Quality Improvement Plans (QIP): Progress Report for QIP

Transcription

1 Excellent Care for All Act Quality Improvement Plans (QIP): Progress Report for QIP This document uses the standard Health Quality Ontario (HQO) template for reporting on the progress as of April 1, 2014 of the RVH QIP. Priority Indicator ED Wait times: 90th percentile ED length of stay for Admitted patients. (Hours: ED patients; Q4 2011/12 Q3 2012/13; CCO iport Access; Performance Performance Goal Progress to date Comments RVH did not meet the 2013/14 target for ED wait times. Review of the action plans demonstrates the opening of more inpatient beds did not improve flow, however did allow for increased volumes of patients to be cared for. Recognizing that space is not the answer to flow and wait times, the current QIP for 2014/15 focuses on work in progress to reduce the time from triage/registration to admit decision combined with an organizational focus on patient flow. The ED Admit challenge is correlated with inpatient capacity. As the demands imposed by the ALC population for in-patient beds declines, the ED experiences a resulting increase in patient flow. All of these issues remain priority indicators for the 2014/15 QIP with complex integrated action plans in place. RVH did experience a significant improvement in admitted patients in the ED, and continues to leverage the opportunity of new inpatient capacity to impact this metric including:

2 Working closely with CCAC and Barrie and Community Family Health Team on HealthLinks and HomeFirst, both of which will target ALC patients and ultimately provide additional inpatient capacity ED remains committed to patient flow improvements, and has several continuous process improvement initiatives underway Further investigation into clinical group level wait time for admitted patients to better understand key performance drivers Percentage ALC days: Total number of acute inpatient days designated as ALC, divided by the total number of acute inpatient days. (% All acute patients; Q3 2011/12 Q2 2012/13; Ministry of Health Portal; Though RVH did not meet the target as set out in the 2013/14 QIP, there was tremendous positive learning and progress on the issue of decreasing ALC days. Some achievements for 2013/14 included: Discharge Planners, Resource Nurses and Unit Managers implemented new workflow collaboration to ensure daily interprofessional patient focused bullet rounds to identify and address patient specific issues and barriers to safe discharge Patient Flow department implemented weekly meetings with CCAC to optimize placements and discuss patient flow to the community RVH & NSM CCAC re-launched the Home First philosophy with engagement and active participation by stakeholders in both organizations, community service agencies and primary care. The continuation and re-launch of this program are captured in the 2014/15 QIP. RVH has identified and is continuing to implement evidence based strategies to maintain optimal condition of frail senior population

3 (Hospital Elder Life Program HELP) Gentle Persuasive Approaches (GPA) in dementia care education has been provided to all staff working within the Geriatric Programs and is rolling out through many other medical units in 2014/15. From NRC Picker: ''Would you recommend this hospital to your friends and family?'' (Percent of those who responded ''Definitely Yes'' or Yes, definitely ). October September [Note: No specification on EP/IP](core-overall) (% Population; Period; Source; RVH is pleased to see the continued positive patient satisfaction up-swing in Q2, and the expectation is for this positive trend to continue into 2014/15. Program specific reporting continues which highlights specific strengths and positive comments as well as opportunities for improvement. Real time surveying through bedside systems is in the initial stages and will reduce time lag associated with receiving data from NRC Picker surveys and give leaders immediate results, focusing on: did you get answers to health care concerns you could understand? did you receive the help you required in a timely fashion? (call bell response measure) Would you recommend RVH to family and friends? RVH continues all of the evidence based strategic tactics that evolved over the past year(s) which continue to support RVH s My Care philosophy and drive this indicator in the positive direction. Our QIP plan 2014/15 reflects our positive growth and future actions. CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospitalacquired CDI, divided by the number of The average annual C. Diff rates met the 2013/14 target of.31. There was positive overall progress on the action plans submitted, though some

4 patient days in that month, multiplied by 1,000 - Average for Jan-Dec. 2013, consistent with publicly reportable patient safety data. (Rate per 1,000 patient days; All patients; 2012; Publicly Reported, MOH; redevelopment of action plans that were not progressing at the expected level did occur. Overall, this increased organization awareness and the learnings have been utilized to further develop action plans for this year. Actions last year that were successfully initiated included: Lab initiated PCR testing for C. Diff. eliminating long wait and uncertainty associated with C. Diff tests. This resulted in earlier identification of C. Diff. Early identification and communication of High Risk patients in ED. This project has had many iterations and continues to develop and progress as noted on the 2014/15 QIP. Trigger Points document for CDI for advanced warning and escalation to SWAT team. Tool Kit created for managers and directors to use in event of a CDI breakout. This process was started and has been carried over onto the QIP for this year. Innovative education series for staff launched Fall 2013, Bug buster Campaign with great staff uptake. The 2014/15 QIP demonstrates RVH s commitment to build on the learnings and successes of the past C.Diff targets. Hand hygiene compliance before patient contact: The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by consistent with publicly reportable Each leader has accountability for promoting consistent hand hygiene practices. Annual renewal of hand hygiene education is mandatory for all staff and is demonstrating great adherance for completion. Physician leaders are also expected to demonstrate the same level of accountability. Successes from QIP 2013/14

5 patient safety data. (% Health providers in the entire facility; 2012; Publicly Reported, MOH; include: More visibility and expansion of auditing presence More visibility and transparency in information and performance reporting Expansion of auditing to include outpatient areas such as chemotherapy clinic and DI Annual Hand Hygiene Day celebration during May 2013 and week-long leader presence at staff and patient entrances More visibility and transparency in performance reporting - public display on inpatient units started May 7th, 2013; Outpatient began October 2013 Action plans through Quality and Operations to ICRT recommendations are almost complete with 90% being complete already Leader Rounding by Manager, Director, Educators and Resource Nurse includes an audit of staff hand hygiene. Patients are asked if staff wash their hands. Overall great success with many wins and the ability to move forward with renewed energy and increased planning for the 2014/15 QIP.