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

Transcription

1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/29/2017 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. University Health Network Elizabeth Street, Toronto, Ontario, M5G 2C4

2 Overview In 2016/17 the University Health Network (UHN) revisited our Purpose, Values & Principles (PVP). In consultation with our patients, caregivers, staff and leaders, we have redefined our purpose as transforming lives and communities through excellence in care, discovery and learning. Our primary value and above all else, the needs of patients come first. To fulfill our purpose and primary value, UHN has been focusing on a major strategic initiative in collaboration with SickKids titled, Caring Safely. Caring Safely represents UHN s commitment to safety both for one another and the individuals we serve, by working towards a culture of zero preventable harm. Hospitals are complex systems where errors can, and do happen. We must not only understand this but know that when there is harm we must learn from it and strive to eliminate it. Caring Safely will become our way of working in the years ahead: with safety as a core value, and an ongoing commitment to becoming an organization that works together to provide the safest possible care for patients and the safest environment for visitors and staff. As such, our 2017/18 Quality Improvement Plan (QIP) is aligned with the Caring Safely strategy and also UHN s Patient Experience Roadmap. The voices and opinions of our Patient Partners are extremely valuable and have been utilized to inform and develop our QIP. To ensure we build an awareness of the scope of the problem of preventable harm which will lead us to develop solutions that result in each employee knowing they can, and must speak up for safety at all times, a priority focus for 2017/18 will be education on Caring Safely high reliability. This will equip all employees at UHN clinical and non-clinical staff, and physicians with the foundational knowledge, skills and values to transform the safety culture at UHN. This education will have a key impact on our outcome indicators related to patient and employee safety. As we foster a culture of safety, we anticipate in 2017/18 an increase in incident rates due to enhanced awareness of patient and employee safety and improved reporting of safety incidents. Therefore, we have set our targets for this year s QIP to focus on collecting reliable baseline data for new indicators or indicators with new measurement methods, and maintaining current performance for indicators measured using the same method as last year. Our focus will be on the change ideas that have been created to measure the progress made on activities aimed at improving the corresponding outcome indicator over the longer term. QI Achievements From the Past Year There have been many quality improvement (QI) achievements in 2016/17, however one of our greatest achievements was in the area of Patient Experience, which highlights UHN s commitment to being compassionate, collaborative, and responsive to patient and caregiver needs, and articulates the ground work for our desired future state of engaging each member of the health care team including all staff, patients and their caregivers, researchers, learners and volunteers to do everything possible to ensure high quality, safe patient experience at UHN. We set out to increase the number and impact of patients and caregivers contributing to important planning and decision making activities in 2016/17. Over 70 Patient Partners shared their perspectives, knowledge and experiences of care in 122 engagement activities at the organization, program and unit level this represents a 139% increase from 2015/16 when we had 51 engagements. Activities included strategic planning retreats, interview panels, co-facilitation of health literacy training for UHN staff, focus groups and presentations. Patient Partners also shared their thoughts through our Virtual Patient Focus Group which offers patients and caregivers an opportunity to participate regardless of access/location by removing physical and financial barriers associated with travel. This success was facilitated by the re-organization of the Patient Experience (PE) Portfolio to bring together the Bioethics, Patient Engagement, and Patient Relations teams which have focused their efforts on University Health Network Elizabeth Street, Toronto, Ontario, M5G 2C4

3 increasing patient and caregiver engagement across the organization. Having patient and caregiver engagement ensures activities that UHN focuses its efforts on are relevant to the needs of our patients and of the communities we serve. Population Health UHN is moving towards a greater focus on population health. UHN is a Hospital Resource Partner within the Mid- West Toronto Sub-Region of the Toronto Central Local Health Integration Network (TC LHIN) to support the improvement, integration, and delivery of primary health care services. A focus on primary care is a first step in a broader population health strategy. The intent is to strive to improve health equity for our patients. We recognize that for some patients in our community with complex care needs, it is increasingly difficult for primary care physicians to meet their needs and have thus launched programs aimed at better serving our community. UHN is integrating primary care in a way that respects the needs that primary care physicians have identified to better serve patients. For example, SCOPE (Seamless Care Optimizing the Patient Experience) is a virtual interprofessional health team that supports primary care providers through a single point of access. Family physicians and nurse practitioners registered with SCOPE can connect to local specialists, imaging, and community services, to serve their patients with complex care needs. SCOPE partners with specialist representatives from the community, Women s College Hospital, and Community Care Access Centres (CCACs). We currently have 128 active SCOPE physicians in the program. TIP (Telemedicine Impact Plus) also strives to improve access for very complex patients by having nurse facilitators present at consultations with specialist teams and primary care physicians, connected via videoconferencing. TIP has nine team locations including UHN, Mount Sinai Hospital, Taddle Creek Family Health Team, Women s College, South East Toronto Family Health Team, Providence Health Care, St. Michael s Hospital, and Sunnybrook Health Sciences Centre (Academic and Emergency Department). In the 6 months post- TIP, 46.2% fewer patients returned to UHN Emergency Department or inpatient units. In January 2017 we launched the myuhn Patient Portal, a secure website where patients and caregivers can access their health record information, receive lab results in real-time and view their appointment schedules. This is offered to all patients and caregivers and allows for remote access to health information, and enables patients the ability to share their health information with family and their primary care provider if they choose to do so. Our early adopter results show that myuhn has empowered patients to make better decisions about their care and has created equal opportunities for good health and sharing information for all patient population groups. Since its launch, over 10,000 patients have signed up for the myuhn Patient Portal. These programs allow UHN to collaborate and also share expertise and transmit skills, allowing for patients to be cared for by their primary care physician who is empowered with the knowledge they need. Resident, Patient, Client Engagement A group of Patient Partners were consulted through a series of focus groups with staff from Patient Experience, Corporate Planning and Patient Safety teams to contribute to the development of the 2017/18 QIP. This was done through a three-pronged approach of Education on patient safety, quality improvement and HACs; Engagement to understand how patients and caregivers can be involved in their own personal care in order to eliminate HACs at UHN; and how Patient Partners can be engaged at the organizational level to advance the Caring Safely mandate; and finally Validation to ensure we understood their perspectives and input (please see diagram below.) This allowed the team to embed a patient and caregiver engagement structure and plan for this work going University Health Network Elizabeth Street, Toronto, Ontario, M5G 2C4

4 forward. A draft of the narrative was circulated to Patient Partners and their input helped to finalize the 2017/18 QIP. Engagement with Patient Partners will be an ongoing process throughout the year as the implementation of change ideas continue to take shape. Moreover, UHN Patient Relations saw over 3,500 patients and caregivers in 2016/17. To enhance the patient experience, Patient Relations was decentralized this year so that each site had a dedicated patient relations resource. When patients and caregivers were asked about their satisfaction level with the patient relations process, 73% indicated that they were satisfied with the process and 56% indicated they were satisfied with the outcome. This data suggests that patients and caregivers were overall satisfied with the patient relations process at UHN, even when the outcome was not their preferred outcome. When UHN staff were asked the same questions, 83% of staff indicated they were satisfied with the process and 74% indicated they were satisfied with the outcome. As UHN is an environment of continuous improvement, we will use these insights to help inform quality improvement initiatives to further improve patient relations. Staff Safety & Workplace Violence Too many people are harmed while providing care for patients or in the day-to-day completion of their work tasks. In 2015/16 UHN saw an increase of 56% in workplace violence incidents, a 19% increase in musculoskeletal incidents and an overall increase of 10% of high-impact workplace incidents, which is why we have chosen to focus on staff safety and workplace violence. As part of Caring Safely, a Workplace Safety transformation plan has been created to reduce incidents that cause harm in high impact areas: musculoskeletal injuries, falls and workplace violence. University Health Network Elizabeth Street, Toronto, Ontario, M5G 2C4

5 We will align workplace safety practices with those for patient safety to create an integrated approach in promoting a culture of safety at UHN. As such, we have included three indicators on the QIP on Staff Safety and Workplace Violence. We have also aligned with priorities as outlined in the provincial Healthy and Safe Ontario Workplaces Strategy for 2017/18. These priorities include measures to address the highest hazards within the health care sector that result in occupational injuries, illness and promote a culture of safety with the workplace. Performance Based Compensation The following indicators were selected to be linked to executive compensation as they reflect our commitment to reducing preventable harm for patients and our staff as well as enhancing the patient and caregiver experience. Executive compensation will be linked to the following indicators (please see table below): Indicator Rationale Target C. difficile Infections: Percentage of completed intervention implementations related to environmental controls Environmental controls are a foundational area of focus for the C. difficile Infection HAC. Establishing and adhering to environmental control protocols will help to ensure that C. difficile Infection does not spread from patient to patient across contaminated surfaces. Central Line Infections: Number of pilot tests of the central line infection prevention bundle completed in the UHN ICUs Surgical Site Infections: Reduce hospital acquired surgical site infections by initiating all planned prevention bundle elements Caring Safely Education: Percentage of UHN staff and physicians who have completed their required training in error prevention and safety behaviours Patient Experience: Number of patients and caregiver partners who are actively engaged in initiatives across UHN Based on reliability science and the experience of other organizations, all elements of the Central Line Infections prevention bundle must be in place and performed consistently in order to achieve meaningful improvement in the outcome. These tests of the prevention bundle will provide the foundation for implementations tailored to the unique needs of each ICU. Based on reliability science and the experience of other organizations, all elements of the Surgical Site Infections prevention bundle must be in place and performed consistently in order to achieve meaningful improvement in the outcome. Initiation of each prevention bundle element includes conducting a current state analysis and developing recommendations for meeting best practice standards. Education will be the foundation for our safety transformation at UHN. By training a critical mass of staff and physicians, we will be better able to achieve other quality improvement initiatives. Engaging with patients and caregivers to learn about their experiences and the opportunities our organization has for improvement will allow UHN to better meet the needs of patients and caregivers. Achieving this target will reflect our commitment to patient engagement activities in the organization. 100% completion in UHN Inpatient and Outpatient areas Target: 4; one pilot test per ICU (CICU, CVICU, MSICU, MSNICU) 100% implementation at TGH and TWH General Surgery 75% of all UHN employees and physicians 90 patients and caregiver partners The following portions of variable compensation will be linked: President and Chief Executive Officer 25% EVP and Chief Business Officer 20% EVP Human Resources 20% EVP and Chief Operating Officer 20% EVP and Chief Medical Officer 20% EVP Technology & Innovation 20% EVP Science & Research 20% EVP Education 20% VP Patient Experience & Chief Health Professions 20% Clinical Vice Presidents 20% University Health Network Elizabeth Street, Toronto, Ontario, M5G 2C4

6 The five targets will be equally weighted. The following incentives will be available for each target: Target achieved 100% 80% of target achieved 80% 50% of target achieved 50% 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 Mr. John Mulvihill Board Chair Dr. Dhun Noria Quality Committee Chair Dr. Peter Pisters Chief Executive Officer University Health Network Elizabeth Street, Toronto, Ontario, M5G 2C4

7 2017/18 Quality Improvement Plan University Health Network AIM Measure Change Quality Issue Measure/Indicator Unit / Population Source / Period Improve person experience From National Research % / A random sample of Corporation Canada (NRCC): UHN Acute and Rehab "Overall, how would you rate the Inpatients care and services you received at the hospital (inpatient care)? The indicator is expressed as a percent (%) of those who responded with a rating of 9 or 10 inclusively on a scale of 0 to 10 where 0 = poor experience and 10 = very good experience. NRC Picker / Q1 and Q2 Current performance Target Target justification Due to the implementation of a new patient experience survey, we anticipate lower scores on patient experience. A more rigorous approach, reporting out the top-end of the Likert scale only (responses of 9 or 10), will allow us to better understand new opportunities to improve the patient experience at UHN. Planned improvement initiatives (Change Ideas) Methods Process measures 1)Increase the number of patients and caregivers partnering across the organization on planning and decision-making activities. Patient Experience and Operations teams to collaborate with leaders in the organization to identify opportunities for patient partner engagement and match experiences accordingly. Enhance our patient and caregiver recruitment activities, e.g. Patient Experience website, internal poster campaign and expanding to social media. Create opportunities for staff to support recruitment of new patient and caregiver partners. Provide education and support to staff to facilitate a culture of excellence in engagement practices. Number of patients and caregiver partners in the Patient Partners program who are actively engaged in initiatives across UHN. (Cumulative number from 2015). Target for process measure 70 (current) 90 (goal) Comments Reduce surgical cancellations The number of same day cancellation and number of scheduled cases each month (excluding organ unacceptable and organ unavailable for transplant patients). The same day cancellation rate was calculated by dividing the number of same day cancellations by the number of scheduled cases. % / All UHN surgical patients (excluding organ/tissue unacceptable and organ/tissue unavailable reasons for cancellations). ORSOS / Q1-Q The target has been aligned with the Surgical Efficiency Targets Program (SETP) which helps to optimize surgical capacity in Ontario, increases access to surgical services and maintains high-quality patient care. The decision to exclude organ unacceptable and organ unavailable for transplant patients was made because cancellation of these cases is due to issues beyond the control of the organization. 2)Increase the number and diversity Embed patient engagement into the of patient and caregiver engagement Patient Experience Roadmap. activities at the organizational, Partner with executive and program and unit level. leadership teams to identify opportunities for patient engagement. 1)Work towards having a dedicated surgical stream for transplants and not mixing these with the other elective/non-elective surgical patients. Complete analysis on cases cancelled due to transplant priority and determine OR resources needed to set up dedicated transplant surgical suites. 2)Implementation of daily review of Daily distribution of key surgical key surgical efficiency metrics at metrics at TWH. TWH; same day cancellations is one of these metrics. 3)Addition of two Flex Rooms per week at TWH. Measure compliance and utilization of the OR Flex Rooms. Number of patient engagement activities at the organizational, program and unit level. (Cumulative number from 2015). Finalized decision by TGH Surgical Executive. Number of in-depth reviews of surgical cancellations conducted. Percentage utilization of OR Flex rooms. 75 (current) 150 (goal). This goal will eventually reach saturation with a finite number of committees and initiatives reducing the scale of the stretch goal for this year. Decision finalized. System implemented. System Implemented. This was implemented at TGH in September 2016 and will be started at TWH for 2017/18. Educate staff and physicians Percentage of UHN staff and physicians who have completed training in safety behaviours and error prevention tools. Number of staff and physicians who have completed education/total number of staff and Completion numbers from Learning Management System (LMS) registration and attendance sheets, plus physicians / All employees manual attendance tracking of UHN clinical and nonclinical, as well as all and anyone without LMS for research, Michener staff, physicians credentialed to access / 2017/18 practice at UHN Under the advice of our external improvement consultants, it was suggested we cover a critical mass of staff with the early wave of education to ensure that there are enough staff with the necessary training to influence a positive change in the organization s safety culture. Due to the large number of participants (approximately 16,000) and limitations on space availability and impact of pulling staff from units/departments, we anticipate taking a little longer than the fiscal year to capture all 100%. 1)Training all UHN Managers and above in high reliability leadership methods, including error prevention tools and safety behaviours. 2)Training all UHN staff and physicians in error prevention tools and safety behaviours. Seven modules to be rolled out between February 2017 and November 2017 covering a variety of leadership methods in high reliability. These modules will be cofacilitated by our external consultants and site Vice-Presidents and run during the third week of each month. Percentage of leadership education completed (number of leaders with a module completed x number of modules delivered)/(total number of leaders x total number of modules). 75% of leadership education completed by December A three hour session, covering Percentage of staff and physicians 75% of staff and didactic and practical simulation, will who have received training/total physicians trained by be provided to all UHN employees and physicians. Training will take place in intact teams as much as number of UHN staff and physicians end of FY 2017/18. (excluding leaders who are receiving separate training). possible. Due to the module rollout schedule it is anticipated most leaders will have completed most modules by November However, with new leaders being hired throughout the year, and some leaders potentially missing individual modules, it is unlikely to reach 100% with the one wave of leadership education. As per the indicator, it is necessary to train as many staff as possible in a short period of time to influence a positive change in safety culture, but there will be logistical challenges to providing training to teams of staff in large numbers without significantly disrupting operations. A target of 75% is anticipated to be sufficient to move forward with the remaining staff to be trained as soon as possible thereafter. 1

8 2017/18 Quality Improvement Plan University Health Network AIM Measure Change Quality Issue Measure/Indicator Unit / Population Source / Period Improve classification of patient safety events Reduce hospital acquired pressure injuries Reduce preventable falls and severity of harm from falls Number of Patient Safety Events Number of Patient Safety UHN Incident reporting classified using the Safety Event events reported / All eform / Q1-Q3 Classification Levels of Harm. Note: The Safety Event Classification Levels of Harm include: Serious Safety Events, current incident types excluding Privacy and Workplace Violence event types. Precursor Safety Events & Near Miss Events. Currently we are focused on classifying the Serious Safety Events only. Number of persons developing a new pressure injury per 1,000 acute inpatient days (Incident Density Rate). Number of rehab/ccc inpatient falls (SSE 1-5) per 1,000 rehab/ccc inpatient days. Pressure Injury Incident Density rate per 1,000 acute inpatient days / Four acute inpatient pilot units (TGH - 6A and 6B; TWH - 3B and PM - 15B) Electronic Patient Record / Q1-Q3 Rehab/CCC inpatient falls Patient Safety Incident rate per 1,000 rehab/ccc Reporting System / Q1-Q3 inpatient days / Rehab/CCC inpatients Current performance Target Target justification We are moving to a new way to classify Patient Safety Events using the Safety Event Classification Levels of Harm. In FY 2016/17, KPMG conducted an internal audit of data quality and performance reporting as part of the Internal Audit Plan for 2016 for UHN. Per the audit recommendations, the Pressure Injuries HAC will continue to work on improving reporting and developing baseline values to allow for meaningful performance reporting. For FY 2017/18 the Pressure Injuries HAC will focus on collecting a reliable baseline and making progress on HAC interventions. The outcome indicators tracked related to Falls have been revised due to a new harm classification system at UHN, therefore there is no true baseline data available. For FY 2017/18, the Falls HAC will be focused on collecting reliable baseline data, as well as making progress on HAC interventions. Planned improvement initiatives (Change Ideas) Methods Process measures 1)Education to clinical and medical leads on the "Safety Event Classification Levels of Harm". 2)Patient Safety team to move to one severity classification framework. 3)Develop guiding principles for Patient Safety team to ensure consistency with severity classifications. 1)Increase reporting of Braden Risk Assessment and Skin Assessment in the EPR for the four pilot units. 2)Finalize format and content of education to ensure widespread knowledge of standardized practices related to pressure injury prevention for the four pilot units. 3)All nursing staff on the four pilot units re-educated on documenting assessments via EPR. 1)Refine falls inpatient Prevention Bundle. 2)Define falls outpatient Prevention Bundle. 3)Define debrief form/process for fall prevention in the inpatient setting. Hold education sessions for clinical and medical leads on the severity classification framework. Standardize one severity classification framework within the Patient Safety team. Education has been rolled out to all clinical and medical leads. Target for process measure Complete by March 31, Classification framework is finalized. Complete by March 31, Develop inclusion and exclusion Guiding principles are finalized. Complete by March 31, criteria for severity classification with input from stakeholders. Develop standardized procedures based on best practice recommendations; implement protocol to ensure processes captured. Ensure that staff have completed the recommended education. Ensure that staff have completed the recommended education. Percentage of assessments completed. Percentage of staff who have completed the recommended education. Percentage of staff who have completed the recommended education. Review elements of falls inpatient Percentage of compliance to full prevention bundle; develop prevention bundle in test areas. standards for each element; test and Percentage accuracy to full implement refined standards. prevention bundle in test areas. Strike outpatient intervention team; develop fall prevention outpatient standards in alignment with accreditation Required Organizational Practices and best practice; engage patient perspective; implement standard across all outpatient clinics. Develop and test debrief tool and process for Falls SSE 1-5. Number of outpatient clinics using outpatient fall prevention bundle. Tool is in use and process identified for falls SSE 1-5 debriefs. >/= 75% compliance from staff documenting Braden Risk Assessment and Skin Assessment in the EPR. >/= 75% of staff who have completed the recommended education. >/= 75% of staff who have completed the recommended education. >= 75% compliance of full prevention bundle. >=75% accuracy of full prevention bundle. >= 75% of outpatient units compliant to full outpatient falls prevention bundle. Process and tool used for >= 75% of SSE 1-5 Falls debriefs. Comments Dependency on UHN Cause Analysis/Root Cause Analysis process updates. 4)Define safety huddle/visual board requirements for falls. Identify safety huddle and visual Percentage of compliance to board requirements for fall requirements in test areas. prevention; test concepts with selected test units; align with Caring Safely pathway in Spring >=75% compliance to requirements in test areas. Dependency on Caring Safely pathway. 5)Implement Post Fall Assessment at Toronto Rehab. Implement post fall assessment across all Rehab/CCC units at Toronto Rehab. Number of units implemented. 100% of inpatient rehab/ccc units. 2

9 2017/18 Quality Improvement Plan University Health Network AIM Measure Change Quality Issue Measure/Indicator Unit / Population Source / Period Reduce preventable falls and severity of harm from falls Number of acute inpatient falls (SSE 1-5) per 1,000 acute inpatient days. Acute inpatient falls rate per 1,000 acute inpatient days / Acute inpatients Patient Safety Incident Reporting System / Q1-Q3 Current performance Target Target justification The outcome indicators tracked related to Falls have been revised due to a new harm classification system at UHN, therefore there is no true baseline data available. For FY 2017/18, the Falls HAC will be focused on collecting reliable baseline data, as well as making progress on HAC interventions. Planned improvement initiatives (Change Ideas) Methods Process measures 1)Refine falls inpatient Prevention Bundle. 2)Define falls outpatient Prevention Bundle 3)Define debrief form/process for fall prevention in the inpatient setting. Review elements of falls inpatient Percentage of compliance to full prevention bundle; develop prevention bundle in test areas. standards for each element; test and Percentage accuracy to full implement refined standards. prevention bundle in test areas. Strike outpatient intervention team; develop fall prevention outpatient standards in alignment with accreditation Required Organizational Practices and best practice; engage patient perspective; implement standard across all outpatient clinics. Develop and test debrief tool and process for Falls SSE 1-5. Number of outpatient clinics using outpatient fall prevention bundle. Tool is in use and process identified for falls SSE 1-5 debriefs. Target for process measure >= 75% compliance of full prevention bundle. >=75% accuracy of full prevention bundle. >= 75% of outpatient units compliant to full outpatient falls prevention bundle. Process and tool used for >= 75% of SSE 1-5 Falls debriefs. Comments Dependency on UHN Cause Analysis/Root Cause Analysis process updates. 4)Define safety huddle/visual board requirements for falls. Identify safety huddle and visual Percentage of compliance to board requirements for fall requirements in test areas. prevention; test concepts with selected test units; align with Caring Safely pathway in Spring >=75% compliance to requirements in test areas. Dependency on Caring Safely pathway. Reduce adverse drug events Number of adverse drug events (Serious Safety Events 1-5 & Precursor Safety Events 1-3) per 10,000 medication doses. ADE rate per 10,000 medication doses / All UHN inpatient units and selected outpatient/ambulatory areas that store and administer medications Patient Safety Incident Reporting System (medication incidents) & BDM Pharmacy (medication doses) / Q1-Q3 The outcome indicators tracked related to Adverse Drug Events have been revised due to a new harm classification system at UHN, therefore there is no true baseline data available. For FY 2017/18, the Adverse Drug Event HAC will focus on collecting reliable baseline data, as well as making progress on HAC interventions. 1)Reinforce medication safety principles through education. 2)Investigate causes of missed/extra doses phenomena. 3)Identify interventions to address high-alert medication incidents. 4)Develop a strategy to find a closed loop solution for Alaris IV pumps to reduce adverse drug events. Ensure that nursing and respiratory therapy staff have completed new Safe Medication Practice - Administration elearning module. Hold focus groups to better understand causes of missed/extra doses across the organization. Identify interventions to address high-alert medication incidents. Develop a strategy to find a closed loop solution for Alaris IV pumps to reduce adverse drug events. Number of staff who have completed Safe Medication Practice - Administration elearning. Focus groups held. Number of interventions identified. Strategy developed. 80% of Pyxis users have completed the elearning module by Two focus groups held at each site by March 31, Three interventions identified by March 31, Strategy developed by Number of adverse drug events near misses (Precursor Safety Events 4 & Near Miss Events 1-3) per 10,000 medication doses. ADE near miss rate per 10,000 medication doses / All UHN inpatient units and selected outpatient/ ambulatory areas that store and administer medications Patient Safety Incident Reporting System (medication incidents) & BDM Pharmacy (medication doses) / Q1-Q3 The outcome indicators tracked related to Adverse Drug Events have been revised due to a new harm classification system at UHN, therefore there is no true baseline data available. For FY 2017/18, the Adverse Drug Event HAC will focus on collecting reliable baseline data, as well as making progress on HAC interventions. 1)Reinforce medication safety principles through education. 2)Investigate causes of missed/extra doses phenomena. 3)Identify interventions to address high-alert medication incidents. 4)Develop a strategy to find a closed loop solution for Alaris IV pumps to reduce adverse drug events. Ensure that nursing and respiratory therapy staff have completed new Safe Medication Practice - Administration elearning module. Hold focus groups to better understand causes of missed/extra doses across the organization. Identify interventions to address high-alert medication incidents. Develop a strategy to find a closed loop solution for Alaris IV pumps to reduce adverse drug events. Number of staff who have completed Safe Medication Practice - Administration elearning. Focus groups held. Number of interventions identified. Strategy developed. 80% of Pyxis users have completed the elearning module by Two focus groups held at each site by March 31, Three interventions identified by March 31, Strategy developed by 3

10 2017/18 Quality Improvement Plan University Health Network AIM Measure Change Quality Issue Measure/Indicator Unit / Population Source / Period Current performance Target Target justification Reduce infections Risk adjusted rate of surgical site Risk adjusted rate of ACS NSQIP (American It is expected that FY 2017/18 infections (TGH General Surgery). surgical site infections / Patients under the services of TGH General Surgery College of Surgeons' National Surgical Quality Improvement Program) and ON - NSQIP (Ontario collaborative) / July 2016 June 2017 will be a maintenance year as a significant movement in the outcome indicator will not be seen in the risk-adjusted data provided by NSQIP due to the 6- month reporting lag. This lag in reporting allows for the data to be collected and submitted and for ACS-NSQIP to provide riskadjusted data which allows more meaningful comparisons of surgical outcomes that take into account the complexity of surgeries performed and the health status of the patients operated on. However, ongoing progress on the SSI HAC will be regularly monitored using raw, unadjusted data. Planned improvement initiatives (Change Ideas) Methods Process measures 1)Ensure appropriate perioperative normothermia for all surgical divisions. 2)Ensure bathing before surgery (decolonization) for all surgical divisions. Decrease infection by improving compliance of bundle element interventions; Educate staff on importance of ensuring perioperative normothermia; Develop standardized procedures based on Safer Healthcare Now! (2014) and other best practice recommendations; implement protocol to ensure processes captured (e.g. temperature documented, warming blankets used). Implement protocol for decolonization and process to capture step; Ensure all elective surgical patients are educated on the importance of bathing prior to surgery and are provided either the new brochure or sub-specialty specific materials. 1) Patient s core temperatures remain between 36.0 C and 38.0 C pre-operatively, intra-operatively, and in PACU. 2) Random prospective audits of perioperative normothermia and passive data collection of protocols. 3) OR temperature remains between 20 C and 24 C (where applicable) and OR humidity remains between 20% to 60%. Monthly audit of the percentage of patients who have received brochure and followed recommendations. Target for process measure 1) 100% of patients who were actively prewarmed in POCU. 2) >/= 50% improvement in patients whose temperature remained within the normal range peri-operatively. 3) >/= 80% compliance of OR temperature and humidity (where applicable). Comments The SSI HAC leads and Working Group decided this intervention was a priority last year and work continues to complete it; this intervention was chosen as part of our prevention bundle based on literature and best practices. 1) >/= 80% compliance The SSI HAC leads and Working Group from staff following new decided this intervention was a priority protocol and providing last year and work continues to complete patients with brochure it; this intervention was chosen as part of and educating patients. our prevention bundle based on literature 2) >/= 60% compliance and best practices. from patients following recommendations. Risk adjusted rate of surgical site infections (TWH General Surgery) Risk adjusted rate of surgical site infections / Patients under the services of TWH General Surgery ACS NSQIP (American College of Surgeons' National Surgical Quality Improvement Program) and ON - NSQIP (Ontario collaborative) / July 2016 June )Ensure perioperative skin antisepsis (skin prep and draping in OR) for all surgical divisions. 4)Follow skin closure protocols for all surgical divisions. Decrease infection by standardizing Audit with vendor to ensure practices for the perioperative implementation of best practices and application of skin antiseptic agents. follow-up with monthly audits. Develop a protocol to guide surgical closure techniques (e.g. closing tray) and process to capture step. Random prospective audits to ensure adherence to surgical closure protocols. >/= 80% compliance from staff preparing patients with appropriate skin preparation protocol. The SSI HAC leads and Working Group decided this intervention was a priority for this year; this intervention was chosen as part of our prevention bundle based on a literature review and best practices. >/= 80% compliance The SSI HAC leads and Working Group from staff following new decided this intervention was a priority for surgical closure this year; this intervention was chosen as protocols. part of our prevention bundle based on literature and best practices. 5)Provide prophylactic antimicrobial coverage and ensure appropriate use of prophylactic antibiotics for General Surgery and Orthopaedic Surgery. Develop recommendations of monitoring surgical antimicrobial prophylaxis use on an ongoing basis. Analysis of process and outcome measures with comparison between workflow analysis groups and noninterventional groups. Capture baseline data for patients who received timely antibiotics and patients who received the appropriate antibiotic. The SSI HAC leads and Working Group decided this intervention was a priority for this year; this intervention was chosen as part of our prevention bundle based on literature and best practices. 6)Maintain perioperative glucose control for all surgical divisions. Create a process map to ensure glucose management. Develop a glucose control protocol for surgical patients. Development of process map and glucose control protocols. Completion of process map and glucose control protocols. The SSI HAC leads and Working Group decided this intervention was a priority for this year; this intervention was chosen as part of our prevention bundle based on literature and best practices. 7)Initiate all planned prevention bundle elements. Strike Comprehensive Unit-based Safety Program (CUSP) teams or sub-groups for each planned prevention bundle element; Do current state analysis and begin developing recommendations for all planned prevention bundle elements. Create CUSP teams and sub-groups for all planned prevention bundle elements. Initiate 100% of the planned prevention bundle element for SSI. Eight interventions total; two initiated (prophylactic antimicrobial coverage and redosing, peri-op glucose control); two in testing (peri-op normothermia, skin closure protocols); one in implementation (decolonization) - based on March 2017 Safety Scorecard. 4

11 2017/18 Quality Improvement Plan University Health Network AIM Measure Change Quality Issue Measure/Indicator Unit / Population Source / Period Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Process measures Target for process measure Comments Reduce infections Number of acute inpatients newly diagnosed with nosocomial C. Difficile (CDI) per 1,000 acute inpatient days. Number of newly diagnosed Central Line Infection (CLI) cases in the ICUs per 1,000 central line days. Nosocomial Acute Inpatient CDI rate per Infection Prevention and Control C. difficile database / ,000 acute inpatient days Q1-Q3 / Acute inpatients ICU CLI rate per 1,000 Infection Prevention and central line days / UHN Control database / Q1-Q3 ICU patients (CICU, CVICU, MSICU, MSNICU) It is expected that FY 2017/18 will be a maintenance year as CDI HAC intervention implementations are planned for the latter half of the fiscal year, following the rollout of the Caring Safely Error Prevention Tools education. In addition, C. difficile epidemiology is very complicated and as such there is a limit to how much impact the interventions can have on nosocomial rates It is expected that FY 2017/18 will be a maintenance year as the CLI HAC intervention implementations are planned for the latter half of the fiscal year, following the rollout of the Caring Safely Error Prevention Tools education. 1)Pilot stool documentation tools. Pilot stool documentation tools. Number of pilots completed. At least one pilot completed at each site by 2)Clorox wipes rolled out to additional outpatient areas. Clorox wipes rolled out to additional outpatient areas. 3)Percentage of completed Includes the rollout of a intervention implementations related to environmental controls (standardized cleaning checklist & ATP monitoring). 4)Rollout standardized terminal cleaning checklist at all sites. 5)ATP monitoring in use at all sites for CDI terminal cleans. 1)Test standardized maintenance bundle kit in the ICUs. 2)Identify insertion best practices for UHN and test re-education methods in ICUs. standardized cleaning checklist and ATP monitoring in place at all four UHN sites by Rollout standardized terminal cleaning checklist at all sites. ATP monitoring in use at all sites for CDI terminal cleans. Create maintenance bundle kits and associated education and test plan. Rollout kit, obtain feedback and iterate approach for successive ICU implementation. Identify insertion best practices for UHN, create corresponding education materials, and rollout in ICUs. Rollout in additional outpatient areas complete. Percentage of intervention implementation completeness. Standardized terminal cleaning checklist in use at all sites. ATP monitoring in use at all sites for CDI terminal cleans. Maintenance kit utilization for dressing changes. Insertion best practice education completed. Rollout completed by 100% Standardized terminal cleaning checklist in use at all sites by All sites are using ATP monitoring for CDI terminal cleans by >=75% utilization. All ICU staff involved with central line insertions educated on CLI insertion best practices. 3)Identify and test safety behaviours related to reducing lines via existing means (i.e. safety huddles/visual boards). 4)Number of pilot tests of the central line infection prevention bundle completed in UHN ICUs. Identify and embed safety behaviours related to reducing CLIs into day-to-day practice. Complete one pilot test per ICU. The program needs all prevention bundle elements in place to see meaningful improvement in the outcome indicator. These tests of the prevention bundle will provide the foundation for future implementation. Safety behaviours identified and in use. Number of pilot tests in UHN ICU patients (CICU, CVICU, MSICU, MSNICU). All ICU staff educated on CLI safety behaviours. 4 5)Continued progress on CLI documentation and data collection using the EPR. Digital team initiated, electronic solution designed and implementation plan created. Methods completed. 100% completion. Improve Workplace Safety Number of serious safety events (resulting in harm to workers) related to slips, trips and falls per 200,000 hours (100 FTE). Number / All UHN employees (excludes non- UHN employees, students, volunteers, service providers, contractors) Employee Incident Reporting System (Parklane/VIP) / Q1- Q While we have FY 2016/17 data, we are not confident baseline has been achieved. With increased awareness and system improvements for reporting, FY 2017/18 will be a year for gathering baseline data. It is anticipated that all preventive measures will need to be implemented to have a meaningful impact on the outcome indicator. 1)Conduct environmental scan and literature review of provincial tools. 2)Develop and implement standardized hazard identification and prevention checklist. Review current assessment tools to identify key common elements for inclusion in UHN tools. Examine current assessment tools and determine common elements required for UHN assessment. Completion of environmental scan and literature review. Common hazard assessment tool used by all Joint Health and Safety Committees when conducting monthly inspections. 100% 100% use of assessment tool. 5

12 2017/18 Quality Improvement Plan University Health Network AIM Measure Change Quality Issue Measure/Indicator Unit / Population Source / Period Improve Workplace Safety Number of serious safety events (resulting in harm to workers) related to musculoskeletal injuries (MSD) per 200,000 hours (100 FTE). Number / All UHN employees (excludes non- UHN employees, students, volunteers, service providers, contractors) Employee Incident Reporting System (Parklane/VIP) / Q1- Q3 Current performance Target Target justification While we have FY 2016/17 data, we are not confident baseline has been achieved. With increased awareness and system improvements for reporting, FY 2017/18 will be a year for gathering baseline data. It is anticipated that all preventive measures will need to be implemented to have a meaningful impact on the outcome indicator. Planned improvement initiatives (Change Ideas) Methods Process measures 1)Identify high risk areas for MSD related incidents. 2)Conduct cause analysis of MSD serious safety events in two departments identified as high risk. 3)Conduct focus groups to review in detail incidents that result in harm to workers. Review employee reported incidents for the period of April 1, 2013 to March 31, Completion of serious safety event analysis using UHN cause analysis framework conducted by interprofessional teams to identify themes and contributing factors to inform preventative measures. Hold interprofessional focus group discussions to analyze incidents identifying themes and contributing factors. Completed review of all 5002 type incidents as reported in Parklane Database. Complete serious safety event analysis using UHN cause analysis framework. Focus groups to include representation from professional groups, frontline staff, management, education and safety. Target for process measure Completed review of all 5002 type incidents reported for the period identified. Serious safety event analysis completed by Cause analysis complete for two high risk areas by March 31, Comments Number of serious safety events (resulting in harm to workers) related to workplace violence per 200,000 hours (100 FTE). Number / All UHN employees (excludes non- UHN employees, students, volunteers, service providers, contractors) Employee Incident Reporting System (Parklane/VIP) / Q1- Q While we have FY 2016/17 data, we are not confident baseline has been achieved. With increased awareness and system improvements for reporting, FY 2017/18 will be a year for gathering baseline data. The workplace violence program needs all measures in place to achieve improvements in the outcome indicator. In addition, we recognize the etiology of behaviours is very complex and multifactorial. As such, a multilayered systems approach is required to have any meaningful impact on reducing harm related to violence. 1)Deliver UHN customized crisis intervention training for employees in high risk units. 2)Revise workplace violence policy and program to ensure it meets current requirements and includes all identified measures and procedures. 3)Conducting risk assessments for all areas previously identified as moderate risk. 4)Assess current UHN flagging system to identify gaps and prepare recommendations. Customized crisis intervention training delivered by Safe Management Group (SMG) to employees in high risk areas. Conduct a review of current policy and program to ensure measures and procedures continue to protect workers from violence. Using UHN's workplace violence risk assessment tool to complete assessments. Focus group discussions led by professional practice including stakeholders - frontline staff, legal, ethics, safety and clinical leaders. Number of training completions as recorded in UHN's Learning Management System. Comprehensive review and revision of policy and program. Validate the risk level for each of these areas. Complete assessment with recommendations. 90% of all employees in identified high risk areas will have completed SMG crisis intervention training. 100% 100% completion of risk assessments for each identified area. 100% Number of Serious Safety Events (resulting in harm to workers) per 200,000 hours (100 FTE). Number / All UHN employees (excludes non- UHN employees, students, volunteers, service providers, contractors) Employee Incident Reporting System (Parklane/VIP) / Q1- Q3 The outcome indicator tracked related to Employee Serious Safety Events is adjusted utilizing a new harm classification system at UHN, therefore no baseline data is available. Current performance is based on mapping existing data to the definitions outlined in the new classification system. For FY 2017/18 the focus will be on collecting reliable baseline data. 1)Implement electronic incident reporting system with a single portal of entry for all incident types. 2)Conduct a comprehensive review of the current state of UHN's cause analysis program for employee incidents. 3)Identify phases and common components of desired incident causal analysis program and compare with UHN's current state of analyzing employee incidents. Develop a communication strategy to inform all UHN employees and service providers how to report incidents that could impact safety (near miss) and/or have resulted in harm. Hold focus group discussions with all UHN safety leads to examine the current state for cause analysis. Complete a gap analysis of UHN's current methods of analyzing incidents with desired analysis program. Number of employees who reported incidents using the online employee incident reporting system. Focus groups held. Complete gap analysis of UHN's current state for incident cause analysis processes with interim cause analysis system developed. 90% of all incidents will be reported using the online incident reporting system by Complete focused group discussions and comprehensive review by Components of desired cause analysis program finalized and implementation plan developed by March 31,