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

Transcription

1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/30/2017 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.

2 Overview The vision of is to be the safest and most effective hospital in Canada characterized by innovation, compassion and respect. For the second time in five years, has the lowest Hospital Standardized Mortality Ratio (HSMR) in Canada, a key measure of patient safety. This achievement was recognized by the Canadian Institute for Health Information (CIHI) in November of CIHI uses HSMR to measure expected deaths versus actual deaths, with a ratio lower than 100 indicating fewer than expected deaths. In the report for , St. Mary s HSMR score was 67 compared to 93 for Canada. To have the top HSMR in the country twice in five years reaffirms our vision to be the safest and most effective hospital in Canada. Through rigorous application of Lean thinking across our organization, staff have generated thousands of ideas to provide safer, higher quality care for our patients. St. Mary s has four True North Pillars and they are Quality & Safety, Patient and Family-Centred Care, Our People and Financial Stewardship. QI Achievements From the Past Year St. Mary s identified several goals in last year s Quality Improvement Plan (QIP) that focused our efforts on achieving the vision of being the safest and most effective hospital in Canada. The goals for 2016/2017 were: - Reduce hospital acquired clostridium difficile infections - Continue to reduce the number of staff injuries from blood and body fluid exposure and musculoskeletal injuries - Reduce the number of avoidable inpatient days with no increase in readmissions Teamwork and the utilization of lean tools have at St. Mary s contributed to: - 50 percent fewer inpatient falls - 30 percent fewer days patients are on ventilators - 94 percent of lab tests in the ED being completed in 45 minutes, up from 82% - 50 per cent fewer cases of hospital acquired C. difficile infection from April to November of 2016, compared to the same time period in per cent fewer cases of hospital acquired MRSA during the same time frame per cent fewer cases of VRE in the same time frame. Lean has helped St. Mary s develop a culture of problem-solvers. After setting a goal of implementing one improvement per employee in 2015/16 we exceeded that target when our 1,300 employees implemented 1,356 improvements. We were inspired to double this goal in 2016/17 and this year are on track to meet our new goal of 2,600 staff-generated improvements by March 31, Population Health St. Mary's is the Regional Cardiac Care Centre and has developed a strategic plan to meet the needs of the cardiac patient population across the region. St. Mary's also provides care to respiratory and thoracic surgery patients. A strategic plan is in place for this patient population. St. Mary's coordinates the care of tuberculosis patients in collaboration with Public Health and provides an outpatient clinic. St. Mary's also provides services to vulnerable patients--those patients with addictions, victims of sexual assault & domestic violence & human

3 trafficking. St. Mary's provides an integrated care approach to specific populations to address and meet their needs post-hospitalization. Equity St. Mary's as part of the mission of the Sisters of St. Joseph's mandate is to provide care to vulnerable persons. St. Mary's provides services for vulnerable populations such as those individuals with addictions, sexual assault, domestic violence, human trafficking and those with cultural requirements. Integration and Continuity of Care One of the most successful integration programs at St. Mary s is the Integrated Comprehensive Care Program (ICC). The ICC was designed by the St. Joseph s Health System to improve the transition from hospital to home for patients requiring support., St. Joseph s Healthcare Hamilton and the Niagara Health System use the ICC model. Each ICC patient has a hospital care coordinator who acts as the patient s navigator, working to wrap care around the individual, based on their specific needs. This ensures seamless access to the right care at the right time and provides ongoing support after discharge. At St. Mary s, patient populations currently eligible for the ICC program are: - Cardiac surgery - Lung surgery - Esophagectomy - Chronic Obstructive Pulmonary Disease (COPD) - Congestive Heart Failure Compared to patients who are not with the ICC program, ICC patients at St. Mary s: - Return home from hospital 2-4 days sooner - Are half as likely to need re-admission to hospital - Are more satisfied with their experience We are working with the WWLHIN and other WWLHIN hospitals to spread the ICC program LHIN-wide. Other integration efforts include those with Grand River Hospital in developing an integrated laboratory system that provides comprehensive laboratory testing. Nuclear Medicine is currently an integrated program with Grand River providing testing at both hospital locations. A pilot project for a new integrated Pharmacy Management system was implemented in the fall of 2016 and will be evaluated in St. Mary s partners with many local agencies including the Waterloo Regional Police Service in the provision of care and treatment for those individuals impacted by sexual assault and domestic violence. The SAT/DVT is a key partner in the Family Violence Prevention initiative and serves clients within Waterloo Region. St. Mary s Counselling Services is also a key partner with community agencies partnering with HERE24/7 a centralized intake for those seeking support with addictions and a satellite office is located in the Lang s Farm Community Health Center in Cambridge. St. Mary s continues to look for opportunities to integrate and improve the continuity of care for our patients and community partners.

4 Grand River Hospital is in the process of procuring a new Hospital Information System and it is our hope that St. Mary s will be in a position to purchase and implement the same system once GRH has implemented. Having a common system for the two hospitals will result in a single patient record across both hospitals so information can be shared and patients won t have to remember what happened during previous hospital admissions or visits at the other hospital. We re anticipating that all WWLHIN hospitals will move to this same HIS at some point in the next five years. Access to the Right Level of Care - Addressing ALC Issues St. Mary s is a key partner in the Waterloo Wellington Patient Transitions Committee who develop strategies to manage the ongoing challenges with alternate level of care patients within the hospital. St. Mary s has recently signed a memorandum of understanding with the Waterloo Wellington Community Care Access Center to examine a more integrated discharge planning model. St. Mary s has WWCCAC Case Managers on site that work closely with the hospital staff to ensure a seamless discharge home. The Integrated Care Collaborative described above is a key initiative to address patient discharge planning and navigation home. Engagement of Clinicians, Leadership & Staff The development of the annual Quality Improvement Plan is a key responsibility of the Board of Trustees Quality Committee. In January 2017, a Board, Patient & Family Advisory Committee and Quality Committee meeting was held to review the current progress on the Quality Improvement Plan and to review the rationale and proposed plan for 2017/18. The proposed plan was also shared at the Leadership Council for feedback. The feedback from that working meeting was reviewed by the Board Quality Committee and adjustments to the Operational Targets and goals have been made. Resident, Patient, Client Engagement The Patient and Family Advisory Committee (PFAC) is a group of volunteers who dedicate time to provide feedback and share their perspective on activities at St. Mary s. Several members of PFAC attended the January 2017, QIP planning meeting providing input and feedback into the 2017/18 plan. The Quality & Risk Management team in partnership with Patient Services will be developing a comprehensive patient engagement framework for implementation in Patient Surveys are conducted at the bedside by Volunteers on a daily basis to receive feedback and information regarding their care. These results are tabulated and available daily on line throughout the organization. Surveys are conducted in the inpatient, diagnostic imaging and emergency departments. Formal patient surveys are sent out via mail utilizing the NRC Patient Satisfaction Survey. Surveys are sent to admitted and emergency patients. A revised patient survey methodology will be implemented in 2017/18 with an emphasis on more real time patient feedback. The Patient Relations process has undergone change over the past year and is now managed by the Quality & Risk team. Patient feedback including complaints and compliments are received by the Patient Relations Coordinator. This feedback is documented and reported to the Board Quality Committee. Staff Safety & Workplace Violence The Joint Occupational Health & Safety Committee meets monthly to monitor and guide the efforts towards staff safety and workplace violence prevention. Staff safety

5 related to blood & body fluid exposure and musculoskeletal injuries is an operational goal for 2016/17 and will continue in 2017/18 with a goal of zero harm to staff. A Violence Prevention Committee has been in place at St. Mary s since 2008 and a Strategic A3 is in place for the work of the Committee. An Environmental Safety Risk Assessment was completed in October 2016 with the assistance of the Public Healthcare Safety Association. Members of the Joint Occupational Health & Safety Committee, Management and Staff participated in completing the risk assessment. The risk assessment will be updated in October A Security Audit has been completed and there is a multi-year plan in place involving capital investments to improve the safety features of the organization. New signage across the organization promoting a Zero Tolerance for Violence has been completed. A patient assessment tool for a risk of violence or responsive behaviours is being piloted and will be implemented across the organization in the spring of The Workplace Violence Prevention policy was updated in the fall of 2016 and the Grant Thornton (anonymous reporting) remains in place. The Corporate Scorecard has an indicator related to violence in the workplace and safety. Performance Based Compensation During the fiscal year St. Mary s will be adopting a Compensation Framework pursuant to the Broader Public Sector Executive Compensation Act (BPSECA). The Compensation Framework may change the manner in which compensation of executive staff is linked to achievement of targets outlined in the QIP. The Compensation Framework will be posted on St. Mary s website as required by the BPSECA and the QIP will be updated. Currently 5% of the President s salary and 3% of the Senior Leadership Team s salary are held back annually. The Quality Committee and Resource Planning Committee of the Board, review the progress towards achievement of the Quality Improvement Targets after March 31. It should be noted, the compensation is NOT a bonus but a holdback of a percentage of the existing salary rate. Contact Information Questions regarding the Quality Improvement Plan can be made to the Administrative Assistant to the President via extension 6544 or via at sbell@smgh.ca Other is committed to Lean and Lean Management systems throughout the organization. Daily status exchanges, huddles and standard work is in place across all departments within the organization. All staff participate in the lean systems with a focus on improvements across the organization. In February 2017, St. Mary s is launching a Leadership Development Program that utilizes Kouzes and Posner s Leadership Challenge in a lean environment for all formal leaders within the organization. The program will be expanded in year 2 to include informal leaders and other staff members. 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

6 Board Chair Quality Committee Chair Chief Executive Officer