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

Transcription

1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/21/2018 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein. Insert Organization Name 1

2 Overview Muskoka Algonquin Healthcare (MAHC) proudly serves the community of Muskoka by providing safe, quality, patient and family centered care at two sites located in Bracebridge and Huntsville. MAHC is a rural teaching hospital and is affiliated with several academic institutions, including the Northern Ontario School of Medicine (NOSM), York University, and Georgian College. We are committed to best practices and delivering the highest quality of care ensuring optimal patient outcomes through an integrated approach to safe, quality patient care with all of our partners. To assist us in fulfilling this commitment, MAHC adopted an iteration of the Health Quality Ontario (HQO) definition of a high quality health system as the definition for Quality at MAHC. The iteration that has been approved by our Quality Committee and the Board of Directors is directly aligned with the definition that the NSM LHIN has adopted. Our Quality Improvement Plan (QIP) reflects the third year that MAHC, the North Simcoe Muskoka Home and Community Care, Muskoka Health Links, the Cottage Country Family Health Team, the Algonquin Family Health Team, and Community Mental Health have worked collaboratively to improve the quality of care for the people of Muskoka and have some shared QIP initiatives. As a collaborative, we are working to improve safe, integrated, effective, patient centered access to care throughout the entire continuum of health care. Our 2018/19 Quality Improvement Plan (QIP) is designed to leverage the forward momentum of our overarching quality and safety culture by ensuring that our environment becomes even safer for our patients, by elevating best patient outcomes through cost effective strategies, by being proactive in anticipating and responding to patient needs, and by improving care transitions from our hospital to the community in collaboration with our partners. Our ongoing quality improvement journey has been informed by our patients and their families, our staff, physicians, Board of Directors, and health care partners. Our collaborative work in the development of our QIP helps to ensure that our patients receive the right care, in the right place, at the right time. Each selected QIP objective, and its associated improvement indicator, is supported by several underlying initiatives to improve quality of care for the Muskoka community. By working together with our partners, we continue to strive toward significantly enhancing care through the following focused strategies: (i) Readmission within 30 days: For patients who are readmitted to hospital within 30 days of discharge, we know that it is challenging for them, their families, and the health system. Readmission, if avoidable, leads to health system waste. We are working closely with our HCC (Home and Community Care) and Family Health Team colleagues to reduce all preventable hospital readmissions but more specifically focusing on patients who have congestive heart failure, chronic obstructive pulmonary disease, and stroke. (ii) Access to the right level of care: With the support of our partners, we are committed to ensuring that patients who no longer require the services of our hospital are discharged in a timely manner. Through very strong partnerships with HCC, long term care facilities, retirement homes, and other community partners, MAHC has made significant improvements in the amount of time that patients wait for discharge/transfer to alternate level of care. Despite the improvements over the course of this past year, performance is Insert Organization Name 2

3 not yet at the target set by the Ministry of Health and Long Term Care and thus remaining as one of our Quality Improvement Plan areas of focus. (iii) Improve the patient experience: MAHC is committed to working with our patients and their families to improve the hospital experience. We are actively creating a culture that will ensure that practices consistently deliver exemplary patient experiences by continuing to spread our service excellence program, and, by spreading our patient and family centered care philosophy. (iv) Medication reconciliation: When admitting patients to hospital, it is extremely important to ensure that an accurate medication history is captured and then matched against hospital admission orders. This ensures that treatment quality and efficacy is maximized. And, medication reconciliation at discharge is an important way to enable safe, seamless care for our patients who are leaving the hospital. (v) Workplace Violence: MAHC is committed to ensuring a safe workplace for all physicians, staff, patients and volunteers. Data collection has begun on reported workplace violence incidents (as defined by the Occupational Health and Safety Act), and this data will be further analyzed to determine current baseline rates and to identify measures to be implemented to reduce the number of incidents reported. Two improvement initiatives will be identified, and an improvement plan implemented in April Associated with all of the QIP objectives above are targeted change ideas that will drive and achieve improvements within the quality dimensions of effective, efficient, patient centered, safe, and timely. These change ideas range from unit level engagement of staff, to quality board huddles, to system wide strategies such as Health Links and Home First that have been collaboratively developed with all of our community partners. The MAHC culture supports and encourages high quality integrated care in each and every patient-family/provider interaction. We believe that together we can build healthy communities that are aligned with regional and provincial priorities. Describe your organization's greatest QI achievements from the past year Last year the NSM Home and Community Care, Cottage Country Family Health Team, Algonquin Family Health Team, Muskoka Health Links, Community Mental Health, and MAHC partnered on a few improvement opportunities with the goal of enhancing the quality, safety, and access to care through shared accountability. Together, we achieved success in key areas and are proud of our second year of accomplishments with a collaborative approach to quality improvement in Muskoka. By working together with our partners, we met with success by: Enhancing the support to our complex patients through hospital-community based initiatives like Health Links and Tele homecare (connecting patients with care through technology). Innovatively and proactively breaking down barriers through an acceptance of all hospital referrals to the Cottage Country Family Health Team COPD rehabilitation clinic regardless of whether the patient is attached to a family health team physician or not. Educating staff and physicians on strategies that support care transitions of the elderly with complex behaviors. Maintaining the successful integration of Home and Community Care employees on site at MAHC in the role of Care Coordinators who assist in a timely and seamless discharge plan for patients requiring additional support in the community. Insert Organization Name 3

4 In January 2017, MAHC held its inaugural Patient and Family Advisory Council meeting with a total of 10 patient and family advisors who represent the diverse regions in Muskoka and all demographic ranges. This new committee will enhance MAHC s focus on providing safe, quality care that meets the expectations of our community. Resident, Patient, Client Engagement and relations MAHC has been very purposeful in elevating the patient voice in MAHC launched its Patient and Family Advisory Council (PFAC) which has enabled transcendence of the patient voice with MAHC initiatives. MAHC recruited 10 patient and family advisors who represent all regions of Muskoka. The Advisory Council has reviewed the QIP on two occasions for input. MAHC has incorporated advisors into 2 corporate committees outside of the PFAC, and on the capital planning task force. The vision is to incorporate advisors onto at least 3 other clinical committees in the year ahead. Collaboration and Integration MAHC actively seeks strategic partnerships to fully realize the potential of integrated care as demonstrated throughout this document. By working closely and collaboratively with our partners, we are creating new opportunities through a shared understanding to improve quality, safety, and access to care in the Muskoka region. We also work extensively with partners within the broader North Simcoe Muskoka Local Health Integrate Network (NSM LHIN) to successfully implement an integrated health system plan through the Second Curve forum. These strategic partnerships have created an interconnected system that promotes shared care models optimizing patient transitions through better information management and information sharing. These interconnected partnerships enhance quality and improve safety for our patients and their families by simplifying the system and designing services that maximize efficiencies. For instance, we are achieving smoother transitions between points of care through integrations such as: Muskoka Health Links: This is a Ministry of Health and Long-Term Care initiative in partnership with the NSM LHIN and the District of Muskoka. Muskoka Health Links brings our partner organizations together to coordinate care for patients with complex needs through the creation of joint personalized care plans. Care Coordinators: This is an integrated Home and Community Care role within MAHC that streamlines the discharge process and transition arrangements for patients who require support following discharge. Tele homecare: This is a great initiative using technology to enhance health care access and support for patients living with congestive heart failure and chronic obstructive pulmonary disease. Regional Planning: MAHC collaborated with the sub region initiative entitled MAHST that was initiated to redesign the Muskoka local health care system. Recommendations were provided to the North Simcoe Muskoka Local Health Integration Network (NSMLHIN). The group continues to meet to explore opportunities to support effective, equitable, and seamless care in the region. Seniors Assessment and Support Outreach Team (SASOT): SASOT works collaboratively with other community partners such as family health teams, nurse practitioner clinics and Home and Community Care Services to ensure patients receive a seamless, integrated service. SASOT assesses and provides outreach support to people aged 65 and older who live in South Muskoka by assessing senior s health and day-to-day function and by linking and referring seniors to appropriate services where available. Through their outreach work, SASOT is reducing emergency department visits and helping seniors to avoid an unnecessary admission to the hospital. alternate level of care (ALC) patients in hospital. Engagement of Clinicians, Leadership & Staff They also work to support the discharge of complex Insert Organization Name 4

5 Engagement of clinical staff and leadership in the development of the MAHC QIP has been broad. Board members, the Senior Leadership Team, front-line managers, front-line clinicians and physician representatives have all collaborated in the development of our QIP. MAHC employees in all departments are involved in quality improvement initiative methodologies such as LEAN, KAIZAN that continuously enhance the quality of care to our patients. As well, all employees are strongly encouraged to identify and implement quality improvement strategies throughout the year. MAHC also led the development of a collaborative QIP with external partners as identified previously. Leadership and front-line staff participate in daily huddles around quality boards to identify current safety issues and to discuss urgent and/or emerging issues. our Senior Leadership Team and clinical leaders, round on both patients and staff creating a visible presence to patients and staff, providing an opportunity to compliment and recognize staff on excellent work and address concerns. Population Health and Equity Considerations Muskoka is an aging sub region within the NSM LHIN, and, is a vacation community. The graphs below depict population by area municipality both from a permanent resident group and from a seasonal population perspective. Over the next twenty years, both permanent and seasonal resident groups will increase slightly. (Image #1 Here) Table Source: MAHST Programs and Services Working Group February 2017 (Image #2 Here) Source: p. (iv): %20Phase%202%20Report%20January% pdf?handle=A704E03AFBB947E58D8DEA825609CB0C The plot below depicts the age-adjusted disease prevalence per 1,000 residents. Disease prevalence for the Muskoka sub region residents is lower than the NSM LHIN average but higher than the Ontario average, with the exception of diabetes. Disease prevalence in the plot below is estimated using hospital diagnosis and, as such, requires people to have had contact with the hospital system. (Image #3 Here) Source: DAD/NACRS 2012/15, Ministry of Finance Population, PSG April 2014 In Muskoka, the social determinants of health are a significant factor that affect whether our patients are able to reach their full health potential. In order to further the goal of health equity, MAHC has partnered with key community initiatives designed to make safe, quality care accessible to all patients. MAHC is an active partner in the Muskoka Health Links work related to coordinated care plans for complex patients including effective transitions to home. This important initiative has provided a coordinated approach to care in the community ensuring that patients and families receive patient-focused support after hospital discharge. As a result of this work, and in conjunction with other best practice initiatives, MAHC has seen a significant decline in 30 day readmissions. MAHC is also partnering with the Muskoka and Area Health System Transformation (MAHST). MAHST is a project supported by the North Simcoe Muskoka LHIN and has a goal of redesigning the local health care system. The project is community-led with a focus on health care equity and effectiveness including seamless transitions. Insert Organization Name 5

6 MAHC is intentionally enhancing initiatives that reinforce a Senior Friendly Hospitals focus. Strategic education to key stakeholders related to screening and care for the patient with identified delirium is underway. Behavioural Support Agents have been specially trained in the complexities of both temporary and permanent behavioural changes associated with aging. At both MAHC sites the Agents work with families, staff, and physicians when patient complexity rises related to delirium and/or dementia. MAHC offers a Spiritual Care program that works with all faith groups to ensure spirituality and/or faith traditions are respected. Services offered include: emotional and spiritual support to patients, families and staff; prayer, meditation or spiritual rituals according to patients' beliefs; spiritual assessment; debriefing, memorial services; and connection to local faith leaders. Insert Organization Name 6

7 Access to the Right Level of Care - Addressing ALC With the support of our partners, we are committed to ensuring that patients who no longer require the services of our hospital are discharged in a timely and appropriate manner. Through very strong partnerships with Home and Community Care, the District of Muskoka, long term care facilities, retirement homes, and other community partners, MAHC is focused on improvements in the amount of time that patients wait for discharge/transfer to alternate level of care. Muskoka witnessed a drastic decline in PSW availability since the early part of this fiscal year. This has resulted in some challenges in meeting our Home First philosophy and reducing our ALC rate. Muskoka has received funding for 12 supportive housing units designed to decant appropriate ALC patients from acute care. It is anticipated that these beds will open in December Over the course of the next year, we will continue to implement strategies to reduce the number of ALC patients in all beds (both acute and post-acute). Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder In Ontario (2015) 734 people died related to opioid overdoses. In the Simcoe- Muskoka region there were 43 opioid related deaths. Of note, the rates of visits to the emergency department for opioid overdoses in Simcoe-Muskoka are significantly higher than the provincial rate. Muskoka Algonquin Healthcare has been collaborating with community partners, including health care providers, provincial corrections staff, law enforcement and mental health providers to identify ways in which we can identify local data to assist us in implementing quality standards (currently in draft form from HQO). This process is ongoing, and it is the expectation that the collaborative group will have recommendations early in In the coming year, we will be reviewing our local data, developing quality initiatives to ensure our population is being appropriately screened and counselled when they present to our emergency department and assessing improvement noted. Workplace Violence Prevention Muskoka Algonquin Healthcare has Policies and Procedures with respect to reducing the risk of violence, reporting of workplace violence, and for summoning immediate assistance in the event there is violence occurring in the workplace. In order to Insert Organization Name 7

8 test our policies we conduct Mock Code Whites (Workplace Violence Code). To support our staff when there are incidents of violence in the workplace formal debriefs are conducted as needed. From a training perspective we currently provide a training program to deescalate confrontational and violent situations. We have recently switched our training program from Non-violent Crisis Intervention (NVCI) to the MANDT training program and it is mandatory for all staff at MAHC to attend. To support the policies & procedures, training and support within MAHC, there is infrastructure in place to help keep people safe. This includes: The ability to summon support and assistance with the use of panic buttons in the Emergency Department and switchboard Safe rooms with cameras for monitoring patients Signage that outlines our expectations of respectful behavior towards staff and appropriate conduct while in our hospital. Overall, the security guard presence at MAHC has been increased to include additional hours of coverage across the organization at our two sites to support peak times of aggression and violent behavior that may sometimes occur. To support the care of our patients and ensure the safety of our staff a Mental Health Working Group was established and recommendations for change were made. The working group became an implementation committee that worked toward the implementation of the recommendations, which have included: Purchase of pineal restraints and safety pajamas Implementing order sets for mental health patients in the emergency department Focus on shortening time to see physician in ED for mental health patients Collaborate with Canadian Mental Health Association (CMHA) to provide onsite support. Working closely with neighbouring schedule one facilities to ensure standardized approaches to care to support transitions Developing a proposal to create additional safe rooms to care for mental health patients. The Joint Occupational Health and Safety Committee and the Emergency Services Committee continue to monitor the implementation of the recommendations and develop strategies to further enhance workplace safety. The overall safety and security of our people at MAHC is of great importance and is on a path of consistent quality improvement as we learn from both violent incidents and near misses. Performance Based Compensation The Ontario government passed the Excellent Care for All Act (ECFAA) and Bill 16 in 2010 which required Hospital Boards to establish an at risk component of executive compensation and achieve targets tied to the QIP. At MAHC, each senior leader develops goals that create synergy with the Strategic Plan and the QIP and that align with responsibilities within their portfolio and in accordance with our Executive Compensation Policy. Executive compensation is linked to performance in three performance assessment categories: Quality, Financial, and Strategic. Performance assessment categories are rated on the following scale: Quality = 50% Financial = 30% Strategic = 20% Each year, all executives at MAHC have 3% of their compensation at risk. This portion of the compensation is held and measured against achievement of goals and objectives. Contact Information Insert Organization Name 8

9 Esther Millar Chief Nursing Executive and Clinical Services Natalie Bubela Chief Executive Officer Evelyn Brown Board Chair Phil Matthews Chair, Quality & Patient Safety Committee Other Sign-off It is recommended that the following individuals review and sign-off on your organization s Quality Improvement Plan (where applicable): I have reviewed and approved our organization s Quality Improvement Plan Board Chair Evelyn Brown (signature) Quality Committee Chair Phillip Matthews (signature) Chief Executive Officer Natalie Bubela (signature) Other leadership as appropriate Esther Millar (signature) Insert Organization Name 9

10 2018/19 Quality Improvement Plan "Improvement Targets and Initiatives" Muskoka Algonquin Healthcare 100 Frank Miller Drive AIM Measure Change Quality dimension Issue Measure/Indicator Type Unit / Population Source / Period Organization Id Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Process measures M = Mandatory (all cells must be completed) P = Priority (complete ONLY the comments cell if you are not working on this indicator) A= Additional (do not select from drop down menu if you are not working on this indicator) C = custom (add any other indicators you are working on) Effective Effective transitions Risk adjusted 30 day P all cause readmission rate for patients with stroke (QBP cohort) Rate / Stroke QBP Cohort CIHI DAD / January December * Maintain target from 2017/18 as unable to fully implement data collection. 1)Review and analyze readmission data for previous 2 fiscal years. 2)Ensure Stroke Order Set is utilized. Retrospective review of readmission data for 2016/17 and 2017/18 to discern trends and identify areas for improvement. Identify readmission rates for 2016/17 and 2017/18 by April 30, Target for process measure 30 day all cause readmission will be at or below 14.0% Quarterly chart audits to identify order set compliance. Stroke Order set compliance will be 100%. 30 day all cause readmission will be at or below 14.0% Comments 3)Ensure Stroke Care Pathway is utilized. Quarterly chart audits to identify care pathway compliance. Care Pathway Compliance will be 100%. 30 day all cause readmission will be at or below 14.0% 4)Identify number of patients referred to Stroke Clinic. 1. Stroke Clinic patient attendance. 2. Review of data 100% of stroke patients will be provided with and compliance by family practice committee. 3. Stroke information regarding the Stroke Clinic. readmission review with community partners as per collaborative QIP. 30 day all cause readmission will be at or below 14.0% Efficient Access to right level of care Total number of P 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 * This indicator is complex for MAHC and requires system improvements with multiple LHIN stakeholders; requires policy adjustment by the LHIN and MOHLTC. 1)Continue to collaborate with HCC (Home and Community Care) on Home First Initiative. 2)Continue to monitor implementation of ALC Designation Policy to identify areas for improvement. 3)Continue daily bed rounds with a focus on identifying at risk for ALC patients and to ensure appropriate referrals are started, as appropriate, by day 3 of admission. Continue weekly collaborative ALC rounds with all stakeholders. Meet with patients/families of at risk for ALC patients on day 2 of admission to review options and create plan. In patient managers to provide education refresh on ALC policy to ensure compliance and to identify areas for improvement. 100% compliance with ALC rounds. Decrease ALC days to 16%. 100% of at risk of ALC patients have plan documented on chart by day 2 of admission. All nursing staff participate in education and are aware of the ALC policy. Decrease ALC days to 16%. 100% of nursing staff participate in education and review of ALC policy. 4)Continue to advocate for additional LTC options and HCC support for Muskoka. Continued collaboration with NSM LHIN and community care partners to identify options for additional LTC and HCC support. Continue with weekly ALC rounds and monitoring of ALC days monthly. Target to reduce ALC days to 16%. Patient centred Person experience "Would you recommend this emergency department to your friends and family?" P % / Survey respondents EDPEC / April 968* June 2017 (Q1 FY 2017/18) Patient and family experiences in the ED are key indicators to 1)Audit NRCC survey data to identify trends quarterly. Provide results from NRCC quarterly and provide to area managers and ED Committee quarterly. Purposeful rounding by 80% of the nurses of random audit dates. 80% of all nurses are performing rounding by March 31, 2019.

11 y identifying successes and 2)Engage ED Committee and PFAC (Patient and 1. Engage ED Committee on patient and family feedback resulting in change ideas and a work plan opportunities for Family Advisory Committee) from quarterly review of data. 2. Implement 4 change improvement through NRCC survey data. on patient and family feedback, resulting in change ideas and a work plan from quarterly review of data. ideas from the work plan by end of March We will identify 4 areas for improvement by the end of March 2019 and will continue to monitor NRC patient satisfaction survey results quarterly. Patient satisfaction, as measured by "Would you Recommend" will be 74.4% by March Safe Safe care/medication safety Medication P 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. C Compliance Before and After Patient Contact: The number of times that hand hygiene was performed before initial patient contact and following patient contact divided by the number of observed hand hygiene indications for before initial contact multiplied by 100. Rate per total number of discharged patients / Discharged patients % / Health providers in the entire facility Hospital collected data / October December (Q3) 2017 Hospital collected data / April 1, 2018 to March 31, * Unable to effectively track medication reconciliation at discharge. 968* Target is 91.4% before patient contact and 93.2% after patient contact. This is a key patient safety indicator to prevent acquisition of hospital acquired infections. 3)implement purposeful rounding by nurses in the ED. 4)Continue to monitor and improve flow through the ED with the Distribution Policy. 1)All patients being discharged will have a complete medication reconciliation completed and communicated at that time. 1)Continue to perform 150 hand hygiene observations per site per month. 2)Mandatory education module to be completed by all staff, physicians and volunteers by March 31, Audit 80% ED nurse compliance with purposeful rounding implementation by the end of March Monitor time from ED orders written to time patient transferred to in patient bed. Purposeful rounding by 80% of the nurses on random audit dates. Quarterly reports to be reviewed by ED Committee to discuss trends and identify areas for improvement. 1. Ensure that every discharged patient will have their 1. PharmNet module implemented. 2. Education of medication reconciled upon discharge. To be monitored 100% of physicians, nursing and pharmacy staff on through chart audits and CERNER reports. 2. PharmNet medication reconciliation at discharge process and module implemented and MAHC pilot by April 1, respective roles. 3. Discharged patients will have a 3. Monthly Medication Reconciliation Working Group medication reconciliation completed and meetings to monitor implementation of project plan, communicated at discharge. data and recommend process changes. 4. Physician, nursing and pharmacy education as per project plan by April 30, IPAC Team and Champions to perform 150 hand hygiene audits per site per month. All staff, physicians and volunteers will be notified to complete the LMS (Learning Management System) education module by March 31, Ongoing monthly reporting of compliance rates to all staff, physicians and volunteers. 90% of all staff, physicians and volunteers will successfully complete the education module. 80% of all nurses are performing purposeful rounding by March 31, Identify baseline time and explore barriers to timely transfer within 30 minutes. PharmNet module implemented. compliance Before Indication 91.4%; compliance After Indication 93.2% compliance Before Indication 91.4%; compliance After Indication 93.2% 3)Refresh Working Group. Reconvene Working Group as department leadership has changed, to identify additional areas for improvement. Working Group to continue to review compliance rates and identify ongoing areas for improvement. compliance Before indication 91.4%; compliance After indication 93.2%. 4)Continue to provide Monthly, quarterly reports to be circulated by the 15th monthly results by site, unit of each month for posting on every unit's Quality Board. and quarterly by provider. Ongoing monthly reporting of compliance rates to all staff, physicians and volunteers. compliance Before indication 91.4%; compliance After indication 93.2%

12 Medication reconciliation at admission: The total number of patients with medication reconciled as a proportion of the total number of patients admitted to the hospital. C Rate per total number of admitted patients / Hospital admitted patients Hospital collected data / October to December (Q3) 2017/18 968* Increase the percentage of patients receiving medication reconciliation at 1)Streamline Medication Reconciliation process and documentation to improve efficiency and accuracy of BPMH (Best Possible Medication History). admission by 2.0%. This is a key indicator to improve patient safety, which has recently been attained. Important to continue focus for an additional year. 1. Re education on the medication reconciliation process to improve quality of BPMH by June Pull data to determine the number of medication reconciliation on admission completed within 24 hours and 48 hours. 3. Review process to determine methods to increase the number of medication reconciliation on admission completed within 24 hours, particularly for high risk patients. MAC (Medical Advisory Committee) to identify high risk patient group. 4. Identify all patients not receiving medication reconciliation on admission or receiving it beyond 48 hours. Review chart to identify reasons. Medication Reconciliation Working Group to discuss potential process changes. 1. On a quarterly basis, measure the number of medication reconciliation completed upon admission as documented in the CERNER system. Pull data for 24 and 48 hours as well. 2. Committee minutes identify reasons for medication reconciliation on admission not being completed and reasons underlying medication reconciliation on admission not being completed within 48 hours. 3. MAC to identify high risk patient group. Process review to be completed by July 1, Develop process to identify missed patients by October 1, Quarterly reports completed and discussed at Pharmacy & Therapeutics Committee. By streamlining the medication reconciliation process and improving accuracy and efficiency, the time to complete a medication reconciliation will be decreased, allowing us more time to complete a larger proportion of medication reconciliation and improve patient safety through reduced number of medication errors. Workplace Violence Number of workplace violence incidents reported by hospital workers (as by defined by OHSA) within a 12 month period. M A N D A T O R Y Count / Worker Local data collection / January December * CB CB We will be collecting baseline data in 2018/19 to ascertain rates and identify areas for improvement. 1)Collect and analyze data from incident reports to identify trends and highlight areas for improvement, utilizing the OHA "Preventing Workplace Violence in the Healthcare Sector" toolkit. 1. Review all incident reports, which contain data regarding "the exercise of physical force by 1. Two improvement initiatives identified to reduce workplace violence. 2. Implementation One (1) improvement a person against a worker in a workplace that plan developed and approved by senior team for initiative causes or could cause physical injury to the worker" to determine baseline and identify measures to be implemented to reduce the incidents of reported violence. 2. Share results of review with Senior Leadership, Occupational Health and Safety Committee and all care committees to identify strategies to reduce violent incidents at MAHC. 3. Develop two strategies to reduce violent incidents at MAHC, utilizing the OHA Toolkit "Preventing Workplace Violence in the Healthcare Sector" to ensure best practice. 4. Develop implementation plan for one measure. one improvement initiative. identified, plan created and implementation by March 31, Implementation plan approved with timelines. FTE=512