2014/2015 Mississauga Halton CCAC Quality Improvement Plan

Transcription

1 2014/2015 CCAC Quality Improvement Plan February, 2014 Approved by the MISSISSAUGA HALTON CCAC Board of Directors March 5, 2014 Community Care Access Centre 1

2 Overview of Our Organization s Quality Improvement Plan (QIP) OVERVIEW The Community Care Access Centre ( CCAC) takes pride in the vital role we play within the health care system ensuring our patients receive the care they need to help them live safely at home and when necessary, supporting them in moving to long-term care. We are committed to our vision of providing outstanding care to every person, every day, and our first Quality Improvement Plan (QIP) aligns with and supports this vision as well as our mission, values, and strategic and operational plans. Our plans in turn support provincial health system priorities, and local priorities as outlined in the Mississauga Halton Local Health Integration Network (LHIN) Integrated Health Service Plan Partnering for a Healthier Tomorrow. Of primary importance for us in our work is being patient-centred, implementing evidencebased practice to drive quality and safety, enhancing co-ordination of care, fostering safe patient transitions, and working together with our contracted service providers and other health system partners to improve care for our patients. FOCUS OF OUR QIP IN In developing this first, formal QIP for the CCAC, we have worked with the 13 other CCACs in Ontario, Health Quality Ontario and the Ministry of Health and Long-Term Care to identify five primary objectives to focus on provincially: Reduce falls among long-stay home care patients Reduce the number of unplanned Emergency Department visits among home care patients Reduce avoidable hospital admissions among home care patients Reduce service wait times Improve patient experience The CCAC Strategic Plan is well aligned with these provincial objectives. In our Strategic Plan, we pledge to our patients that we will keep them safe at home, eliminate needless wait times and eliminate needless hospitalizations. Much of our work over the past three years has been guided by these pledges. Through this QIP, we want to guide our next quality improvement efforts to build on these successes by achieving measurable improvements in some of the five measures. In doing so, we will also sustain and improve our performance in others. As a result, the Mississauga Halton CCAC has chosen to focus improvement initiatives on three of these five primary objectives: 1) Reduce falls among long-stay home care patients 2) Reduce service wait times 3) Improve patient experience Community Care Access Centre 2

3 We ve chosen these three objectives because we want to be focused on things that we can reliably and accurately measure and report on in a timely way. For the remaining two provincial objectives (reducing unplanned Emergency Department visits and avoidable hospital admissions) current, reliable, near-real time data is not available. Working to reduce unplanned Emergency Department visits and avoidable hospital admissions is still important and we work every day with our service provider and hospital partners to try and avoid them: We have standardized our care coordination practices through the implementation of the population based Client Care Model and its associated Standards of Care which ensure regular patient follow-up, regular reassessment of care needs and helps patients navigate through the health care system Our work with hospitals, family health teams, community support services agencies, long term care homes and others through Health Links focuses on supporting and caring for patient who are very high users of the health system (i.e. have frequent Emergency Department visits and hospital admissions) We have moved towards evidence based care coordination by adopting pathways to guide our patient care, and, Our work in Primary Care Integration helps connect our Care Coordinators more closely with Family Physicians and Family Health Teams, strengthening the health care team supporting patients and helping to prevent visits to the Emergency Department We ll work to get better, more reliable, near-real time data in place on unplanned Emergency Department visits and avoidable Hospital admissions in the next year, and use it to identify new focused improvement initiatives to include in our next QIP. For the three objectives we have chosen to focus on (reducing falls, reducing service wait times and improving patient experience), the planned improvement initiatives included in our 2014/15 QIP reflect improvement work already identified in our Strategic and operational plans, and are outlined below: 1) Reduce falls among long-stay home care patients To reduce falls among home care patients, we will: Develop and implement a Chronic/Complex Patient Population programming that will include: o Leveraging the LHIN falls prevention program o Continuing to spread our Medication Management program (the use, nonuse or inappropriate use of medications is a contributing factor to falls) o Continuing to leverage evidence based practices in caring for patients with complex or chronic conditions. Develop and implement a Home Independence Program targeting seniors to help them regain independence in activities of daily living following a decline in health or hospitalization Community Care Access Centre 3

4 2) Reduce service wait times Our work in reducing service wait times will focus on waits for Personal Support Worker (PSW) services for Complex Patients, and waits for Nursing services. Improvement initiatives identified to reduce service wait times are: Redesigning our process for assessing patients at intake which will change the way we assess patient needs when they first call or are referred to the CCAC for services. Improving how we assess patients when they first come to the CCAC helps us determine their needs, develop care plans and start Personal Support Worker (PSW) or Nursing visits more quickly. This is part of a larger initiative at the CCAC we call Core Business Redesign. Using technology to provide a better means means of sharing patient information with our health system partners. This lets CCAC staff access the patient information they need to develop patient care plans and start PSW and Nursing visits for patients more quickly. We call this work the One Clinician Model. 3) Improve patient experience We will work to improve patient experience with CCAC services through two main initiatives: Implement our Share Care Council which provides a direct voice for patients and their caregivers in informing the development of our new programs and services Redesigning our processes for system navigation at intake and for care planning and monitoring (also part of our Core Business Redesign work) o Improving system navigation at intake means when patients, caregivers or family members call the CCAC to ask about or start services, we are better able to connect them not only to services provided through the CCAC, but also to services offered by our other health system partners (and helps reduce frustrations patients feel in trying to navigate the health system). o Improving care planning and monitoring means we are working to ensure we re caring for the whole person - not just a medical condition - as a care team to keep patients safe at home and connect them with needed supports. This includes making sure patients are involved in their care planning and care, they have the information they need to live safely at home, and know who to call if they have any questions. Community Care Access Centre 4

5 INTEGRATION AND CONTINUITY OF CARE CCAC continually looks for collaboration and integration opportunities with our health system partners (service provider organizations, hospitals, long-term care homes, community support services agencies, family health teams, family physicians and other organizations). We also work closely with the other CCACs in the province to ensure consistency in the CCAC services provided across Ontario, and work to ensure continuity of care when patients move from one CCAC to another. In addition to involving our health system partners in our QIP improvement initiatives (outlined in the previous section above), we are also working with them on a number of other initiatives, including: Development of a shared balanced scorecard for community services, with Central West CCAC, and community health services and mental health and addictions agencies in the Central West and LHINs, to help us understand our performance and identify opportunities for shared quality improvement initiatives Working more closely with our primary care partners (an area of focus for the CCAC) to better connect Family Physicians and Family Health Teams with the CCAC and improve the care provided to our shared patients. In some instances, embedding CCAC Care Coordinators in the primary care office is helping to improve access to broader community services for patients and thereby reducing avoidable hospital use and proactive care planning. Establishment of Health Links within the LHIN to improve care for seniors and others with complex conditions. This work brings together family physicians, specialists, hospitals, long-term care providers, community support agencies, CCACs and others to improve care planning, co-ordination of care and information sharing among health providers. Implementing Outcomes Based Pathways for wound care, hip and knee replacements, and palliative (end-of-life) patients with Service Providers and other CCACs across the province to ensure we are providing standardized, evidence-based care to patients with these conditions CHALLENGES AND RISKS Improvement initiatives which are within the CCAC s ability to influence or control are at much lower risk than those that require commitment from broader health system partners. However, a potential risk to accomplishing these improvement initiatives is the draw on resources that occurs with competing priorities. By focusing on our identified improvement initiatives and ensuring alignment of this work with our strategic priorities, we will optimize the organizational capacity to respond to new, emerging priorities without compromising the success of these improvement initiatives. Once we have completed the improvement initiatives identified in our QIP, we will evaluate their impact. By that time we expect to have our data on unplanned Emergency Department visits and avoidable hospital admissions and understand the impact of our QIP work on these measures, in addition to our three primary objectives (reduce falls, reduce service wait times, improve client experience). Community Care Access Centre 5

6 INFORMATION MANAGEMENT CCAC relies heavily on information to provide care to patients, plan services to meet community needs, manage day-to-day operations, and anticipate future needs for the organization and the community we serve. Managing information effectively and using technology to collect, store and exchange information within the organization and with partners helps provide a seamless patient care experience and helps the organization function effectively. As well, we adhere to our privacy policies and procedures related to the protection and confidentiality of personal health information. Because of the importance of information to the work we do, we have developed a Business Information Management (BIM) Strategy that outlines our information management and technology needs and priorities. The BIM Strategy includes a road map which identifies the specific pieces of work the organization will do over the next 3 years to improve the information and technology enabling our Care Coordinators to deliver high quality, safe care to our patients every day, monitor how well we are achieving our performance (including QIP) objectives and ensuring value for money in the services we deliver. To help us monitor our performance towards our Strategic Plan and quality improvement objectives, CCAC has a Balanced Scorecard. The Balanced Scorecard reports on our performance against key measures and targets we have established for ourselves, and is reviewed quarterly by our senior executives and by our Board of Directors. ENGAGEMENT OF STAFF AND LEADERSHIP Each staff member at the CCAC has a role to play in providing high quality, safe health care to patients - from client facing staff members and organizational support staff to organizational leaders and Board members. Just as we work to collaborate with our health system partners to improve the services we, and the health system, provide, we work to engage and include our staff members in our improvement work too. Staff members from across the organization participate in our improvement work in various ways, including as members of the working groups leading each improvement initiative, as participants in visioning exercises or focus groups, or as Champions (local experts) for some of our change initiatives. ACCOUNTABILITY MANAGEMENT Our QIP will be monitored and tracked throughout the year by our Senior Leadership Team, the Client Services & Quality Committee of the Board, and the CCAC Board of Directors. As well, the QIP indicators and data will be shared with Mississauga Halton CCAC staff, our Quality Council, and with our service provider organizations at quarterly meetings. In addition, the completion of individual improvement initiatives are incorporated as objectives into the performance evaluations of individual leaders accountable Community Care Access Centre 6

7 for implementing these initiatives. Their success at obtaining the initiative s objectives influences their final overall performance evaluation which in turn affects their merit-based compensation increases. Accountability Sign-off I have reviewed and approved the CCAC's 2014/2015 Quality Improvement Plan. Caroline Brereton Chief Executive Officer Rob Stansfield Board Chair Community Care Access Centre 7