2) Reduce falls through "Falling Star" program. 3) Reduce falls by providing education to staff and residents

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1 Yee Hong Centre for Geriatric Care Mississauga Division: Quality Improvement Plan /17 Aim Measure Change Ideas Quality Dimension & Objective Falls Measure/Indicator % residents who had a recent fall (in the last 30 days) Current 11.3% 10.8% 9% justification better HQO ON Avg. 14.1% YH Avg. 9.5% HQO 9% Planned improvement initiatives Change Ideas) Methods Process measures 1) Conduct root cause analysis in post fall huddles 2) Reduce falls through "Falling Star" program 3) Reduce falls by providing education to staff and residents 4) Reduce falls by providing education to families A huddle is being held after each fall incident. The purpose is to investigate root causes in relation to infections, responsive behaviors, worsening bladder continence, etc. Data are being analyzed and compared on a monthly and quarterly basis. Nurse managers send s to remind staff and inter-disciplinary team on a monthly basis. Staff update "falling star" signs for resident with frequent fall incidents. The "falling star" logo will be serves as a reminder for the team including families, volunteers and students to take caution and extra attention on frequent fallers. Stars will be put on mobility devices, resident charts and flow sheets, beside room number outside the room. Residents will be discharged from the falling star program when there is no fall incidents in 3 months Physiotherapy Assistants conduct falls prevention exercise education to residents twice a week per floor in morning group exercise class. Mandatory participation of all staff in falls prevention program education once a year. Provide education to families through newsletter at least once a year. % of post fall huddles completed every quarter % of compliance for updating the star status for residents who are high-risk for fallers on a monthly basis % of fall prevention exercise education done per week % of fall prevention education done for families on an annual basis Goal for change ideas by June 30, by June 30, for fall prevention exercise education done per week by June 30, Complete at least 1 newsletter by December 31, 1 P a g e

2 Worsening of Pressure Ulcers % residents who has a pressure ulcer that has become worse recently 2.4% 2.33% 1% better HQO ON Avg.3.4% YH Avg. 1.9% HQO 1% 5) Review and improve current practice on fall prevention and post fall management To continue to improve and maintain effectiveness and quality of care, we maintain our current practice for worsened pressure ulcer stages 2 to 4 indicator sand closely monitor those residents who are at risk. The HQO stretch benchmark is 1% (top 90th percentile in the province of Ontario). We are performing near that benchmark. Establish and implement a corporate task force on fall prevention # of meetings and actions implemented 2017 the Use of Restraints Effectiveness: To Reduce the Inappropriate Use of Anti psychotics in LTC Effectiveness: To Reduce Worsening Bladder Control % residents who are physically restrained (daily) % residents on antipsychotics without a diagnosis of psychosis % residents with worsening bladder control during a 90-day period 4.5% 4.38% 14.1% 11.46% 19.3% 5.96% 3% 24.9% 12% better HQO ON Avg. 6.9% YH Avg. 3.7% HQO 3% better provincial ON Avg. 24.9% YH Avg. 15.7% HQO better HQO ON Avg. 18.2% YH Avg. 16.7% HQO 12% Our physical restraint numbers continue to be stable. We have incorporated our least restraint policy and procedure. The residents who are on physical restraints are mainly due to strong request from families. We will participate in the corporate task force on reducing falls and restraints. We will continue to monitor the use of restraints closely. Yee Hong Mississauga is performing well on this indicator. Continue to maintain current practices and closely monitor. 1) Provide education regarding POC documentation for continence for PSW's Educate POC documentation for continence for PSWs. ADRC will provide POC continence documentation education for PSW's at least 2 times per floor per year and for newly hired staff. % of education provided to each floor by June 30, 2 P a g e

3 2) Review MDS coding associated with continence to ensure accurate coding. 3) Verify the accuracy of worsened bladder prior to completing MDS assessment each quarter or when there s significant change in health status 4) Ensure all residents continence assessments are completed and including health condition change Aim Measure Change Quality Dimension & Objective Resident-Centred Care: Receiving and utilizing feedback regarding resident quality of life. "Having a voice". Measure/Indicator % residents responding positively to: "What number would you use to rate how well the staff listen to you?" (NHCAHPS) Current 51.67% More justification better divisional Baseline data Audit MDS assessments to measure data accuracy related to coding of worsening of bladder control and follow up with registered staff as appropriate on a monthly basis Primary nurses will review those with worsening bladder and will verify the information with PSWs if the information is correct each time they updated the MDS assessment RNs/RPNs will complete continence assessments for all residents and when there s health condition change % of MDS audits conducted monthly % of review completed by primary nurses % of assessment completed Planned improvement initiatives (Change Ideas) Methods Process measures 1) Increase staff awareness on resident-centred care Annual training for staff to review policies and procedures on resident abuse, duty to report, concern and complaint, and whistle blower protection. % of staff attending the corporate training every year Goal for change ideas % of residents responding positively to: "I can express my opinion without fear of consequences." (InterRAI QoL) 50.0% 63.33% More 50.0% better divisional Baseline data 2) Listen and address to the residents/families concerns and complaints 3) Enhance residents' experience by incorporating feedback from resident council meetings Track each concern/complaint and document actions taken to address the concern/complaint and review at DQC Ask for residents' feedback at Resident Council meetings every quarter on the following programs: falls, restraints, infection control, continence care, skin and wound care programs Number of concern and complaint per quarter Number of programs reviewed at Resident Council meeting per year 3 P a g e

4 4) Promote family and resident engagement by providing education on the topic Collaborate with resident and family to develop a brochure on family and resident engagement Include the brochure in the admission package and go through the topic during admission. The brochure is completed and the process is implemented by June. Residents/families eager to get involved and/or participate in committee work actively. Resident Centred Care: Receiving and utilizing feedback regarding resident quality of life. "Overall Satisfaction" % residents responding positively to: "Would you recommend this nursing home to others?" (NHCAHPS) 71.67% More better divisional Baseline data 5) Promote family and resident engagement by sharing care program information and actively seeking their feedback for improvement 6) Simplify the care plan language so residents and families can be better engaged 7) Draw feedbacks from residents/families of those transferring to another facility and from families of deceased resident Post the brochure in reception area for visitor pick up. Prepare care program information in layperson language, present to members of resident and family councils and seek their feedback Establish a working group to review the current care plans then collaborate with the inter-professional team, residents and families to revise the care plans. Exit interview on resident transferred to another LTC home, consider interview family of deceased resident Presentation is produced for all care programs by June Care program information is presented to each family and resident council meeting. Number of care plans revised every quarter Number of exit interviews conducted Members of Resident and Family Councils satisfied with the information provided and eager to provide suggestions for improvement. 30% of care plans revised by December 31, Integrated: To Reduce Potentially Avoidable # emergency department (ED) visits for modified list of ambulatory better corporate 8) Understand why residents do not want to recommend Yee Hong then make improvement accordingly 1) Yee Hong Mississauga is performing well for this indicator. Continue to maintain current practices Add follow up questions to the resident survey to investigate why residents do not want to recommend Yee Hong then make appropriate improvement based on the residents comment. All residents do not recommend Yee Hong are asked the follow up questions in the yearly survey. Residents are willing to provide suggestions to Yee Hong and Yee Hong makes necessary improvement accordingly, 4 P a g e

5 Emergency Department Visits care sensitive conditions* (ACSC) per 100 long-term care residents Corp. Avg 17.6 ON Avg 24.6 HQO and closely monitor. 5 P a g e

6 Progress Report on 2015 QIP Aim Measure Progress Report Quality Dimension & Objective Falls Measure/Indicator % residents who had a recent fall (in the last 30 days) Current 11.3% 10.8% 9% justification Meeting HQO ON Avg. 14.1% YH Avg. 9.5% CHANGE IDEA 1)Conduct root cause analysis in post fall huddles 2)Reduce falls through "Falling Star" program 3)Reduce falls by providing education to staff and residents 4)Reduce falls by providing education to families 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? Performing well? Yes or No: No No Enter summary here: Will continue with the post fall huddles immediately after the fall incident. Yes Include Falling star logo awareness for students, families and volunteers Enter summary here: Residents with frequent fall incidents have improved. We will continue with promoting awareness of the Falling star program for all staff, students, families and volunteers Yes New admitted residents will be closely monitored. Client coming in with high risk for falls will be flagged on admission. Enter summary here: PTAs continue daily morning group exercises that include education for preventing falls for residents. Annual fall prevention education provided to all staff and on orientation for new staff. Yes Include in the Newsletter for families and residents Enter summary here: Education on Fall prevention was given at family council. Worsening of Pressure Ulcers the Use of Restraints % residents who has a pressure ulcer that has become worse recently % residents who are physically restrained (daily) 2.4% 2.33% 4.5% 4.38% 1% 3% Meeting HQO ON Avg.3.4% YH Avg. 1.9% Meeting HQO ON Avg. 6.9% YH Avg. 3.7% 1)Reduce the use of restraints by providing education and training to staff Enter summary here: Continue with current practice and closely monitor pressure ulcers Yes Introduced half trays for resident with full lap trays with effect. Enter summary here: Our physical restraint numbers continue to be stable. We have incorporated our least restraint policy and procedure. The residents who are on physical restraints are mainly due to strong request from families. We will participate in the corporate task force on reducing falls and restraints. We will continue to monitor the use of restraints closely. 6 P a g e

7 Effectiveness: To Reduce Worsening Bladder Control Effectiveness: To Reduce the Inappropriate Use of Anti psychotics in LTC Resident-Centred: Receiving and utilizing feedback regarding resident quality of life. "Having a voice". % residents with worsening bladder control during a 90- day period % residents on antipsychotics without a diagnosis of psychosis % residents responding positively to: "What number would you use to rate how well the staff listen to you?" (NHCAHPS) % of residents responding positively to: "I can express my opinion without fear of consequences." (InterRAI QoL) 19.3% 5.96% 14.1% 11.46% 51.67% 50.0% 63.33% 12% 24.9% Meeting HQO ON Avg. 18.2% YH Avg. 16.7% Meeting provincial ON Avg. 24.9% YH Avg. 15.7% 0 No benchmark available. Collecting baseline for comparison. 0 No benchmark available. Collecting baseline for comparison. 2)Reduce the use of restraints by providing education to families 3)Increase the accuracy for capturing the use of restraints 4)Reduce the use of restraints by increasing the use of alternative approaches 1)Increase staff awareness for resident-centred care 1)Enhance residents' experience by incorporating feedback from resident council Enter summary here: Provided education on Physical restraints on family council. Will include in newsletter Enter summary here: Since the introduction of POC, PSWs have been documenting on restraint monitoring in POC Enter summary here: Alternatives are tried first and to reduce restraint use, other devices were introduced and are effective. Performing well? Yes or No: No Enter summary here: With the introduction of POC March 2015, we have seen an increase incidents of worsening bladder. Will need to validate the data accuracy from the frontline. 1. Educate POC documentation for continence for PSWs. ADRC SP will provide POC continence documentation education for PSW's every quarter and for newly hired staff. 2. RN/RPNs will review those with worsening bladder to verify the information with PSWs if the information is correct every time they updated the MDS. 3. Ensure all residents continence assessments are completed and including condition change Enter summary here: Continue with current practice and closely monitor the appropriate use of antipsychotics Yes Promote customer service Enter summary here: Continue with current practice Enter summary here: Corporately is looking at revising the questions asked when translated to Chinese and to be culturally sensitive. 7 P a g e

8 Resident Centred: Receiving and utilizing feedback regarding resident quality of life. "Overall Satisfaction" Integrated: To Reduce Potentially Avoidable Emergency Department Visits % residents responding positively to: "Would you recommend this nursing home to others?" (NHCAHPS) # emergency department (ED) visits for modified list of ambulatory care sensitive conditions* (ACSC) per 100 longterm care residents 71.67% No benchmark available. Collecting baseline for comparison Meeting Mississauga Halton LHIN Ccrp. Avg 17.6 ON Avg 24.6 meetings 1)Improve residents' overall satisfaction by encouraging resident participation in auditing laundry items Enter summary here: Corporately is looking at revising the questions asked when translated to Chinese and to be culturally sensitive. Enter summary here: We will continue with our current practices and will monitor the appropriate ED transfer closely. These practices include: 1) Collecting ED transfers data and analysis for referral reasons grouped by diagnosis, referral time of a day & days of a wee to identify any educational needs of the staff in reducing potential avoidable ED visits. 2) Nursing staff will consult NP at resident condition changes for proactive treatment 3) Inter-professional staff discuss with residents/sdm to establish his/her advance care planning/ goals of care on admission and review at annual care conference, at significant change of conditions and at palliative care team meetings. 4) Continue to keep balance between the best utilization of the resources and the culture values of the residents and their families. 8 P a g e