Quality Improvement Plans (QIP): Progress Report for 2017/18 QIP

Transcription

1 Quality Improvement Plans (QIP): Progress Report for 20 QIP The Progress Report is a tool that will help organizations make linkages between change ide and improvement, and gain insight into how their change ide might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality improvement activities. Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ide, and inform robust curriculum for future educational sessions. ID 1 Meure/Indicator from Total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed census data on performance represents Q2 20. h been met and considerable effort h been expended to achieve these results. Runnymede is proud of its performance in this area considering significant systemic challenges. Change Ide from Lt ears QIP (QIP 20) Develop brochure for Substitute Decision Makers (SDM) regarding their role in discharge planning. Standardize and strengthen preadmission screening with referring hospitals. W this change idea implemented intended? (/N) N Lessons Learned: (Some Questions to Consider) What w your experience with this indicator? What were your key learnings? Did the change ide make an impact? What advice would you give to others? Feedback from patients and families h been positive. The provision of the roles and responsibilities of a SDM prior to hospitalization would be most advantageous. There is benefit to addressing this issue at the system level to reduce varied communications amongst different facilities. The Patient Flow team currently follows this practice. Broader engagement and identification of patients at risk for becoming ALC will be achieved by incorporation of ALC avoidance screening tool into the Discharge policy, which is currently in the review and approval process. 625 Runnymede Road, Toronto, ON M6S 3A3 1

2 Develop information packet for patients/families outlining discharge destination options e.g. retirement home, long term care and supports to sist transition to community, activity of daily living (ADL) community programs Cohorting ALC patients with focus on long stay patients i.e. greater than 40 days Information regarding community resources availability and discharge options h been obtained and used to customize the information for each patient. The Social Work team strives to be patient-centred so each information package is tailored to each patient s needs and situation. Further plans to incorporate LHIN working group learnings to design a Short Stay unit are underway. Alternate Level of Care patients are clustered on one patient floor. The development of a standard of care for these long stay patients awaiting Long Term Care (LTC) is in progress and will include a letter outlining expectations (i.e. nursing care expectations and a maintenance focus in allied health intervention) will be provided. 625 Runnymede Road, Toronto, ON M6S 3A3 2

3 ID 2 Meure/Indicator from Overall, how would you rate the quality of care and services you receive here? (add together % of those who responded Excellent, Good ) Complex Continuing Care on performance represent an annual survey period of March All proposed change ide have been implemented. Change Ide from Lt ears QIP (QIP 20) Revise Patient Family Advisory Committee structure and mandate adopting patient and family centred approach including input into quality initiatives. Implement Floor bed Patient/Family meetings Implement nursing service expectation standards Implementation of online patient feedback and safety W this change idea implemented intended? (/N button) Lessons Learned: (Some Questions to Consider) What w your experience with this indicator? What were your key learnings? Did the change ide make an impact? What advice would you give to others? This change idea is in the early phes of implementation however, we are confident that there will be significant benefits realized through greater incorporation of the patient voice in organizational activities. Patient/family engagement meetings have strengthened the integration of patient/family centric approaches into day to day clinical processes and operations. It h become an important opportunity for patients and families to discuss local concerns and engage in health care service decision making activities. Leveraging nursing standards and competencies related to therapeutic relationships provides the structure for expected professional behavior among nurses during interactions with patients. Ongoing audit and discussion with both leadership and direct care teams are essential to successfully embed such standards in nurses day to day practices. Success of this change idea w sisted through the sharing this opportunity at the regular patient and family council meetings well leveraging 625 Runnymede Road, Toronto, ON M6S 3A3 3

4 and risk learning system including accessibility to patients/families Clinical operation audits to address experience and safety related concerns e.g. medication safety, environmental clutter/cleanliness, customer excellence tenets Video story-telling Develop a Patient Experience Framework Runnymede`s social media presence and channels. The use of technology with links, hhtags, etc. w one mechanism. Local awareness w also achieved through posting compliments and concerns process via internal posters, bulletin boards, cafeteria and elevator information stations to capture a wide, on-site audience. Structured data collection and management process is needed to ensure validity and reliability of the data gathered. This change idea is in the early phes of implementation however, we are confident that there will be significant benefits realized through greater incorporation of the patient voice in this creative manner. The effectiveness of a patient experience framework are bed on incorporation the themes and dimensions of respect, coordination and integration of care, communication, emotional support and involvement of family and friends. These principles are embedded in customer service expectations for all staff. 625 Runnymede Road, Toronto, ON M6S 3A3 4

5 ID 3 Meure/Indicator from Would you recommend this hospital to your friends and family. Positive response is definitely yes. LTLD on performance represents results from Q2 20. All proposed change ide have been implemented and Runnymede is proud of its performance in this area. Change Ide from Lt ears QIP (QIP 20) Revise Patient Family Advisory Committee structure and mandate adopting patient and family centred approach including input into quality initiatives. Implement Floor bed Patient/Family meetings Implement nursing service expectation standards Implementation of online patient feedback and safety and risk learning system including accessibility to patients/families W this change idea implemented intended? (/N button) Lessons Learned: (Some Questions to Consider) What w your experience with this indicator? What were your key learnings? Did the change ide make an impact? What advice would you give to others? This change idea is in the early phes of implementation however, we are confident that there will be significant benefits realized through greater incorporation of the patient voice in organizational activities. Patient/family engagement meetings have strengthened the integration of patient/family centric approaches into day to day clinical processes and operations. It h become an important opportunity for patients and families to discuss local concerns and engage in health care service decision making activities. Leveraging nursing standards and competencies related to therapeutic relationships provides the structure for expected professional behavior among nurses during interactions with patients. Ongoing audit and discussion with both leadership and direct care teams are essential to successfully embed such standards in nurses day to day practices. Success of this change idea w sisted through the sharing this opportunity at the regular patient and family council meetings well leveraging Runnymede`s social media presence and channels. The use of technology with links, hhtags, etc. w one mechanism. Local awareness w also achieved 625 Runnymede Road, Toronto, ON M6S 3A3 5

6 Clinical operation audits to address experience and safety related concerns e.g. medication safety, environmental clutter/cleanliness, customer excellence tenets Video story-telling Develop a Patient Experience Framework through posting compliments and concerns process via internal posters, bulletin boards, cafeteria and elevator information stations to capture a wide, on-site audience. Structured data collection and management process is needed to ensure validity and reliability of the data gathered. This change idea is in the early phes of implementation however, we are confident that there will be significant benefits realized through greater incorporation of the patient voice in this creative manner. The effectiveness of a patient experience framework are bed on incorporation the themes and dimensions of respect, coordination and integration of care, communication, emotional support and involvement of family and friends. These principles are embedded in customer service expectations for all staff. 625 Runnymede Road, Toronto, ON M6S 3A3 6

7 ID 4 Meure/Indicator from Percentage of patients receiving complex continuing care with a newly occurring Stage 2 or higher pressure ulcer in the lt three months. on performance represents Q2. Change ide aligned with organizational priorities have been implemented however, the target is not on track to be met. Change Ide from Lt ears QIP (QIP 20) Develop and initiate Skin Injury Committee Wound rounds Engage in International Pressure Ulcer Prevalence Survey to monitor pressure rates and practice W this change idea implemented intended? (/N button) N Lessons Learned: (Some Questions to Consider) What w your experience with this indicator? What were your key learnings? Did the change ide make an impact? What advice would you give to others? Consolidation of the various patient safety committees to be under one overarching patient safety and quality committee is currently underway in order to use time, focus and resources wisely. Wound rounds are valuable for oversight of wounds, maintaining compliance with recommendations, documentation, and treatments and are a valid source of data. Goal w to spread expertise within team members. Rounds were previously NP led and now APN led, with a focus on inclusion of front line staff. Runnymede conducted internal Pressure Ulcer Prevalence Survey in February, Key Learnings include: More frequent routine skin and wound sessments needed to establish risk and introduce interventions for prevention. Skin and wound sessments (Braden Score) will occur more frequency i.e. Weekly bed on best practice. Education via Learning Management System to all nursing staff occurred in December Introduction of turning clocks a visual management tool to trigger staff to turn and change patient positions. Recommendations were incorporated in the revised policy - Revision of Skin and wound program and will be change ide for this indicator for the Quality Improvement Plan. 625 Runnymede Road, Toronto, ON M6S 3A3 7

8 ID 5 Meure/Indicator from Falls with harm rate per 1000 patient days/all patients complex continuing care population on performance represents Q All change ide have been implemented however, the target h not been met. Change Ide from Lt ears QIP (QIP 20) Develop process to improve presence of and access to fall prevention equipment e.g. lap tray, chair alarms, floor mats Modify the semi-annual falls audit process to ensure resulting data is relevant for program evaluation W this change idea implemented intended? (/N button) Lessons Learned: (Some Questions to Consider) What w your experience with this indicator? What were your key learnings? Did the change ide make an impact? What advice would you give to others? Centralizing the storage of fall safety equipment and redesigning access and return process required the active participation of Falls Committee, Quality and Risk Management, Facilities, Environmental Services, SSW, IPAC, clinical and non-clinical staff and volunteers. Quality Improvement approach w used to define the goals, develop a future process, engage stakeholders and implement the solutions. Initial feedback from staff is overwhelmingly positive regarding the idea of constant access to safety devices to meet the needs of their patients. ly designing an evaluation plan for the new process with an attempt to meure impact over next year. Streamlining the audit process allowed it to be completed with minimal available staff over a period of 1-2 weeks semi-annually and made it sustainable. Immediate positive impact on the workflow of the committee membership. Opportunity for improvement in design and distribution of results report. 625 Runnymede Road, Toronto, ON M6S 3A3 8

9 Implement patient safety huddles on each floor focusing on falls prevention Patient safety huddles now occur on all 3 patient care floors. Huddles are proving an excellent venue for falls education by members of the falls committee to front-line staff. Opportunity for further improvement and standardization of falls information transfer during huddles. 625 Runnymede Road, Toronto, ON M6S 3A3 9

10 ID 6 Meure/Indicator from Falls with harm rate per 1000 patient days/all patients, low tolerance long duration rehabilitation patient population on performance represents Q TD. All change ide have been implemented however the target h not been met. Change Ide from Lt ears QIP (QIP 20) Develop process to improve presence of and access to fall prevention equipment e.g. lap tray, chair alarms, floor mats Modify the semi-annual falls audit process to ensure resulting data is relevant for program evaluation Implement patient safety huddles on each floor focusing on falls prevention W this change idea implemented intended? (/N button) Lessons Learned: (Some Questions to Consider) What w your experience with this indicator? What were your key learnings? Did the change ide make an impact? What advice would you give to others? Centralizing the storage of fall safety equipment and redesigning access and return process required the active participation of Falls Committee, Quality and Risk Management, Facilities, Environmental Services, SSW, IPAC, clinical and non-clinical staff and volunteers. Quality Improvement approach w used to define the goals, develop a future process, engage stakeholders and implement the solutions. Initial feedback from staff is overwhelmingly positive regarding the idea of constant access to safety devices to meet the needs of their patients. ly designing an evaluation plan for the new process with an attempt to meure impact over next year. Streamlining the audit process allowed it to be completed with minimal available staff over a period of 1-2 weeks semi-annually and made it sustainable. Immediate positive impact on the workflow of the committee membership. Opportunity for improvement in design and distribution of results report. Patient safety huddles now occur on all 3 patient care floors. Huddles are proving an excellent venue for falls education by members of the falls committee to front-line staff. Opportunity for further improvement and standardization of falls information transfer during huddles. 625 Runnymede Road, Toronto, ON M6S 3A3 10