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

Transcription

1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 02/1/2017 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. North York General Hospital 1

2 Overview A Quality Improvement Plan (QIP) is a formal, documented set of commitments that a health care organization makes to its patients, staff and community on an annual basis to improve quality through focused targets and actions. This narrative contains the summary of North York General Hospital s (NYGH) QIP journey over the past year. It shows how our culture of quality and safety has evolved while maintaining our focus on patient- and family-centred care. NYGH s QIP was developed through the hospital s QIP committee. The committee is comprised of an interdisciplinary group of staff, physicians and a patient and family advisor. The NYGH 2016/17 QIP includes feedback from our Patient and Family Advisory Council, Quality of Care Committee, Board Quality Committee, and hospital performance data. In 2017/2018, North York General will continue to work with the Joint Centres for Transformative Health Care Innovation (The Joint Centres). The Joint Centres is a unique partnership between six large community hospitals including Mackenzie Health, Markham Stouffville Hospital, Michael Garron Hospital, North York General Hospital, Southlake Regional Health Centre and St. Joseph s Health Centre. The inclusion of the work of the Joint Centres in our QIP is intended to reinforce our commitment to improvement through collaboration and to leveraging the knowledge, expertise and experience of our partners to maximize the benefits across all of our hospitals. The member hospitals will continue to work together on a number of spread initiatives designed to improve quality, safety and value in healthcare including: reducing the rate of Clostridium difficile infections, reducing the percentage of Caesarean Sections (C-section) performed and reducing unnecessary tests through Choosing Wisely which received ARTIC funding through Health Quality Ontario (HQO) and Council of Academic Hospitals of Ontario (CAHO) to further advance spread of leading practices across the participating hospitals and affiliated primary care practices. In addition, all six hospitals are sharing leading practices for adaptation for the prevention of workplace violence. This work includes creating a common approach to identification, assessment and care planning for patients at risk for violence. For , an additional area of focus for the Joint Centres will be on reduction of harm through an applied learning approach. This year, NYGH will add two new priority indicators to the QIP measuring patient satisfaction with information received on discharge and rate of palliative patients discharged home with supports. As well, we will include reduction of 30 day readmissions for Congestive Heart Failure, reduction in avoidable C-Section rates, and medication reconciliation on discharge. Three others indicators from the 2016/2017 QIP, reduction in 30 day readmission rates for select Health Based Allocation Model Inpatient Groupings, clostridium difficile (C. Diff) infection rate, and medication reconciliation on admission, will be discontinued for the 2017/2018 QIP. The C. Diff infection rate will be removed from the QIP because of NYGH s strong performance on this indicator. We will continue to post C. Diff rates on NYGH s external website. The rate of medication reconciliation on admission will also be removed in 2017/18 because the hospital has achieved the targeted performance level. Both indicators will continue to be monitored and reported on North York General s internal Quality Dashboard to ensure sustained improvements. North York General Hospital 2

3 QI Achievements from the past year In early 2016, NYGH became accredited with Exemplary Standing, the highest designation given by Accreditation Canada. Every two to four years, hospitals, long-term care facilities and other health organizations participate in a voluntary accreditation process to assess performance against national standards of health care excellence. In addition, NYGH s breast cancer care program, which includes the BMO Financial Group Breast Diagnostic Centre, became the first comprehensive breast cancer care program in Canada to receive full accreditation from the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. Accredited breast centres must demonstrate compliance with standards established by the NAPBC for treating women who are diagnosed with breast disease. The standards include proficiency in the areas of: centre leadership, clinical management, research, community outreach, professional education and quality improvement. A breast centre that achieves NAPBC accreditation has demonstrated a firm commitment to offer its patients every significant advantage in their battle against breast cancer. NAPBC accredited centres ensure patient access to: Comprehensive care, including a full range of state-of-the-art services, A multidisciplinary team approach to coordinate the best treatment options, Information about ongoing clinical trials and new treatment options and most importantly, Quality breast care close to home. Since 2012, North York General s surgical program has led the provincial wait times in four specific areas: hip and knee replacements, and cataracts and cancer surgery. In 2015/16, NYGH, for the third year in a row, was acknowledged by Cancer Care Ontario (CCO) for being the top performing hospital for cancer surgery wait times, measured from the decision to treat to the start of treatment. North York General Hospital 3

4 Population Health An analysis of neighbourhood demographics within NYGH s service area suggests that significant differences exist between different communities in our catchment area. With neighbourhoods ranging in population from several thousand to approaching 30,000 inhabitants, the overall construct of these communities differ with respect to their demographic characteristics. New evidence is showing us that as our population ages, so do the rates of chronic diseases, and we are seeing higher rates of diabetes among minority populations. We also know that people living with chronic illness often have other types of illness as well, such as asthma, diabetes, and high blood pressure. This data supports the Local Health Integration Network (LHIN) priorities to improve senior care, including greater access to mental health programs and improved chronic care management. To better manage and improve the health of our community, NYGH has initiated many programs in partnership with primary care and other community partners. For our senior population, we have: Rolled out the Confusion Assessment Method tool to assist with the identification of symptoms of confusion or delirium, Launched Assess and Restore in partnership with the Central Community Care Access Centre (CCAC) to identify frail seniors who have the potential to regain functional ability caused by a medical event or decline in health, Launched an innovative model of shared care within our Geriatric Outreach Team that has a family physician with Care of the Elderly designation and a CCAC care coordinator to see our frail, elderly and homebound population in their homes, and Continued to increase the number of Hospital Elder Life Program (HELP) volunteers to increase touch time with the frail elderly through visits, support with mobilization and assistance with daily activities on our inpatient units. To provide greater access to mental health programs, we have: Created a standard process for managing and triaging referrals. Re-launched our Access to Resources and Community Support (ARCS) program which provides short-term case management to patients who present to the emergency department (ED) experiencing a mental health crisis. The goal of the program is to expedite patients to the appropriate outpatient or community mental health program. To improve chronic care management, we have: Enrolled over 700 patients in the North York Central Health Link and we are completing approximately 30 Coordinated Care Plans each month in partnership with the Central CCAC, primary care, Toronto Paramedics, community support and mental health agencies to improve care to individuals with complex care needs, Helped facilitate warm handoffs between specialists and primary care providers through our new physician directory available on our external website, North York General Hospital 4

5 Increased access for family physicians to General Internal Medicine physicians through medical consults on-call to obtain a quick, urgent opinion in order to avoid unnecessary ED visits and improve patient experience by reducing unnecessary waiting and redirects, and Implemented Integrated Funding Models in partnership with Central CCAC, Saint Elizabeth Health Care, North York ProResp Inc., West Park Healthcare, Circle of Care and the North York Family Health Team, to provide a transitional program where persons with chronic diseases can develop skills to self-manage Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). These areas of focus and programs are integral components in the NYGH strategic plan. Not only does our strategy strive to address the needs of our community but it also aligns with the Ministry of Health and Long-Term Care (MOHLTC) and Central LHIN s priorities of patients first, appropriate care in the right setting, access to care across the continuum of need (acute, ambulatory, long-term care), integration, and reduced variation in access and care outcomes. North York General Hospital 5

6 Equity Partnering with our patients and families is at the heart of our patient- and family-centred care philosophy at North York General Hospital. We recognize that all patients and families bring with them unique personal values, beliefs and customs. These characteristics are important to us, helping our staff to provide the best care experience possible. Guided by a diversity framework, NYGH has mobilized individuals from different disciplines across the hospital to form our Diversity Working Group. This group works collaboratively to identify opportunities and to provide recommendations on programs and initiatives designed to meet the needs of our diverse staff and patient population. In addition, the hospital has developed a multi-module diversity champions training program, which has produced 114 graduates who now act as ambassadors for diversity and inclusion at NYGH. Enhancing our awareness and knowledge of underrepresented groups drives enhanced sensitivity and improved care for our patients and their families. In 2016, more than 700 staff and volunteers have attended enhanced diversity workshops. These information sessions moderated by guest speakers from representative groups/community agencies have touched upon a number of topics, including: Deaf-Blindness 101 Supporting Refugees from Syria Religious Understanding (Hinduism, Islam, Buddhism) Introduction to LGBTQ Emotional and Mental Health Changing Labour Market: Generational Differences Mental Health Stigma NYGH s Diversity Services program develops tools to help staff understand and respond to patients and families needs. This year s highlights for Diversity Services include: An annual Diversity Calendar and a Cultural and Religious Diversity Guide created to improve awareness of different cultural observances. An Adversity pamphlet recently released in high-volume areas of our hospital, offering information on services and resources available at NYGH to assist patients and families overcome potential barriers related to language or culture. More than 2,000 hours of on-site interpretation and 14,000 hours phone interpretation services offered in more than 60 languages. A communication tool developed in our Reactive Acute Care Unit to assist patients who have difficulties expressing themselves and communicating following a stroke. North York General Hospital 6

7 Integration and Continuity of Care Integrated Care Collaborative The Integrated Care Collaborative (ICC) is a model of care based on Michael Porter s Healthcare Value Based Model to improve patient care. Learning from two previously successful ICC implementations, NYGH has decided to launch a third ICC, focused on colorectal cancer patients using guidelines from CCO s clinical pathway. A key component of any ICC is the role of the Nurse Navigator. As a result, the aim of the project is to implement and assess the Nurse Navigator role as it relates to the new model of care delivery for colorectal cancer that integrates hospital care with primary care and community providers. The Colorectal ICC is a one-year pilot project. NYGH s Colorectal Cancer ICC is poised to achieve the following outcomes by September 2017: Improved health outcomes of colorectal cancer patient populations, Improved coordination and care of patients across the care continuum, Increased volumes, Decreased cost per weighted case and cost of providing high quality services below Qualitybased Procedure Funding, and Increased patient satisfaction. Integrated Funding Models Ontario needs innovative system transformation that integrates care across the healthcare continuum for people living with CHF and COPD. The Integrated Funding Model (IFM) was proposed by the Ministry of Health and Long-Term Care as a solution to allow patients to easily transition across health care sectors through navigation lead by one health care provider known as a clinical care consultant. The aim of the IFM is to provide a transitional program where persons with chronic diseases can develop skills to self-manage their chronic diseases of CHF and COPD. NYGH is leading a provincially supported IFM for patients living with CHF and COPD, called The North York Central Integrated Care Collaborative for COPD Patients. NYGH is working in partnership with Central CCAC, Saint Elizabeth Health Care, North York ProResp Inc., West Park Healthcare, Circle of Care and the North York Family Health Team in the development, implementation and evaluation of clinical pathways that stretch from hospital admission to 60 days after hospital discharge. A target patient population of mid to late stage progression of CHF or COPD was selected as patients who are most likely to benefit from targeted disease education. Project framework and pathways were developed in partnership with patient family advocates, community provider agencies, and interprofessional acute care teams including physicians and specialists. Standardized care pathways start on admission to NYGH and continue for eight weeks after discharge. Pathway innovations include consistent case management, a 24/7 phone line; a Pulmonary Rehab program; patient specific Action Plans and a Heart Function Clinic. Health Links Since the launch of the North York Central Health Link, an integrated team of acute, community and primary care professionals, have worked together to support 765 patients with complex needs. Health Link clients are identified by having four or more co-morbidities, economic characteristics and social determinants of health or part of specific sub-group including frail elderly, palliative and/or mental health and addictions. This target population represents the top 5% of health care system users. North York General Hospital 7

8 The Health Links approach identifies this target population in our sub-region, attaches them to a dedicated care coordinator, develops a Coordinated Care Plan based on the patient's goals with input from all members of the care team and manages and coordinates their care. Some innovative features of the North York Central Health Link include flagging enrolled patients in the hospital information system to ensure the care team is aware of them and can leverage the Coordinated Care Plan, and holding Community Rounds once a month with our community partners to discuss and review challenging cases. As well, an active Patient and Caregiver Advisory Committee provide feedback and ideas to the model of care to ensure it is best meeting the needs of our target population. Health Links works with the IFM team to ensure that patients appropriate for Health Links are identified at a certain point along the prescribed CHF or COPD care pathway. The referral to Health Links will result in coordinated care extended beyond the purview of the IFM pathway, with the aim of decreasing re-admissions to acute care. Over the next year, the North York Central Health Link will focus on increasing the identification of patients in the community and primary care, ensuring that all patients have a Coordinated Care Plan within 30 days of enrollment and increasing patient and caregivers understanding of Health Links and their Coordinated Care Plan. Collaboration with our Community Care Access Centre (CCAC) NYGH is working with the Central CCAC to arrange joint family meetings earlier in the process as a first step in supporting timely and appropriate discharge planning. Joint Centres for Transformative Healthcare Innovation The Joint Centres for Transformative Healthcare Innovation is a partnership between large community hospitals to share innovations focused on improving quality and value in health care. This includes creating a platform for the sharing of innovations focused on improving quality and value in health care with an aim to: Seek and share innovative ideas that improve service delivery and/or value across the system Serve as a living laboratory to demonstrate innovation Provide a forum for the rapid execution of new ideas, technologies, products and processes to improve system performance Provide a test environment for Ministry of Health and Long-Term Care and/or LHIN sponsored innovation and demonstration projects Create opportunities for shared innovation, learning, and knowledge transfer among the member organizations, their staff and physicians This work also supports broadening the perspective around: Community integration, Health system funding reform, Innovative delivery models, Teaching and education, and Innovation and research in patient centered care. NYGH will continue to work with the Joint Centres to share and adapt leading practices of direct relevance to large community hospitals to improve quality, patient safety, value and accountability in health care and support participation of patient and family advisors in the joint activities. Strategies to drive further improvement in reducing C-difficile infections, reducing the rate of unnecessary C- Sections, and reducing incidents of workplace violence are identified and shared amongst the Joint Centres. North York General Hospital 8

9 Access to the Right Level of Care - Addressing Alternate Level of Care Issues In seeking to improve the efficiency of care at NYGH, previous QIPs have consistently included the rate of Alternate Level of Care (ALC) across the organization. ALC refers to the time a patient occupies a hospital bed but does not require the intensity of resources/services provided in this care setting, as defined by the Ministry of Health and Long-Term Care. NYGH has emphasized ALC as an important indicator due to the demand it represents on scarce acute care resources and its impact on enabling patient flow from the emergency department (ED) to inpatient care. One initiative introduced to tackle the issue of rising ALC rate across the province has been Assess and Restore (A&R) Project. The A&R Project is a 3-year LHIN partnership with NYGH and community partners, where patients are provided enhanced restorative service while in hospital, preventing deconditioning and allowing those that might normally have been in ALC status to go home with community support services. Once in the community, these patients receive rapid access to community support service through the CCAC to help prevent readmission. The A&R Project is enabled by the development of an integrated pathway to rehabilitation that follows A&R patients across care settings, reducing hand-offs and assessments, and providing more continuity for patients and families. NYGH first focused on enhancing both in-hospital and in-home rehabilitative therapy services to frail seniors awaiting placement in a specialty rehabilitation hospital, with a plan to widen the target population to patients at risk of becoming ALC and those presenting to the ED with rehabilitative needs. The combined goal of the in-hospital and in-home therapy enhancements is to reduce the hospital length of stay, as well as to enable home rehabilitation as an alternative to a specialty rehabilitation hospital or convalescent care facility. In the first full year between August 2015 and August 2016, 744 patients have received enhanced services. In this time, 89 clinicians have been trained in providing the A&R care pathway, and the program has been able to maintain performance to target on key quality performance metrics: Percentage of unplanned readmissions to hospital within 30 days of discharge has maintained at 9.3% with a target of 9%. Percentage of unplanned, less-urgent ED visit within the first 30 days of discharge has maintained at 2.2% with a target of 2%. Annual ALC rate by post-acute inpatient rehabilitative care services has maintained at 33.4% with a target of 30%. Additionally, there has been a significant improvement in Quality of Life scores, from an initial mean score of 0.43 to 0.63 by April Due to North York General s strong implementation performance the Central LHIN has asked and the program is currently developing a peer education program which will deliver on a roadshow to other hospitals in aim to expand the success of our programs work to other organization. Meanwhile, the implementation of the program has indicated that regular follow-up with referral sources are required address the challenges related to patient identification and referral to the program. The NYGH journey towards care integration will continue by remaining to work closely with our community partners. North York General Hospital 9

10 Engagement of Clinicians, Leadership & Staff In a health care setting where patient experience and great care is at the forefront of every hospital, employee, physician and volunteer engagement goes hand-in-hand with patients receiving high quality care. North York General was recently recognized as having the most engaged staff among 30 participating hospitals. At NYGH, employee engagement is measured through anonymous employee and physician engagement surveys delivered through the National Research Corporation Canada (NRCC). NYGH s overall employee engagement score was 78.5% and our physician engagement score was 89.4%. The survey is sent out to staff, volunteers and physicians on a yearly basis. NRCC analyses the results, shares the final scores with the hospital, as well as positioning each organization in relation to other participating Ontario Hospital Association hospitals. Data collected between from participating hospitals show that NYGH scored top marks for employee engagement, health and safety, patient care and trust in the organization. Several studies show that employees who are engaged at work, who enjoy what they do and care about the organization they are a part of, deliver better work. In an organization such as NYGH, a supportive and collaborative culture is the foundation to providing patients with exceptional care. At NYGH, we recognize that fostering a culture that promotes innovation, learning and staff development is vital in keeping our employees engaged. Highly-engaged teams feel pride in the work they do at the hospital and are committed to providing exceptional care to their patients. North York General Hospital 10

11 Resident, Patient, & Client Engagement Our Patient and Family Advisors play an important role in helping develop a patient- and family-centred care culture at NYGH. Patient and Family Advisors are volunteers who provide important perspectives and have a direct impact across a wide range of hospital initiatives, programs, services and policies to improve the experience of care. Individuals are eligible to become a Patient and Family Advisor if they have received care at NYGH within the past two years or have been the family member of someone who has. We partner with our Patient and Family Advisors to offer them a forum for sharing their unique thoughts and perspectives and to help ensure that the voice of patients and families are heard, considered and included in programs and plans. Currently we have a group of over 50 advisors spread out across our three sites, and an active and engaged Patient and Family Advisory Council composed of 12 advisors alongside staff representatives. Besides being advocates for patients and families, many advisors bring a non-health care industry perspective to NYGH s internal processes and procedures to improve patient experience. Patient and Family Advisors participate in committees related to strategy and quality of care, and the majority of new projects or activities across the organization, including capital redesign, quality improvement projects, employee interviews, new employee orientation, staff education and steering committees, to name but a few. Our aim is to include an advisor s voice at the table in the majority of new and ongoing initiatives to ensure we are always aware of the patient perspective and include it in decision making. The Patient and Family Advisory Council has also had input in the creation of the 2017/2018 Quality Improvement Plan and will continue to work towards the creation of the 2018/2019 Plan. To supplement the expertise of Patient and Family Advisors, NYGH uses both NRCC patient engagement survey data and data received through the Patient Relations Office to identify opportunities for quality improvement. These data also aid in assessing the impact of current quality improvement initiatives. Developing patient- and family- centred care continues to be an organizational priority as reflected by its inclusion in the corporate strategy under the People and Culture Foundation. In 2015/16, the Patient and Family Advisory Council, Patient- and Family-Centred Care (PFCC) Champions and other staff, leaders and physicians were engaged in creating a sustainable work plan that will extend to the end of the current strategy. This work plan is aligned to the People and Culture Strategy and focuses on evolving the PFCC journey to create sustainability practices by ensuring: Leadership accountability for PFCC practices: PFCC Steering Committee has been established to advise, champion and provide guidance in the PFCC journey, as well as to ensure broad representation, participation, input and accountability from the NYGH community Continued involvement of Patient Family Advisors in leadership selection committees, inclusion of PFCC interview questions in interview panels, evaluation of leader s role in contributing to PFCC in the performance management process. The PFCC Advisor Program has been restructured to mirror the organization, recruitment and orientation process of Volunteer Services in order to ensure standardization, transparency and equity in all aspects of recruitment. North York General Hospital 11

12 Identification and implementation of high impact organizational practices: NYGH educated 552 staff members through PFCC education sessions in 2015/16 NYGH educated 623 staff members through PFCC education sessions in 2016/17 New Employee Orientation was restructured to include a 2 hour PFCC simulated educational session. The sessions are facilitated in partnership with Patient and Family advisors Continued partnership with Patient and Family Advisors: To date over 50 Patient and Family Advisors have been recruited across the General site as well as the Branson site For every pillar and foundation, the strategy team worked with Patient and Family Advisors to develop patient impact statements that describe the differences we hope to achieve from a patient s perspective; Patient and Family Advisors contributed their input to a number of initiatives including the development of the Master Plan, the delirium policy, the Freeman Centre for Advanced Palliative Care refresh and to Research and Innovation initiatives. An Advisor has also been an active member of the Workplace Violence Prevention Joint Centres Project. Finally, in 2016, NYGH took the Better Together pledge to eliminate restrictions on visiting hours and improve family presence, to be fully implemented by the end of the current strategy on March 31, North York General Hospital 12

13 Staff Safety & Workplace Violence North York General Hospital is committed to the prevention of workplace violence across the continuum of care, including staff, patients, volunteers and visitors. A multidisciplinary Workplace Violence Prevention program is in place that defines and guides actions to prevent and manage workplace violence and harassment. Elements of this program include: workplace violence prevention and harassment policy, workplace violence risk assessment, reporting, workplace violence training and education. In 2016, NYGH partnered in a Joint Centres spread team project that focused on the implementation of best practices and will support the prevention of violence and reduction in the number and severity of workplace violence incidents at NYGH. The Project aimed to build on strategies developed by all hospitals to create safe and secure workplaces that help achieve the objective of zero tolerance for violence. Leading practices are being identified and developed into a spread playbook that can be shared and adapted by each hospital in areas such as risk assessment, training, flagging, reporting and leadership and staff engagement. An established workplace violence subcommittee is currently reviewing the workplace violence program, planning the integration of in the Joint Centres Spread Project strategies on preventing workplace violence, and raising awareness about workplace violence. Incidents of workplace violence relating to the Occupational Health and Safety Act are reported to the Occupational Health, Safety and Wellness Department through the Safety Learning Incident Management Process (SLIP). SLIP incidents are to be reviewed, followed up upon and signed-off by the respective managers. Occupational Health also works closely with Patient Experience Specialists in the Patient Experience and Quality Department. One initiative that will come to fruition in 2017 includes the revision of the SLIP reporting process for workplace violence incidents after feedback from our frontline staff. It is our goal to ensure that all incidents are reported and can be done in a clear manner for our staff. Training is also an integral part of the workplace violence program. On-line modules through the Learning Management System on various topics, such as a workplace violence module to be completed upon hire, a code white training module, and a non-violent crisis intervention module. Workplace violence and code white training modules are mandatory and metrics are reported to leadership. Some staff members have completed training on the Montessori method and Gentle Persuasion for patients with dementia. Classroom training is also provided to certain staff on the topic of the prevention and management of aggressive behaviour. In 2017 we are focusing on a visual awareness campaign across the facility to remind all persons of the importance of our culture of violence prevention. Our work with the Joint Centres Spread Project continues to develop and evolve to make our hospital a safe and transparent place for everyone at NYGH. North York General Hospital 13

14 Seniors Health Centre In the fall of 2016, the Commission on Accreditation of Rehabilitation Facilities (CARF) International, a leading long-term care accreditation body, accredited NYGH s Seniors Health Centre (SHC) with the highest accreditation status. This was the second time Seniors has been accredited separately from the hospital. SHC has a number of committees in place that oversee Quality as part of their mandates, including a Resident s Council and a Family Council. In addition, a management committee, made up of senior staff from NYGH and Sienna Senior Living meets on a quarterly basis and reviews key metrics. A number of quality improvement initiatives have taken place over the past two years, to improve resident care including: Restraint minimization Fall prevention Customer service training Skin and wound management Improving the admissions process Care planning documentation In addition to the hospitals mandatory training requirements, SHC has nine additional training modules that are required under the Long-Term Care (LTC) Act. Beginning in 2015, all long term care homes were required to submit a Quality Improvement Plan. SHC has been tracking and reporting metrics to Health Quality Ontario and Canadian Institute for Health Information. Five metrics, which are currently publicly reported, have been added to the NYGH balanced scorecard: % of residents taking anti-psychotic medication % of residents with worsening bladder (worsened bladder continence) % of residents who had a worsening pressure ulcer (Stage 2 to Stage 4) % of residents who were physically restrained (daily physical restraints) Rate of potentially preventable ED visits The Team Member Engagement Survey was completed in the fall of 2016, 64% of team members participated in the survey. Overall satisfaction rated at 94%, 4% increase from 2015, and a 10% increase from The resident satisfaction survey was completed in the fall of 2016, 90% of residents (those with a CPS score of three and under) participated in the survey with assistance from volunteers. The average response rate for Sienna Senior Living was 68%. Overall resident satisfaction was 85%, an 8% increase from the previous year. Families of resident s were also surveyed in the fall of 2016, the response rate was 19%. The average response rate for Sienna Senior Living was 34%. Overall family satisfaction was 77% which was a 10% decrease from the previous year. North York General Hospital 14

15 Performance Based Compensation NYGH s senior leadership team are accountable for achieving the targets for the following indicators: Dimension Patient-Centred Safe Timely Indicator Home support for discharged palliative patients Improve patient satisfaction (Would you recommend) Reduction in incidents of workplace violence that result in lost time Increase proportion of patients receiving medication reconciliation upon discharge Reduce wait times in the ED The following roles from our senior leadership team are included in this process: President and Chief Executive Officer (10%) Chair, Medical Advisory Committee (5%) Vice President, Medical & Academic Affairs (5%) Vice President, People, Strategy and Clinical Support (5%) Vice President, Clinical Programs, Quality & Risk, Chief Nursing Executive (5%) Vice President, Information & Corporate Services, Chief Financial Officer (5%) Vice President, Planning, Facilities & Support Services (5%) North York General Hospital 15

16 Contact Information For QIP inquiries please contact: Jennifer Quaglietta Director, Patient Experience and Quality Transformation T x6216 C E Jennifer.Quaglietta@nygh.on.ca North York General Hospital nygh.on.ca North York General Hospital 16

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