnancy clinic. This clinic is the first of its kind in North America focussed on pregnancy and birth care plans for pregnant women with physical disabilities. Access to the Right Level of Care - Addressing Alternate Level of Care For many Sunnybrook patients, after they have finished their acute hospital care, they require additional care provided by another organization (called Alternate level of Care or ALC ). Our Alternate Level of Care QIP includes plans to improve internal processes to increase consistency in how we support patients to make the best choices for their next level of care. In addition, we collaborated with SPRINT (Senior Peoples' Resources in North Toronto) Senior Care, LOFT Community Services and the Toronto Central Local Health Integration Network (LHIN) resulting in the opening of a 69-bed facility, Pine Villa. This new innovative partnership leverages the expertise of each organization to provide high quality transitional care. Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder Sunnybrook strives to provide patients with an interdisciplinary approach to pain management that considers best practices, patient preferences, and novel research in this area. Opioid medications often have a role to play in pain management, but the recognized potential for misuse and dependence require that this class of medications are prescribed and monitored appropriately. Sunnybrook is dedicated to decreasing these risks through care provider education and appropriate prescribing to prevent adverse outcomes, in addition to screening for misuse and providing treatment for addiction when it does occur. In addition, Sunnybrook has initiated a collaborative research and clinical program with other hospitals in the Toronto Central Local Health Integration Network to address the addictive potential of opioids by providing safer alternatives to patients. Workplace Violence Prevention Sunnybrook has a comprehensive approach to violence prevention for staff and patients that has been shared with many other organizations as a leading practice. Key program components include: Harassment, Discrimination and Violence policy Respect policy and Diversity statement and principles Harassment and Discrimination, Violence Prevention and Code White training Violence Prevention Oversight Committee Our QIP 2018/19 for Violence Prevention continues our focus on reducing the number of incidents as well as decreasing the level of severity of these incidents by applying many measures.

5 Performance Based Compensation For many years, Sunnybrook has had an at-risk component to its executive compensation for the CEO and Senior Leadership Team. A percentage of the executive s compensation (21-30%) is based on the achievement of annual goals and objectives that are aligned to the organization s strategic goals and to the person s portfolio. Sunnybrook s Executive Performance Management Program is well established, comprehensive and governed by the Performance and Compensation Committee of the Board of Directors. The Program includes both a 360 o performance evaluation (built on the foundation of leadership competencies) and specific performance goals that are used to drive quality and organizational improvement. For April 1, 2018 March 31, 2019, five QIP objectives will be linked to executive performance and compensation. (Please see table below) Sign-off I have reviewed and approved our organization s Quality Improvement Plan Board Chair (signature) Quality Committee Chair (signature) Chief Executive Officer (signature) All cover photos are taken from except the top right photo which is from and can also be found in context here:

6 Appendix: Performance Based Compensation MEASURE (from Hand Hygiene plan) Rate of hand hygiene performance (hand hygiene events divided 47.9% Q1 17/18 average across five 60% in at least one of the five pilot units in any by hand hygiene opportunities measured via e-monitoring). pilot medical/ surgical units. three months of Target Achieved: 60.0% in at least 60.0% in at least one of 60.0% in at least one of Not applicable Performance is < 60% in all units one of the five pilot units in any three the five pilot units in any two the five pilot units in one in all months of 2018/19. months of months of month in MEASURE (from Alternate Level of Care plan) Average number of rehabilitation referrals per patient measured as an average over any three consecutive (Source: Resource Matching & referral system data extract) * (Q ) months in 2018/19 * Target Achieved (Performance is 2.10 Performance is 2.07 and Performance is 2.04 and Performance is > Performance is 2.00 (i.e. no measured as an average over any three < < and < improvement or worsening consecutive months in 2018/19) performance). * Note: Referrals where there are limited rehabilitation destinations and/or where there are specialized needs related to flow or clinical care have been removed. These include the following referral types: Burn, Spinal Cord, Amputee, Cardiac, Respiratory and Wound. MEASURE (from Violence Prevention Plan) Indicator Current Performance Target for 2018 The total number of Patient Safety Care Plans developed and 35% (Jan Dec 2017) 80% in 2018 implemented as a proportion of the total number of Patient Safety Care 1 13 Patient Safety Care Plans implemented Plans required* Cases that met criteria (> 3 incidents) *Notes: Patient Safety Care Plans are required in cases when there are 1 Patient Safety Care Plans are a new tool, first implemented fall incidents/inpatient. Incidents are defined as reports tracked by 2 37 cases is an annualized projection for 2017 based on three quarters Occupational Health and Safety of active physical violence, or a threat of of data (began collecting data April 1, 2017) active physical violence, by a current inpatient. Target Achieved: Performance is 65% Performance is 50% Performance is > 35% Performance is 35% (i.e. no improvement or 80% and < 80%. and < 65%. and < 50%. worsening performance).

7 MEASURE (from Total Margin plan) Total Margin (consolidated): Percent, by which total corporate (consolidated) revenues exceed or fall short of 2.48% 0% total corporate (consolidated) expenses, excluding the impact of facility amortization, in a given year. Target Achieved (Total margin is 0%) or would have been achieved, adjusting for circumstances beyond management control. after NA NA NA Total margin is below 0% MEASURE (from Accessible Care Pregnancy Clinic plan) 1 Develop Package of Care for Accessible Care Pregnancy Clinic. Package of Care is under consideration 1 This Package of Care will should receive prenatally. specify key best practices that a pregnant woman with a physical disability Package of Care developed by March 31, 2019 Package of Care developed by March 31, 2019 NA NA NA Package of Care is not developed by March 31, 2019 NA = Not applicable