Current Performance as stated on QIP2016/17

Transcription

1 Excellent Care for All Quality Improvement Plans (): Progress Report for The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and gain insight into how their change ideas might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality improvement activities. Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ideas, and inform robust curriculum for future educational sessions. ID Measure/Indicator from 1 CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospital-acquired CDI during the reporting period, divided by the number of patient days in the reporting period, multiplied by 1,000. ( Rate per 1,000 patient days; All patients; January 2015 December 2015; Publicly Reported, MOH) as QHC is achieving target. Change eas from Last Years ( ) Create protocol to review patients having recurrent CDI with ICP & MRP to identify need to refer to Specialist for enhanced care plan (MRP: MC) Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Key Success Factor: 1) Frequent reminders (e.g., discussions at staff huddles and weekly s) from Infection Prevention and Control staff to unitbased Managers and Patient Care Leads regarding the need for timely stool auditing and isolation of patients with abnormal stooling. 2) Working closely with Housekeeping Staff to ensure timely and thorough cleaning as needed. Cleaning using sporicidals and other standard cleaning best practices. Loose stool monitoring and auditing continues to be an important tool managing CDI and for reducing other types of enteric infections.

2 Measure/Indicator from 2 ED Wait times: 90th percentile ED length of stay for Admitted patients. ( Hours; ED patients; January December 2015; CCO iport Access) as Target as stated on QHC is slightly off target. QHC's Grassroots Transformation initiative is focused on patient care & flow from the Emergency Department through to the inpatient units, and aims to realize significant improvements overall and in ED Length of Stay for admitted patients. Change eas from Last Years ( ) Utilize Discharge Passport to inform patients of discharge process/plans Scheduled care planning conferences with patients and/or families (MRP: HC) No No Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? We were unable to implement an effective approach to ensure the patient received the Discharge Passport. While it was completed and discussed with the patient as a document to take home, it was often found discarded in the patient s room on the day of discharge. We have now changed the discharge passport to a discharge ticket that is posted on the wall in the patient s room so staff can review with every patient prior to discharge. We do not do this with all patients on our acute medicine units. We do this very well on the BSTU and in the ICU. We are currently trialing bedside rounding on our acute medicine units with all new admissions with the purpose of care planning with the patient and family.

3 Measure/Indicator from as 3 From Real-Time Patient Experience Surveys: Percent of ED patients who responded positively to their overall quality of care. ( %; ED patients; October September 2015; In-house survey) (corrected) QHC is achieving target. Change eas from Last Years ( ) Monitor the completion rate of the newly implemented real-time Patient Experience surveys monitoring overall quality of care #real-time Patient Experience Surveys/month (BGH - 20; PECMH - 20; TMH - 20; NHH - 20) Implement 1 improvement idea per quarter per Hospital based on feedback received from real-time Patient Experience Surveys Implement survey software to enable broad use of real-time patient experience surveys Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Key success factors are: 1) Strong leadership and support is required by Directors and from the executive level leadership to embed and sustain surveying as standard work. 2) Sharing and utilizing the feedback in a timely manner with direct care staff Each of the QHC EDs utilized patient and family feedback from the real-time patient experience surveys to identify improvement ideas such as improving communication with patients while they are waiting for care, improving the temperature of food, and improving communication about care planning with patients. QHC is using Survey Monkey to administer the real-time patient experience surveys. Key Success Factors are: 1) Only changing questions once quarterly 2) Setting mandatory questions across the organization and like units. 3) Frequent reminders for survey completion.

4 Measure/Indicator from as 4 Hand Hygiene Compliance Before Patient Contact (corrected) ( %; Health providers in the entire facility; Jan- Dec 2015; HQO public reporting website) QHC is achieving target; however, methodology for measuring this indicator has changed throughout the year. In this FY, we changed from 'unknown' auditors to a mixed methodology including peer-based auditors. Change eas from Last Years ( ) Implementation of Hand Hygiene audit software and related tools Expand number of No trained unknown Hand Hygiene auditors (MRP: MC) Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Hand hygiene audit software was selected and is now being added as an app to unit-based ipads to enable peer-to-peer auditing. Software will enable more timely data collection and tracking and will facilitate timely reporting back to direct care staff. QHC has also decided to provide in-the-moment feedback if staff member has missed a hand washing moment. A key success factor continues to be the need to continually shift focus from one strategy to the next to keep Hand Hygiene in the forefront of everyone s mind A lesson learned was that it is difficult to identify individuals to serve as unknown auditors and maintain this status within a community hospital. In addition, with unknown auditors it was not possible to provide in-the-moment prompts to cue physicians or staff to a missed moment of hand hygiene. Moving from unknown to a mixture of known or peer auditors has resulted in fluctuating indicator data results. However, the spirit behind this indicator is to keep hand hygiene compliance top of mind for direct care providers.

5 Measure/Indicator from 5 Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital ( Rate per total number of admitted patients; Hospital admitted patients; most recent quarter available; Hospital collected data) as QHC is achieving target. Change eas from Last Years ( ) Re-programmed med rec software Increase the number of BMPH done in preadmission for knee surgery patients Monitoring of completed Med Rec on Admission by day and month-todate idea implemented as intended? (Y/N Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Re-programming software efforts continue with vendor. QHC is a test site for new software development and as a beta site, reprogramming has required additional time. BPMH is now completed form patients awaiting hip & knee surgery at the pre-admission clinic. Key Success Factor is: 1) Embedding this as standard work. Med Rec on Admission is monitored daily and monthly by the Director of Pharmacy. Key Success Factor is: 1) Frequent monitoring has enabled increased focus on the importance of medication reconciliation.

6 Measure/Indicator from 6 Percentage of acute hospital inpatients discharged with selected HBAM Inpatient Grouper (HIG) that are readmitted to any QHC acute inpatient hospital for nonelective patient care within 30 days of the discharge for index admission. ( %; HBAM Inpatient Grouper; July June 2015; Hospital collected data) as (updated) (updated) (Q3) QHC is not achieving target. We have implemented the discharge ticket process and are trialing rounding with Patient Flow Coordinators and nursing at the bedside to improve care and communication with patients & families. We are also meeting with HealthLinks and considering the LACE tool for a readmission predictor. Change eas from Last Years ( ) Continue to monitor utilization of pathways for all Patients with CHF, COPD, Pneumonia Utilize Discharge Passport to inform patients of discharge process/plans Discharge follow-up phone calls for patients from ACE and Acute Medicine No No Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Pathways assist with the patient journey. Our experience has been that we need to focus on patients transferred from ICU to Acute Medicine. We were unable to implement an effective approach to ensure the patient received the Discharge Passport. While it was completed and discussed with the patient as a document to take home, it was often found discarded in the patient s room on the day of discharge. We have now changed the discharge passport to a discharge ticket that is posted on the wall in the patient s room so staff can review with every patient prior to discharge. Our focus was on a subset of the medicine patients; those with COPD. We were able to contact 80% of those patients post-discharge. This process is time consuming and often difficult in that there are a percentage of patient who declined follow-up phone calls or were unable to be reached post discharge.

7 Measure/Indicator from as 7 Risk-Adjusted 30-Day All Cause Readmission to (updated) QHC Rate for Patients with COPD (QBP cohort) ( %; COPD QBP Cohort; January December 2014; CIHI DAD) (updated) QHC is not achieving target, This will continue to be an area on focus in the /18. Change eas from Last Years ( ) Continue to monitor utilization of pathways for all identified COPD Patients Discharge follow-up phone calls for COPD patients Develop a regional care plan for COPD patients in the SE LHIN for the purpose of reducing the acute care readmission rate for COPD patients. Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Pathways assist with the patient journey. Our experience has been that we need to focus on patients transferred from ICU to Acute Medicine. QHC created a COPD Navigator role to conduct follow-up phone calls. QHC was an active participant in the SE LHIN COPD Working Group. This Working Group is developing its action plan and business case.

8 Measure/Indicator from 8 Total number of ALC inpatient days contributed by ALC patients within the specific reporting period (open, discharged and discontinued cases), divided by the total number of patient days for open, discharged and discontinued cases (Bed Census Summary) in the same period. ( %; All patients; October September 2015; CCO iport) as Target as stated on QHC is not achieving target. Low conversion rates have been achieved in. QHC is challenged with accessing LTC beds. Change eas from Last Years ( ) Open Acute Care for the Elderly (ACE) unit Unit-specific measuring and reporting of ALC conversion (i.e., CCB, CCC, Rehab, LTC) Develop standard work for managers and their team to identify patients who are atrisk for non-appropriate ALC conversion as intended? (Y/N Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? This unit opened in April With low conversion rates in 2016, this initiative was not routinely required on each unit and therefore challenging to embed in manager standard work. While this work was initiated, it was difficult for managers to prioritize amongst other priority change initiatives being implemented. This will be renewed as a key change idea in /18.