Strategic and Operational Plan Quarterly Report #3 April 15, 2015

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1 Strategic and Operational Plan Quarterly Report #3 April 15, 215

2 Table of Contents Executive Summary... 3 Introduction 4 Priorities 4 Improving Access to Care Across All Sectors... 4 Improving Quality and Safety Preventing Disease, Protecting Health and Promoting Wellness Engaging Staff and Physicians Balancing the Budget Other Enabling Priorities Summary

3 Executive Summary This report provides the April 15, 215 update on progress in implementing the Fraser Health Strategic and Operational Plan confirmed in June 214. This progress report is delivered quarterly to the Ministry of Health in fulfillment of the requirement set out in Ministerial Order #282. It is anticipated that the Plan will soon be superseded by the recently released Ministry of Health Policy Papers, which are undergoing consultation now. It is also anticipated that the next series of reporting will focus on progress made with respect to specific, targeted improvement plans being created now. The Strategic and Operational Plan ( Plan ) identified 1 priority actions for quality and sustainable service delivery including: (1) Capacity for care across all sectors; (2) Quality and safety; (3) Public health measures; (4) Accountability; (5) Staff and physicians; (6) Patient centeredness; (7) Governance; (8) Operational organization and management; (9) Lower Mainland collaboration; (1) Budget accountability. Progress on these priority actions is measured using quantitative performance indicators published monthly on the Fraser Health website under the heading Our Health Care Report Card. Progress is also measured using qualitative indicators from the past quarter, which are identified in this report along with plans for the coming quarter. Progress highlights include the following: Improving access to care across all sectors continues to be a challenge. The following indicators are 1% or more off target: the number of long-stay patients in hospitals; the number of patient days classified as alternate level of care (ALC); the number of patients awaiting inpatient bed placements; and the number of patients in Emergency admitted to an inpatient bed within 1 hours. Vigorous implementation of improvement strategies outlined in this report (including a recent $5 million investment in augmenting health care professionals and their accountabilities for preventing admission and supporting weekend discharges) continues. Progress has been made on improving quality and safety, with targets met or exceeded in seven of eight key indicators. Improving the experience of patients in Emergency is an area of particular need, and this report identifies several strategies underway. Public Health measures are well aligned with targets. Accountability processes have been put in place, with particular emphasis on public reporting of performance indicators. Work continues on engaging staff and physicians, with targets met or exceeded in three of six measures. Efforts to improve the WorkSafe claim duration and rate are underway, and Fraser Health is looking forward to a fresh set of engagement data from the Gallup Q12 survey which will be conducted in September. Work continues on pursuing a culture of patient and family centeredness. Board Governance practices are being strengthened. Progress has been made in strengthening operational organization and management structures and processes. Lower Mainland collaboration continues to be improved. Work continues to ensure optimized service delivery within a balanced budget. At the end of Period 12 (February 26, 215), Fraser Health reported a year-to-date surplus. 3

4 Introduction Information presented in this report is driven by the 1 priorities identified in the Plan for Fraser Health (June 214) and organized to be consistent with Our Health Care Report Card. For each of the performance measures, this report identifies the performance level relative to the target performance level and then highlights progress in recent initiatives, along with initiatives that are expected during the next quarter. Additional measures are included in some sections as they were identified in the Review and are important to the overall improvement efforts. The performance measures presented in this report are based on the most up-to-date, analyzed information available at the time of report preparation. They are also reflected in Our Health Care Report Card (March 215 edition). Priorities Improving Access to Care Across All Sectors Capacity to support growth as well as the aging of the Fraser Health population will be increased by developing efficiencies throughout the acute and community sectors and increasing investment in primary and community care 1. Optimized use of hospital and non-hospital resources will liberate resources to be used elsewhere and help ensure clients, patients and residents receive the right care, in the right place, at the right time. It is important to note there is no one strategy to improve a specific measure of access to care; rather, multiple applied and sustained best practices, in combination, improve the patient journey and Fraser Health s indicator performance. 1 Primary care includes a variety of community-based clinics such as Diabetes, Respiratory, Cardiac, Aboriginal Health, and Mental Health and Substance Use, and may utilize the services of a nurse practitioner and/or family physician as well as members of an interdisciplinary team. Primary care also includes the 1 Divisions of Family Practice. Community care includes Home Health, End of Life care, Mental Health and Substance Use (MHSU), Residential and Assisted Living, and Acquired Brain Injury care, clinics and services. 4

5 ALOS / ELOS Ratio ALOS / ELOS Ratio Avg LOS (Days) Avg LOS (Days) Average Length of Stay (ALOS) and ALOS compared to Expected Length of Stay (ALOS:ELOS) FH Avg LOS - Annual Performance Vs Avg LOS By Hospital - Apr214-Feb FH ALOS: ELOS Ratio - Annual Performance Trend Vs ALOS:ELOS Ratio By Hospital - Apr-Jun The Average Length of Stay (ALOS) of 8.5 days this period (fiscal Period 12), is an increase over the previous Quarterly Report period (8.2 in Period 1). Year to date ALOS is unchanged at 8.3 days, higher than the three-year target of 7.8 days. The numerator for ALOS has two components acute days and alternate level of care (ALC) days. Continued focus on reducing both components is required. Many ALC patients have complex clinical, social and housing needs. An ALOS that is higher than the expected length of stay (ELOS) may reflect delays in the timely transition of patients from the hospital to home or residential care. Simply stated, more discharges need to be done on a more timely basis. This measure informs quality improvements in both the acute and community settings. Strategies initiated in the previous quarter to increase structure, accountability and focus on daily hospital operations are being maintained and enhanced. Site-based administrative and medical leaders are working with Hospital Operations Management Committees (HOMC) to monitor site performance against targets and to act on initiatives and process changes aimed at ensuring timely and appropriate discharges. In order to increase the adoption of best practices, three high-priority clinical protocols (48/6, Catheter Associated Urinary Tract Infection (CAUTI) and patient mobility) have been audited monthly since October and actions are underway to ensure each protocol is fully implemented for all patients. Compliance continues to increase at all sites, and accountability for performance on these measures is being embedded into normal work processes. These protocols will improve quality of care while decreasing length of hospital stay. 5

6 % ALC Days % ALC Days Number of Patients Number of Patients Strategies to increase the use of Estimated Date of Discharge (EDD) and patient whiteboards are well underway. Whiteboards have been installed at most sites, and site-based discussions about the importance of EDD for quality care and patient flow have taken place. A tool that allows physicians to access EDD from CIHI data has been developed and made widely available. Rollout will continue for several months, and includes identifying and partnering with physician leaders, since using EDD is a significant change in practice and culture in many areas. Site-based implementation of action plans to improve compliance with priority clinical care protocols (48/6; CAUTI; patient mobility) is underway, as is site work by the HOMCs on their action plans. Fraser Health is strengthening the use of targeted best practices in patient flow, daily patient rounds, bedside whiteboards, EDD and patient mobility. Fraser Health recently announced a $5 million investment aimed at improving care and reducing the use of hallway or other inappropriate inpatient locations. This includes adding geriatric emergency nurse clinicians and quick response case managers aimed at helping to prevent unnecessary hospital admission,; and increasing patient care coordinators, social workers and occupational therapists on weekends to support discharges for hospitals that do not already have this available. This best practice will reduce variation in discharge patterns and occupancy rates. Long Stay Patients Staying Over 3 Days and Alternate Level of Care (ALC) Patient Days in Acute Care Beds FH Long Stay Patients - Annual Performance Trend Vs / /214 Apr214-Feb Long Stay Patients By Hospital - Apr214- Feb % FH ALC - Annual Performance Trend Vs 4% ALC By Hospital - Apr-Nov 214 3% 2% 1% 13.7% 12.8% 14.3% 3% 2% 1% 27.5% 21.8% 22.2% 2.5% 2.4% 21.1% 17.7% 14.4% 15.1% 11.5% 7.4% 4.6% % 212/ /214 Apr-Nov 214 % 6

7 According to the most recent data available (November 214), the year-to-date, ALC rate of 14.3% is higher than the three-year 1% target. At 527, the number of long-stay patients (>3 days LOS) is also higher than the fiscal year-end target of 455. By definition, patients classified as ALC no longer require acute care. They include elderly patients waiting for placement in residential care and patients affected by mental illness, substance use and acquired brain injury who need specialized housing. Others may require complex home care and some with complex family and social issues take additional time to match their care needs to housing and social supports. Some of these resources are not available in sufficient quantity. In addition to patients classified as ALC who no longer require acute care, many long-stay patients are not considered ALC and require extended hospital stays to receive complex or specialized care that is not available in the community. Both these measures identify possible inappropriate use of acute care resources and delays moving patients to more ideal care environments. To achieve or exceed targets here, investments need to focus on: (1) strengthening the primary and community sectors appropriately by shifting resources from acute to the community and by building efficiencies throughout the community sector; (2) promoting the development of the General Practitioner for Me (GP4ME) initiatives that support longitudinal primary care; (3) enhancing approaches and services in chronic disease management; and (4) supporting vulnerable populations living in the community. Strategies implemented in the previous quarter are being sustained. These include opening additional residential care capacity (24 beds in Mission and the conversion of 12 beds to complex care in Surrey) and increasing home health capacity by identifying efficiencies in service delivery. In late March 34 new residential care beds are opening to serve Burnaby and Tri-Cities populations. Residents will be admitted from Burnaby Hospital and Eagle Ridge Hospital. Twelve existing residential care beds have been reallocated to care for medically complex patients who often have very long hospital stays due to their complex needs. The 3 year Financial Plan received Board approval this period, and includes $32.8 million for increased capacity to be implemented through a Residential Request for Proposal process which will have added positive impact on long-stay patients. The process to manage complex and long-stay patients continues to undergo improvements including targeted reviews of longest stay patients at each site, and adjustments to the complex discharge rounds process for Medicine units. The policy and tools to support complex discharges have been updated. These process improvements aim to improve the early identification and monitoring of long-stay patients. Many sites have prioritized decreasing ALC and long-stay patients in their HOMC action plans. All strategies identified in reducing the ALOS and ALOS: ELOS also apply to these measures. Following a review of the utilization of community-based convalescent beds in the health authority, 75 existing convalescent care beds will be converted to residential care. Adjustments will be made to referral processes and community supports to ensure that the needs of patients previously cared for in convalescent beds will continue to be met. 7

8 With short-term strategies well underway, our activities will be shifting to longer term strategies to reduce ALC patients in Fraser Health hospitals. This work will begin with a detailed analysis of the ALC population and a review of initiatives planned or in process to reduce ALC rates and the extent to which existing initiatives will help us meet the ALC and long stay reduction goals. Decrease Readmission Rates According to the most recent data available (214/15 Quarter 2 abstracted data reported to CIHI), the readmission rate of 1.6% is higher than the three-year target (1%). Fraser Health has completed a detailed analysis of the top three patient populations driving readmissions. Information from the analysis (top three being respiratory, mental health and cardiac populations) will be used to target and strengthen patient management strategies. The strategies identified in the previous quarterly report are being actively pursued. These include community-based actions to support chronic disease management (chronic obstructive pulmonary disease [COPD], heart failure and diabetes); strategies in the Emergency Department to prevent admissions; and strengthened hospital discharge planning to prevent readmissions. Fraser Health s focus on chronic disease management has resulted in improvements to the hospital discharge process and changes to the community surveillance nurse role to provide better support to patients transitioning back to home and community. A pilot is underway in Abbotsford in which discharged chronic disease patients receive coaching on self-management from a surveillance nurse to improve their health, and to decrease readmissions. A review of positions in the Emergency Department that support diversions to community services to avoid admissions has been completed. This review confirmed the effectiveness of these positions in preventing admissions, and identified opportunities to improve their effectiveness. Based on these outcomes, as previously mentioned a $5 million investment is being made to increase the number of these positions so that preventable admissions and readmissions are reduced. In some communities, work is underway to complete a root cause analysis to better understand what drives admission and readmission rates by population, disease and hospital. Regional analysis of readmission data provided insight into some of the patterns by community, by site, and within sites. This information was provided to clinical teams who are already working on improvements in these areas, to inform and refine their work. 8

9 Hospitalizations per 1, Population >7 Admissions per 1, People Aged >75 Admissions per 1, People Aged <75 Patient and family teaching strategies are being updated to reflect information gained from new initiatives in COPD care and the prevention of readmissions. A road map outlining Fraser Health s chronic disease management strategy focusing on the overall strategy for prevention, integrated management and best practices will be completed. Work to improve clinical management of COPD and increase uptake of BreatheWell (the communitybased program to support COPD management at home) will continue. The effectiveness of positions in the Emergency Department to reduce admissions and readmissions will be monitored. ed investments in staffing will be made in Emergency Departments. Decrease Admission Rates for Selected Conditions and Patient Populations 4 ACSC (Aged 75-) - Annual Performance Trend Vs /29 29/21 21/ / / /214 Apr-Jun 214 4, 3, 328 ACSC (Aged 75+) - Annual Performance Trend Vs , 1, 28/29 29/21 21/ / /213 Apr-Dec Age Std Admission Rate (7+) - Annual Performance Trend Vs /29 29/21 21/ / / /214 9

10 % Admitted Patient % Admitted Patient Ambulatory care-sensitive conditions are chronic diseases that, when treated effectively in community settings, should not, in most cases, advance to hospitalizations. Hospitalizations related to these conditions are often referred to as avoidable hospitalizations and are considered an indirect measure of access to primary health care, care in the community and the ability of the health care system to manage chronic conditions. The admission rate for the under age 75 population in the first quarter of 214/15 was 245 per 1, residents, not yet achieving the three-year target of 234. The admission rate for the over age 75 population in the third quarter of 213/14 was 3,154 per 1, residents, not yet achieving the target of 3,48. The strategies that apply to reducing ALOS, ALOS: ELOS and readmissions apply to ambulatory caresensitive conditions as well. In particular, community-based chronic disease management programs and services that are population specific (e.g. South Asian Health Centre in Surrey) offer culturally responsive services to promote self-management of chronic diseases. Findings from the root cause analysis (described above) will be used to identify the areas of greatest opportunity to support individuals and their families in their communities to maintain their own health and prevent worsening of chronic diseases through formal (e.g., GPs, Fraser Health) and informal (e.g., Canadian Diabetes Association) services. This will further inform Fraser Health s approach to a community-based system of health. Emergency Patients Admitted to Hospital (an Inpatient Bed) Within 1 hours 75% 5% 25% FH % Patients Admitted Within 1 Hrs - Annual Performance Trend Vs 38.2% 36.6% 75% 5% 25% % Patients Admitted Within 1 Hrs By Hospital - Jan-Feb, % 52.9% 32.1% 31.6% 18.8% 6.9% 43.7% 46.3% 32.9% 34.4% 27.% 25.2% % % 214 Jan-Feb,215 Year to date, 36.6% of patients requiring admission from the Emergency Department are admitted to an inpatient bed within 1 hours. This rate falls well below the fiscal year target of 55%. The majority of sites are well below the target. Improving this measure requires network-wide, community- and hospital-specific strategies to improve access to, and flow into, an inpatient bed. Actions described for other measures of accessing care will contribute to improvements in this measure, as well as better patient outcomes and improved patient experience. 1

11 Number of Patients Number of Patients Emergency Department (ED) congestion is influenced by a number of factors the number of patients presenting for care; efficiency of patient assessment and treatment; efficient movement of admitted patients from the ED to inpatient wards; and inpatient length of stay. Strategies to improve these measures help to reduce ED congestion. To continue reducing the number of patients presenting for care, the ED team has developed individual care plans for 142 of 312 patients who are frequent users of the ED (>2 visits/yr), generally individuals with complex health and mental health / substance use issues. The size of this patient population was previously reported to be 518 however, closer analysis has revealed that 188 patients have specific medical treatments requiring care planning (e.g. IV therapy) and 18 patients have expired ( =312). The electronic care plan is available to all hospitals. In addition, we are creating plans for individuals with complex medical challenges as part of crisis prevention. Investments are being made to increase positions in EDs aimed at preventing admissions and providing community-based care and follow up for patients presenting to EDs. Site-based work to improve 1-hour rule performance is ongoing, under the leadership of Hospital Operations Management Committees. Efforts have included reviewing current processes, identifying opportunities for improvement and increasing shared accountability for moving patients from the ED quickly. Work continues to develop prototypes for triage practices at Royal Columbian and Surrey Memorial hospitals to decrease congestion. The real-time patient survey at Surrey Memorial, Peace Arch and Delta hospitals continues. Early results are being reviewed and findings will be used to support care and service improvements. The next site for survey implementation is Abbotsford Regional Hospital. Work continues to improve site processes and streamline moves from EDs to inpatient units. A networkwide session to share learnings and strategies to improve 1-hr rule performance will be held in the next quarter. Planned investments to decrease the number of patients waiting for inpatient beds (in EDs and other locations) are targeted at decreasing hospital occupancy, which will accelerate the flow of patients from EDs to inpatient units. Admitted Patients Awaiting Inpatient Bed Placement (including Emergency Admits) FH Patients Waiting Bed - Annual Performance Trend Vs Patients Waiting Bed By Hospital - Apr214- Feb

12 At the end of Period 12, the year-to-date average of 28 for this measure falls short of the fiscal period target of 165. The numerator for this measure is the sum of two components the average number of patients receiving care in a location not typically designed for inpatient care (hallways and other locations) and the average number of patients located in Emergency waiting for an inpatient bed. It is a combined measure reflecting the balance between supply and demand for inpatient beds. Focused efforts are underway at the larger sites to improve this measure. Fraser Health is investing $5 million to decrease the number of patients waiting for inpatient bed as follows: Increasing and expanding coverage of positions in the Emergency Department to prevent unnecessary admissions; Implementing projects at targeted sites to improve care and discharge planning; Extending Patient Care Coordinator coverage (evenings and weekends) to improve care planning and patient flow 7 days/week; Adding on-call allied health (social work / occupational therapy) to support weekend discharges; Increasing home health supports on weekends to improve care planning and patient flow 7 days/week; Decreasing bed turnaround time in residential care to decrease the number of days patients in acute care are waiting for a residential bed. The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Improving Quality and Safety The overarching goal is to improve safety and access across all sectors. One area of focus is to improve care for patients who are at risk of deterioration. Multiple programs have worked together to increase early detection and help patients get the care they need as quickly as possible. Escalation of care is spreading throughout the Medicine, Surgical, Rehab, Older Adult and Renal programs (with support provided by both Critical Care and Emergency), meaning there is now a trend and trigger tool for all sites. 12

13 Rate per 1, Hospitalizations Rate per 1, Hospitalizations % Cases % Cases Percent of Hip Fracture Fixations Completed within 48 Hours FH % Hip Fracture Fixations Within 48 Hrs - Annual Performance Trend Vs % Hip Fracture Fixations Within 48 Hrs By Hospital - Apr214-Feb215 1% 84.2% 92.% 1% 93.% 92.% 9.% 89.% 86.% 96.% 91.% 91.% 75% 75% 5% 5% 25% 25% % 213/214 Apr214-Feb215 % ARH BH CGH LMH PAH RCH RMH SMH By the end of February 215, 92% of hip fractures are being repaired within 48 hours, exceeding the fiscal period target of 9% at an organizational level. Two hospitals have not achieved the 9% target: Langley Memorial (89%) and Peace Arch (86%). The results of this measure are analyzed each period with targeted strategies put in place at individual hospital sites. All patients admitted with hip fractures are closely monitored using a data collection tool to identify common themes and barriers to surgery. Dedicated time in operating rooms has been allocated for hip fracture patients. A hip fracture escalation protocol to reduce and eliminate barriers to surgery has been implemented. Increased awareness among all care providers of the need for specialized care and timely surgery to improve outcomes is helping ensure Fraser Health can continue to exceed this target. In addition, focused attention on pain management, enhanced nutrition and early and frequent mobility will ensure quality standards are met or exceeded. The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Reducing Nursing-Sensitive Adverse Events (NSAE) 6 4 FH NSAE Rate (Age 55+) - Annual Performance Trend Vs NSAE Rate (Age 55+) By Hospital - Jan-Dec Jan-Dec

14 Rate per 1, patient days Rate per 1, patient days According to the most recent data available (December 214), the year-to-date rate of 39.2 for nursingsensitive adverse events (NSAE) is continuing to decline. With the observed trend moving in the right direction, it is likely the annual target (43.1) at the organizational level will be achieved. NSAE performance targets are not being met at four hospitals: Burnaby (5.8); Ridge Meadows (5.7); Surrey Memorial (45.1); and Peace Arch (43.7). Performance is trending towards target at Ridge Meadows, Surrey Memorial, Burnaby and Peace Arch. Specific actions for Burnaby Hospital include: nursing staff education modules on CAUTI (Catheter-Associated Urinary Tract Infections) and oral care, and a focus on clinical practice guidelines for CAUTI; daily huddles to discuss Foley catheter use; and support for patient mobilization through the use of patient-centred bedside whiteboards. Hospital Operations Management Committees are reinforcing support for, and expectations of, site operations and clinical directors for leading process changes, achieving improvements and reviewing results. Implemented actions include: mobile educational carts that visit nursing units for staff teaching huddles; the posting of unit results on quality boards; NSAE newsletters; checklists for reducing urinary tract infections and pneumonia; and chart reviews and audits to assist clinical teams in monitoring and improving practice. Site-based leaders are working with staff and physicians, especially on those units with the highest rates, to identify the underlying issues and challenges, take corrective action and improve quality of care. Dedicated physician strategies include increased use of protocols and improved documentation. The performance targets for NSAE are under provincial review and likely to become 1-2% more aggressive. Fraser Health s implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Facility-Associated Clostridium difficile Infection (CDI) Incidence FH CDI Rate - Annual Performance Trend Vs CDI Rate By Hospital - Apr214-Feb The year-to-date Clostridium difficile infection (CDI) incidence rate is 3.9 as of the end of February 215, which is on track to meet the target (6.) for this key measure at an organizational level. 14

15 Rate per 1, patient days Rate per 1, patient days Annual targets are not being met at two hospitals: Eagle Ridge (6.6) and Fraser Canyon (9.2). These are smaller sites with fewer patient days in the denominator. Random statistical fluctuations may contribute to higher CDI incidence rates at these sites. An infection prevention and control practitioner is now serving Eagle Ridge Hospital, which should contribute to further reduction in the CDI rate. A unique tracking tool identifies vulnerable units for Clostridium difficile infection and facility-associated methicillin-resistant Staphylococcus aureus. Managers with vulnerable units are accountable to develop and execute on an action plan that is aligned with best practices and current policy/practice. The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Facility-Associated Methicillin-Resistant Staphylococcus Aureus (MRSA) Incidence FH MRSA Rate - Annual Performance Trend Vs MRSA Rate By Hospital - Apr214-Feb The calendar year-to-date rate of facility-associated methicillin-resistant Staphylococcus aureus (MRSA) is 6.7 as of the end of February 215, on track to meet the target (7.) for this measure at an organizational level. Annual performance targets are not being met at five hospitals: Ridge Meadows (1.4); Delta (8.2); Burnaby (7.4); Mission Memorial (8.); and Surrey Memorial (7.8). Delta and Mission Memorial are smaller sites with fewer patient days in the denominator. Random statistical fluctuations may contribute to higher MRSA incidence rates at these sites. Intensification of antibiotic-resistant organism screening is leading to the identification of more cases upon admission, some of which are attributed to health care interactions in the previous six months. These improvements in screening are related to a targeted program to increase identification of carbapenemase-producing enterobacteriaceae (CPE). In addition to improvement activities previously reported, funding will be redirected to support an antimicrobial stewardship program, to recruit a physician lead for this work as well as site-based pharmacists. These steps will help reduce facility-associated MRSA and CDI rates. At Ridge Meadows there is a specific action plan to address the facility-associated MRSA rate. The plan features maintaining effective hand hygiene, de-cluttering and cleaning the environment, following cohort isolation practices and screening every admission for 3 days (to determine whether a high community prevalence contributes to higher facility-associated MRSA rates). 15

16 % of Employee Compliance % of Employee Compliance Ratio Ratio The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Hospital Standardized Mortality Ratio (HSMR) FH HSMR - Annual Performance Trend Vs HSMR By Hospital - 213/ According to the most current data available (fiscal 213/14), Fraser Health s hospital standardized mortality ratio is 82. This achieves the target (1) for this key performance indicator at an organizational level and at every site. Fraser Health will align its target to the provincial average HSMR which has significantly improved over the past 5 years. During this period the national average reached 85% of its original baseline, while the provincial average improved further to 81% in 213/14. When Fraser Health s current performance is compared to the more aggressive provincial average target, it falls short. The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Hand Hygiene Compliance 1% 75% 5% 25% % FH Hand Hygiene Compliance Annual Performance Trend Vs 38% 61% 72% 79% 85% 1% 75% 5% 25% Hand Hygiene Compliance By Hospital - Apr214-Feb215 8% 86% 89% 87% 92% 9% 82% 85% 87% 81% 89% 86% % As of the end of February 215, the year-to-date hand hygiene compliance rate of 85% exceeds the target (8%) for this measure at an organizational level, and at all 12 hospitals. 16

17 % of Patients % of Patients Compliance audits each fiscal period provide feedback to staff and physicians on their opportunities to improve. Performance data by staff group is posted at the unit level so staff, physicians, families and visitors know how well hand cleaning is being done. Hand hygiene compliance is a standing agenda item at local infection prevention and control committees and hand hygiene education is now a mandatory requirement for appointment to the medical staff. Increasing physician hand hygiene compliance is discussed at the monthly Health Authority Medical Advisory Committee (HAMAC). The Provincial Health Services Authority (PHSA) cooperative student auditor model has been implemented. The student auditor is actively working with staff at Abbotsford and Langley Hospitals to increase compliance. The student is also doing on-the-spot education so reporting and reviewing is spontaneous. Physician leaders are hosting discussions with physicians who demonstrate persistent poor hand hygiene performance. This has led to more requests from physicians for support and education. The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Emergency Patient Experience 1% 75% FH ED Patient Experience - Annual Performance Trend Vs 8% 81% 81% 83% 83% 77% 79% 1% 75% ED Patient Experience By Hospital - Apr-Jun % 82% 81% 75% 8% 73% 79% 82% 9% 82% 7% 5% 5% 25% % 25% % According to the most recent data available (June 214),the patient experience satisfaction survey score of 79% falls short of the target (9%) at an organizational level. The target is being met at Royal Columbian Hospital (9%) but is not being met at 11 sites: Surrey Memorial (7%); Langley Memorial (73%); Abbotsford Regional (73%); Delta (75%); Mission Memorial (79%); Eagle Ridge (8%); Chilliwack (81%); Burnaby (82%); Ridge Meadows (82%); and Peace Arch (82%) hospitals. Activities to date to improve the experience of Emergency patients include: pain medication delivered upon patient s arrival, following their assessment; information brochures for patients and families; Strangers in Crisis training for all Emergency staff and physicians, registration staff, BC Ambulance Service staff and laboratory staff and volunteers; real-time patient satisfaction surveys at Delta, Peace Arch and Surrey Memorial Emergency departments, with plans to expand to Abbotsford Regional Hospital and other sites; discharge packages for patients providing specific information about their visit; and discharge checklists for staff. 17

18 Rate per 1 Residents Also in this quarter two new nurse practitioners started with the Surry Memorial and Abbotsford hospitals forensic nursing teams, working collaboratively with the Divisions of Family Practice in Surrey/North Delta and Abbottsford, non-government agencies and other community stakeholders to provide primary care follow-up to patients who have experienced episodic or chronic intentional violence. The implementation and strengthening of multiple existing strategies to monitor and improve this measure will continue. Falls that Result in an Injury in Residential Care Facilities Injury Rate in RC - Annual Performance Trend Vs Not reporting site by site data here as there are more than 83.5 residential care facilities /29 29/21 21/ / / /214 Apr-Dec 214 According to the most recent data available (December 214), the year-to-date rate of falls resulting in injury at residential care facilities is 2.6 for every 1 residents. Although the target (3.) is being met for this measure at an organizational level, there has been a slight deterioration in performance compared to the previous quarter (2.5). Maintain and build on multiple existing strategies to monitor, and continue to improve this measure. Other Quality and Safety Activities Outside the Report Card In addition to the report card measures described above, work continues to monitor and take steps to improve on other quality and safety indicators, some of which were identified in the Review. Integrated Plan of Care The integrated plan of care is a patient safety initiative to standardize and strengthen best practice patient care, streamline documentation practices across the care continuum, and improve the patient experience by defining the specific roles and responsibilities of members of their care team. Since this work began in March 214, a catalogue of standardized abbreviations, acronyms and symbols has been released and the current Fraser Health Documentation Policy has been revised. In addition, standardized 18

19 practices for signature record of staff and physicians have been implemented along with 45 unique bestpractice care standards. Over the last period, care and documentation standards have been implemented across the health authority for all professions, with the exception of physicians. Continue to sustain and support the use of the care and documentation standards. Subject to capital funding approval, advance the electronic documentation system. Reducing Carbapenemase-Producing Enterobacteriaceae (CPE) Transmissions In 213/14 there were 41 transmissions of CPE in Fraser Health. The target is a 5% reduction to a total of 21 cases. Screening activities were implemented after the data collection period in 213/14. The number of transmissions in 214/15 will likely exceed the target because the screening processes are working effectively (identifying transmission from previous hospital admissions, many months ago in some cases). This is expected to self-correct after this year, and 214/15 will become the base year for comparison at Surrey Memorial Hospital. Funding was recently approved to purchase GeneXpert, creating the ability for Fraser Health to conduct in-house, same-day molecular testing for CPE and Mycobacterium tuberculosis. This will enable appropriate proactive precautions against transmission and appropriate use of resources. There are many other activities underway to monitor and reduce the incidence of CPE. The multi-drugresistant organism and CPE screening-and-flagging protocol has been implemented for all patients in intensive care and high acuity units to identify patients at risk to ensure effective communication amongst care providers and allow transmission tracking. All CPE cases are investigated to determine inhospital transmission and the cause, with case reporting to the provincial surveillance system. Fraser Health is trialing automated surveillance and reporting for CPE. A CPE oversight group has been created at Surrey Memorial Hospital to identify and implement additional actions to reduce transmissions. A protocol is in place to escalate screening on all patients in units where ongoing transmission is evident. Fraser Health has provided extensive education, supported by hand hygiene and personal protective equipment champions, to front line leadership and front line staff. Maintain and build on multiple existing strategies to monitor, and continue to improve this measure. Reducing Harm Related to Medication Errors There has been increased attention by the executive team on supporting further implementation and spread of both the Safe Medication Order Writing Policy and the medication reconciliation work already underway. The compliance requirements for the Safe Medication Order Writing Policy have been communicated to all site leadership teams. Passing the provincial safe medication order writing course is now a mandatory requirement before appointment (or reappointment) to the medical staff. Audit data for medical staff have been reviewed with regard to compliance with the Medication Management Policy and demonstrated a small (34 to 28.6%) reduction in the use of Do-Not-Use abbreviations. Audits for compliance with the Medication Management Policy for other clinical staff are underway. 19

20 There is a renewed focus on medication reconciliation as a key strategy to reduce harm related to medication errors. Compiled data regarding medication errors beyond the Patient Safety Learning System will be more broadly shared with a view to broad-based learning and the initiation of further quality improvement strategies. Work continues in all hospitals to implement the new intravenous infusion pumps as well as medication reconciliation at admission. During 215/16 the automated drug dispensing cabinets at Royal Columbian Hospital will be brought into operation, bringing to five the number of sites using the system. A business case for ongoing operating funds to support the implementation of strip packaging at Peace Arch, Delta and Burnaby hospitals as part of the closed loop medication system (system to reduce errors) will be reviewed for implementation in 215/17. Clinical Care Management s for Venous Thromboembolism (VTE) and Surgical Site Infections (SSI) 2

21 According to the most current data available (Period 3,,June 19, 214), the percentage of surgical cases complying with surgical site infection (SSI) prevention and surgical checklist use are both at 9%, below the target of 95%. However, compliance with Venous Thromboembolism (VTE) prevention reached a year-to-date average of 97.7% as of Period 3. There are many activities underway to monitor and address clinical care management improvement targets. For VTE prevention, Fraser Health has implemented new standardized pre-printed orders and provides data at the unit and program level so accountable managers have data to share and to develop specific actions to increase compliance. For SSI prevention and surgical safety, data are provided at the unit level and discussed at local surgical quality committees to develop improvement plans. The Surgical Quality Action Network Collaborative is focusing on teamwork and communication to improve the measures. Monitor and reinforce continuation of required practices. Preventing Disease, Protecting Health and Promoting Wellness The goal of these measures is to strengthen population health to protect, promote and improve the health and well-being of those living in Fraser Health through integrated and collective actions. By improving the health and the quality of life of the population and by working towards the prevention of disease, long-term health is ensured in the communities leading to a reduction in the burden on the health care system. These are just three of many measures that Population and Public Health reports on 21

22 % Children and all three are aligned with, and contribute to, the direction outlined in the BC Guiding Framework for Public Health (Promote, Protect, Prevent: Our Health Begins Here) and other Ministry of Health action plans and frameworks (e.g., Healthy Minds, Healthy People; Seniors Healthy Living Framework). Increasing Immunization Rates in Young Populations % 2-Year Olds with Up-To-Date Immunizations - Annual Performance Trend Vs 1% 75% 5% 25% % 61% 65% 65% 64% 65% 67% 68% 67% 71% 72% 71% 71% 69% 68% 67% 67% 68% 71% 69% 65% According to the most current data available (fiscal Quarter 3, 214/15), the immunization rate for the two-year old population is 65% (68% year-to-date). The target for fiscal Quarter 4 is 73%. The target will be raised to 8% by 216/17. This indicator is part of the BC Guiding Framework for Public Health. ed immunization clinics for the 18-month age group continue to be offered at all health units. Data cleaning processes continue along with active solicitation of immunization records from parents and physicians to improve accuracy and completeness of records. Additional short, medium and long-term activities from the immunization review have been prioritized and are pending approval from senior leadership. Engagement sessions with the Divisions of Family Practice have affirmed findings from the GP workforce survey, and have identified ongoing and future areas of enhanced collaboration between Fraser Health s primary care and public health programs to improve coverage rates, particularly around education, immunization promotion and electronic data sharing. Engagement sessions continue into April 215, and ongoing collaboration continues with each Division through the local Medical Health Officer and health unit(s). An immunization coverage survey is currently gathering data to assess the accuracy of records in the provincial database, as well as gathering socio-demographic information on children who are underimmunized. Upcoming release of the Office of the Chief Medical Health Officer s Annual Report on Communicable Diseases and Immunizations aims to engage the public and community partners on the importance of immunizations. The next steps include continuation of targeted immunization clinics for the 18-month age group and cleanup of internal and GP immunizations data to improve accuracy and completeness. A review of target populations with incomplete or inaccurate records is being planned for when results of the immunization coverage survey are available in May

23 % with Strategy % Compliance Percent of Drinking Water Systems Complying with Microbial Monitoring Requirements % Drinking Water Systems Complying with Microbial Monitoring Requirements - Annual Performance Trend Vs 1% 75% 5% 25% % 94.% 96.% 95.% 96.% 97.% 93.% 95.% 95.4% 95.4% 95.% Jul-Sep 212 Oct-Dec 212 Jan-Mar 213 Apr-Jun 213 Jul-Sep 213 Oct-Dec 213 Jan-Mar 214 Apr-Jun 214 Jul-Sep 214 Oct-Dec 214 According to the most recent data available (end December 214), the year-to-date rate of 95% compliance with the microbial monitoring system for drinking water -is meeting the year-end target (95%) for this measure. The target will be raised to 98% by 216/17. This target is aligned with the BC Guiding Framework for Public Health goal to improve the safety of drinking water for British Columbians. Environmental health program staff members communicate with non-compliant water system operators by phone and mail, and follow up with inspections as part of a routine process. Some water systems still have challenges meeting their responsibilities, and working with the operators of these systems will continue to develop practical solutions. Increased frequency of water-system-monitoring compliance reviews for systems that have not met their prescribed monthly sampling is planned for the next period. Work continues to implement the above strategies. Percent of Communities with Healthy Living Strategic Plans 1% % Communities with Healthy Living Strategic Plans - Annual Performance Trend Vs 75% 5% 4% 6% 6% 25% % 211/ / /214 According to the most current annual data available (213/14) 6% of communities in Fraser Health have a healthy living strategic plan. This meets the Fraser Health performance target (6%) for the year and exceeds the Ministry of Health Service Plan target (35%). 23

24 The internal and community components for this measure contribute not only to the vision of healthy living and healthy communities outlined in the BC Guiding Framework for Public Health, but also to the goals of preventing injury and harm from substance use, and supporting good mental health. All the values and guiding principles (e.g., across the lifespan, equity) of the Guiding Framework for Public Health underpin this work. The number of communities with healthy living strategic plans continues to increase. Burnaby and White Rock now have healthy living strategic plans in place. Tri-Cities (including Anmore and Belcarra) have made significant progress towards a combined healthy living strategic plan; this will be a revision for Tri- Cities but new for Anmore and Belcarra. New Westminster and Maple Ridge have passed and are now implementing enhanced smoking bylaws. Progress continues to be made with internal engagement and capacity-building in the area of healthy schools. An engagement session with the school district superintendents is planned for late April. Two school districts collaborated with Fraser Health and received $7,5 School Readiness Grants from the Directorate of Agencies for School Health. These community partnerships are leveraged to strengthen internal activities in four strategic priority areas: chronic disease prevention; substance use prevention, and mental health and well-being; unintentional injury prevention; and healthy aging. Committees have implemented Year 1 workplans for regional health promotion and prevention strategies and are now developing Year 2 workplans, looking to further leverage internal and external partnerships to achieve greater impact on health outcomes. The visions of each of the committees are: Chronic Disease Prevention Smoke-free Fraser Health Substance Use Prevention, Mental Health & Well-being An inclusive and stigma free culture (as related to mental health and substance use) Unintentional Injury Prevention Stay active, healthy and safe Healthy Aging Age-friendly Fraser Health and communities Work continues to maintain or exceed achievement of target levels on this indicator, and to implement the strategies outlined in the priority action plan. Engaging Staff and Physicians A health system is only as strong as the health care providers who work within it. Engaged, skilled, healthy and well-led health care professionals provide the backbone of our health system and the goal of any health care employer should be to ensure that their staff members are supported to use their full knowledge and expertise in a supportive, healthy environment. This strategy will invariably produce better patient, resident and client quality outcomes. Any strategies focused on health human resources in the health system must incorporate strong and effective change management and engagement principles that emphasize a culture of collaboration with key stakeholders, such as unions, in a disciplined and purposeful manner, while building on the Fraser Health values of respect, caring and trust. Aspects of this strategy will focus on the skills of the people leading the change, transparent communication with those impacted by the change, and ongoing assessment and review of the change to ensure it is sustainable into the future. Enabling effective change 24