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

Transcription

1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/29/2017 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. Muskoka Algonquin Healthcare 1

2 Overview Muskoka Algonquin Healthcare (MAHC) proudly serves the community of Muskoka by providing safe, quality, patient and family centered care at two sites located in Bracebridge and Huntsville. MAHC is a rural teaching hospital and is affiliated with several academic institutions, including the Northern Ontario School of Medicine (NOSM), York University, and Georgian College. We are committed to best practices and delivering the highest quality of care ensuring optimal patient outcomes through an integrated approach to safe, quality patient care with all of our partners. To assist us in fulfilling this commitment, MAHC recently adopted an iteration of the Health Quality Ontario (HQO) definition of a high quality health system as the definition for Quality at MAHC. The iteration that has been approved by our Quality Committee and the Board of Directors is directly aligned with the definition that the North Simcoe Muskoka Local Health Integration Network (NSM LHIN) has adopted. Our Quality Improvement Plan (QIP) reflects the second year that MAHC, the North Simcoe Muskoka Community Care Access Centre (CCAC), Muskoka Health Links, the Cottage Country Family Health Team, the Algonquin Family Health Team, and Community Mental Health have worked collaboratively to improve the quality of care for the people of Muskoka. As a collaborative, we are working to improve safe, integrated, effective, patient centered access to care throughout the entire continuum of health care. Our 2017/18 QIP is designed to leverage the forward momentum of our overarching quality and safety culture by ensuring that our environment becomes even safer for our patients, by elevating best patient outcomes through cost effective strategies, by being proactive in anticipating and responding to patient needs, and by improving care transitions from our hospital to the community in collaboration with our partners. Our ongoing quality improvement journey has been informed by our patients and their families, our staff, physicians, Board of Directors, and health care partners. Our collaborative work in the development of our QIP helps to ensure that our patients receive the right care, in the right place, at the right time. Based on feedback from our patients and families through a refresh of our Patient Values, Rights, and Responsibilities, they asked us to commit to the following as it relates to quality of care: I have a right to quality care delivered by professional staff in a setting that meets established quality standards. Our refreshed strategic plan supports the feedback from our patients and identifies quality care and safety as one of 5 key foundational pillars. Our QIP is one of many tools that we use to help document and review our commitment to our community around quality performance. Each selected QIP objective, and its associated improvement indicator, is supported by several underlying initiatives to improve quality of care for the Muskoka community. By working together with our partners, we continue to strive toward significantly enhancing care through the following strategies: (i)readmission within 30 days: For patients who are readmitted to hospital within 30 days of discharge, we know that it is challenging for them, their families, and the health system. Readmission, if avoidable, leads to health system waste. We Muskoka Algonquin Healthcare 2

3 are working closely with our CCAC and Family Health Team colleagues to reduce all preventable hospital readmissions but more specifically focusing on patients who have congestive heart failure, chronic obstructive pulmonary disease, and stroke. (ii)access to the right level of care: With the support of our partners, we are committed to ensuring that patients who no longer require the services of our hospital are discharged in a timely manner. Through very strong partnerships with CCAC, long term care facilities, retirement homes, and other community partners, MAHC has made significant improvements in the amount of time that patients wait for discharge/transfer to alternate level of care. Despite the improvements over the course of this past year, performance is not yet at the target set by the Ministry of Health and Long Term Care and thus remaining as one of our Quality Improvement Plan areas of focus. (iii) Improve the patient experience: MAHC is committed to working with our patients and their families to improve the hospital experience. We are actively creating a culture that will ensure that practices consistently deliver exemplary patient experiences by continuing to spread our service excellence program, and, by spreading our patient and family centered care philosophy. (iv) Medication reconciliation: When admitting patients to hospital, it is extremely important to ensure that an accurate medication history is captured and then matched against hospital admission orders. This ensures that treatment quality and efficacy is maximized. And, medication reconciliation at discharge is an important way to enable safe, seamless care for our patients who are leaving the hospital. (v) Reducing emergency department wait times: MAHC is committed to ensuring that patients who come to one of our two emergency departments (ED) receive timely access to care. Over the past year, MAHC has focused on improvements in wait times for admitted patients who are waiting for an inpatient bed. We have seen very positive improvements in this area, despite an increase in complexity of those patients waiting in our Emergency Departments. Associated with all of the QIP objectives above are targeted change ideas that will drive and achieve improvements within the quality dimensions of effective, efficient, patient centered, safe, and timely. These change ideas range from unit level engagement of staff, to quality board huddles, to system wide strategies such as Health Links and Home First that have been collaboratively developed with all of our community partners. The MAHC culture supports and encourages high quality integrated care in each and every patient-family/provider interaction. We believe that together we can build healthy communities that are aligned with regional and provincial priorities. QI Achievements From the Past Year Last year the NSM CCAC, Cottage Country Family Health Team, Algonquin Family Health Team, Muskoka Health Links, Community Mental Health, and MAHC partnered on a few improvement opportunities with the goal of enhancing quality, safety, and access to care through shared accountability. Together, we achieved success in key areas and are proud of our first year accomplishments with a collaborative approach to quality improvement in Muskoka. Muskoka Algonquin Healthcare 3

4 We exceeded our individual targets in the following areas: ED wait times for admitted patients, alternate level of care days, and, reducing 30 day readmit rates. By working together with our partners, we met with success by: Enhancing the support to our complex patients through hospital-community based initiatives like Health Links and Tele homecare (connecting patients with care through technology). Innovatively and proactively breaking down barriers through an acceptance of all hospital referrals to the Cottage Country Family Health Team COPD rehabilitation clinic regardless of whether the patient is attached to a family health team physician or not. Educating staff and physicians on strategies that support care transitions of the elderly with complex behaviors. Maintaining the successful integration of CCAC employees within MAHC in the role of Transitional Care Coordinators who assist in a timely and seamless discharge plan for patients requiring additional support in the community. In the early winter of 2017, MAHC established its Patient and Family Advisory Council with a total of 10 patient and family advisors. This new committee will enhance MAHC s focus on providing safe, quality care that meets the expectations of our community. Population Health Muskoka is an aging sub region within the NSM LHIN, and, is a vacation community. The graphs below (Image 1 and Image 2) depict population by area municipality both from a permanent resident group and from a seasonal population perspective. Over the next twenty years, both permanent and seasonal resident groups will increase slightly. Table Source: MAHST Programs and Services Working Group February 2017 Table Source: MAHST Programs and Services Working Group February 2017 The plot below (Image 3) depicts the age-adjusted disease prevalence per 1,000 residents. Disease prevalence for the Muskoka sub region residents is lower than the NSM LHIN average but higher than the Ontario average, with the exception of diabetes. Disease prevalence in the plot below is estimated using hospital diagnosis and, as such, requires people to have had contact with the hospital system. Source: DAD/NACRS 2012/15, Ministry of Finance Population, PSG April 2014 Muskoka Algonquin Healthcare 4

5 Muskoka Algonquin Healthcare 5

6 Equity In Muskoka, the social determinants of health are a significant factor that affect whether our patients are able to reach their full health potential. In order to further the goal of health equity, MAHC has partnered with key community initiatives designed to make safe, quality care accessible to all patients. MAHC is an active partner in the Muskoka Health Links work related to coordinated care plans for complex patients including effective transitions to home. This important initiative has provided a coordinated approach to care in the community ensuring that patients and families receive patient-focused support after hospital discharge. As a result of this work, and in conjunction with other best practice initiatives, MAHC has seen a significant decline in 30 day readmissions. MAHC is also partnering with the Muskoka and Area Health System Transformation (MAHST) collaborative. MAHST is a project supported by the NSM LHIN and has a goal of redesigning the local health care system. The project is community-led with a focus on health care equity and effectiveness including seamless transitions. Integration and Continuity of Care MAHC actively seeks strategic partnerships to fully realize the potential of integrated care as demonstrated throughout this document. By working closely and collaboratively with our partners, we are creating new opportunities through a Muskoka Algonquin Healthcare 6

7 shared understanding to improve quality, safety, and access to care in the Muskoka region. We also work extensively with partners within the broader NSM LHIN to successfully implement an integrated health system plan through the Second Curve Forum. These strategic partnerships have created an interconnected system that promotes shared care models optimizing patient transitions through better information management and information sharing. These interconnected partnerships enhance quality and improve safety for our patients and their families by simplifying the system and designing services that maximize efficiencies. For instance, we are achieving smoother transitions between points of care through integrations such as: Muskoka Health Links: This is a Ministry of Health and Long-Term Care initiative in partnership with the NSM LHIN and the District of Muskoka. Muskoka Health Links brings our partner organizations together to coordinate care for patients with complex needs through the creation of joint personalized care plans. Transitional Care Coordinators: This is an integrated CCAC role within MAHC that streamlines the discharge process and transition arrangements for patients who require support following discharge. Tele homecare: This is a great initiative using technology to enhance health care access and support for patients living with congestive heart failure and chronic obstructive pulmonary disease. Regional Planning: MAHC continues to collaborate with the new initiative entitled MAHST that is in place to redesign the Muskoka local health care system. This is a community-led initiative designed to support effective, equitable, and seamless care in the region. Access to the Right Level of Care - Addressing ALC Issues With the support of our partners, we are committed to ensuring that patients who no longer require the services of our hospital are discharged in a timely and appropriate manner. Through very strong partnerships with CCAC, long term care facilities, retirement homes, and other community partners, MAHC has made significant improvements in the amount of time that patients wait for discharge/transfer to alternate level of care. Despite the improvements over the course of this past year, performance is not yet at the target set by the Ministry of Health and Long Term Care. Over the course of the next year, we will continue to reduce the number of ALC patients in all beds (both acute and post-acute). Engagement of Clinicians, Leadership & Staff Engagement of clinical staff and leadership in the development of the MAHC QIP has been broad. Board members, the senior leadership team, front-line managers, frontline clinicians, and physician representatives have all collaborated in the development of our QIP. MAHC employees in all departments are involved in quality improvement initiative methodologies such as LEAN, KAIZAN that continuously enhance the quality of care to our patients. As well, all employees are strongly encouraged to identify and implement quality improvement strategies throughout the year. MAHC also led the development of a collaborative QIP with external partners Muskoka Algonquin Healthcare 7

8 as identified previously. Leadership and front-line staff participate in daily huddles around quality boards to identify current safety issues and to discuss urgent and/or emerging issues. Our senior leadership team, and clinical leaders, round on both patients and staff creating a visible presence to patients and staff providing an opportunity to compliment and recognize staff on excellent work and address concerns. Resident, Patient, Client Engagement MAHC has been very purposeful in elevating the patient voice in MAHC launched its Patient and Family Advisory Council this fiscal year which has enabled transcendence of the patient voice with MAHC initiatives. MAHC recruited 10 patient and family advisors who represent all regions of Muskoka. The Advisory Council has reviewed the QIP on two occasions for input. Staff Safety & Workplace Violence Muskoka Algonquin Healthcare has Policies and Procedures with respect to reducing the risk of violence, reporting of workplace violence, and for summoning immediate assistance in the event there is violence occurring in the workplace. In order to test our policies we conduct Mock Code Whites (Workplace Violence Code). To support our staff when there are incidents of violence in the workplace formal debriefs are conducted as needed. From a training perspective we currently provide a training program to deescalate confrontational and violent situations. We have recently switched our training program from Non-violent Crisis Intervention (NVCI) to the MANDT training program and it is mandatory for all staff at MAHC to attend. To support the policies & procedures, training and support within MAHC, there is infrastructure in place to help keep people safe. This includes: The ability to summon support and assistance with the use of panic buttons in the Emergency Department and switchboard Safe rooms with cameras for monitoring patients Signage that outlines our expectations of respectful behavior towards staff Overall, the security guard presence at MAHC has been increased to include additional hours of coverage across the organization and our two sites to support peak times of aggression and violent behavior that may sometimes occur. To support the care of our patients and ensure the safety of our staff a Mental Health Working Group has been established and recommendations for change have been made. The working group has now formed an implementation committee to work towards the implementation of the first phase of recommendations, which have included: Purchase of pineal restraints and safety pajamas Implementing order sets for mental health patients in the emergency department Focus on shortening time to see physician in ED for mental health patients Collaborate with Canadian Mental Health Association (CMHA) to provide onsite support Muskoka Algonquin Healthcare 8

9 The overall safety and security of our people at MAHC is of great importance and is on a path of consistent quality improvement as we learn from both violent incidents and near misses. Performance Based Compensation Accountability Management: The priorities and targets within our QIP support priorities identified in our Strategic Plan to improve patient engagement, experience, and outcomes. These targets and priorities are further supported by the MAHC business commitments which form the performance based compensation structure of the senior leadership team. To ensure that the QIP initiatives become part of the MAHC fabric, unit specific goals and objectives are developed by front-line leaders and staff and reviewed at huddles and staff meetings to guarantee target success. With oversight from the Board of Directors, the senior leadership team will be held accountable for the overall performance of the organization through monthly reviews of the quality indicators. Performance Based Compensation: The Ontario government passed the Excellent Care for All Act (ECFAA) and Bill 16 in 2010 which required Hospital Boards to establish an at risk component of executive compensation and achieve targets tied to the QIP. At MACH, each senior leader develops goals that create synergy with the Strategic Plan and the QIP and that align with responsibilities within their portfolio and in accordance with our Executive Compensation Policy. Executive compensation is linked to performance in three performance assessment categories: Quality, Financial, and Strategic. Performance assessment categories are rated on the following scale: Quality = 50% Financial = 30% Strategic = 20% Each year, all executives at MAHC have 3% of their compensation at risk. This portion of the compensation is held and measured against achievement of goals and objectives. Health System Funding Reform: MAHC is an evidence-based organization and continues to advance evidence-based care with the adoption of best practices outlined in Quality Based Procedures including, but not limited to, chronic obstructive pulmonary disease, congestive heart failure, pneumonia, stroke, reducing readmissions within 30 days for specific case mix groups, and decreasing ED wait times for admitted patients. MAHC will continue to seek partnerships and strategies that improve our fiscal health including the health system funding reform alignment thoughtfully embedded within our QIP. Contact Information Karen Fleming, Chief Quality and Nursing Executive Natalie Bubela, Chief Executive Officer Evelyn Brown, Muskoka Algonquin Healthcare 9

10 Board Chair Sign-off I have reviewed and approved our organization s Quality Improvement Plan Board Chair Evelyn Brown Quality Committee Chair Phil Matthews Chief Executive Officer Natalie Bubela Other leadership as appropriate Karen Fleming Muskoka Algonquin Healthcare 10

11 2017/18 Quality Improvement Plan "Improvement Targets and Initiatives" Muskoka Algonquin Healthcare 100 Frank Miller Drive AIM Measure Change Quality dimension Issue Measure/Indicator Unit / Population Source / Period Organization Id Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Process measures Target for process measure Comments Effective Effective transitions Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? % / Survey respondents CIHI CPES / April - 968* June 2016 (Q1 FY 2016/17) X 1)Not part of our QIP X X X MAHC evaluates this indicator through post discharge calls and in real time makes adjustments to our system and process based upon the feedback. Risk-adjusted 30-day all-cause readmission rate for patients with CHF (QBP cohort) Rate / CHF QBP Cohort CIHI DAD / January December * Reduction in 30 day readmits for CHF based on CIHI/DAD 1)QBP implementation for CHF 1.1 Ongoing education of all physicians and staff related to the utilization of the QBP order sets, the QBP pathway, the rationale for the utilization, and the importance of meeting the pathway timelines. 1.2 Implement an electronic standardized order set system to facilitate and monitor order set initiation and utilization 1.3 Audit compliance with use of order set and pathway every quarter through a standardized chart audit tool. Results are reported to Quality Council, MAC, and front-line staff Increase utilization of order sets from 40% to 80% by initiating them in the ED and completed by the MRP upon discharge Increase utilization of clinical pathway to 80% through education of all ED physicians, inpatient nursing staff and Family Practitioners Monitor utilization of the electronic standardized order set system to achieve 80% compliance of system use for CHF order sets Monitor the trends for compliance with the order set and pathway to achieve 80% compliance. Reevaluate both for improvements as per evidence and best practice. 80% compliance with order sets and pathways as demonstrated through quarterly chart audits by end of March 2)Work collaboratively with CCAC to increase the number of patients enrolled in the CCAC Tele homecare. 2.1 Collaborate with CCAC on a sustainability plan specific to patient enrolment Maintain or increase current number of patients enrolled in the monitoring stream of Tele homecare for fiscal year Five (5) hospital patients at each site enrolled in the Tele homecare monitoring system with a diagnosis of CHF to reduce readmissions by 2% at end of March Increase medication reconciliation by 100% for this population.

12 3)3) Implement medication reconciliation upon discharge. 3.1 Ensure medication reconciliation on discharge is completed for 100% of CHF patients by January Audit to identify 100% medication reconciliation completed for CHF patients by January Five (5) hospital patients at each site enrolled in the Tele homecare monitoring system with a diagnosis of CHF to reduce readmissions by 2% at end of March Increase medication reconciliation by 100% for this population. Risk-adjusted 30-day all-cause readmission rate for patients with COPD (QBP cohort) Rate / COPD QBP Cohort CIHI DAD / January 2015 December * Reduction in 30 day readmits for COPD based on CIHI/DAD data. 1)QBP implementation for COPD. 1.1 Ongoing education of all physicians and staff related to the utilization of the QBP order sets, the QBP pathway, the rationale for the utilization, and the importance of meeting the pathway timelines. 1.2 Implement an electronic standardized order set system to facilitate and monitor order set initiation and utilization. 1.3 Audit compliance with use of order set and pathway every quarter through a standardized chart audit tool. Results are reported to Quality Council, MAC, and frontline staff Increase utilization of order sets from 40% to 80% by initiating them in the ED and completed by the MRP upon discharge Increase utilization of clinical pathway to 80% through education of all ED physicians, inpatient nursing staff, and Family Practitioners Monitor utilization of the electronic standardized order set system to achieve 80% compliance of system use for COPD order sets Monitor the trends for compliance with the order set and pathway to achieve 80% compliance. Reevaluate both for improvements as per evidence and best practice. 80% compliance with order sets and pathways as demonstrated through quarterly chart audits by end of March 2)Work collaboratively with FHTs to increase the number of COPD patients enrolled in their pulmonary rehab programs. 2.1 Collaborate with all primary care providers in Muskoka on a sustainability plan specific to patient enrolment Number of patients enrolled in the programs at each FHT for fiscal year Ten (10) hospital patients at each site enrolled in FHT pulmonary programs to reduce readmission rate to 2% by end of March 3)Work collaboratively with CCAC to increase the number of patients enrolled in the CCAC Tele homecare. 3.1 Collaborate with CCAC on a sustainability plan specific to patient enrolment Maintain or increase current number of patients enrolled in the monitoring stream of Tele homecare for fiscal year Five (5) hospital patients at each site enrolled in the Tele homecare monitoring system with a diagnosis of COPD to reduce readmission rate to 10%.

13 4)Implement medication reconciliation upon discharg. 4.1 Ensure medication reconciliation on discharge is completed for 100% of COPD patients by January Audit to identify 100% medication reconciliation completed for COPD patients by January Increase medication reconciliation by 100% for this population. Risk-adjusted 30-day all-cause readmission rate for patients with stroke (QBP cohort) Rate / Stroke QBP Cohort CIHI DAD / January December * Reduction in 30 day readmits for Stroke 1)QBP implementation for Stroke 1.1 Ongoing education of all physicians and staff related to the utilization of the QBP order sets, the QBP pathway, the rationale for the utilization, and the importance of meeting the pathway timelines. 1.2 Implement an electronic standardized order set system to facilitate and monitor order set initiation and utilization Increase utilization of order sets from 40% to 80% by initiating them in the ED and completed by the MRP upon discharge Increase utilization of clinical pathway to 80% through education of all ED physicians, GIM practitioners, inpatient nursing staff and Family Practitioners. 80% compliance with pathways as demonstrated through quarterly chart audits by end of March 1.3 Audit compliance with use of order set and pathway every quarter through a standardized chart audit tool. Results are reported to Quality Council, MAC, and frontline staff Monitor utilization of the electronic standardized order set system to achieve 80% compliance of system use for COPD order sets Monitor the trends for compliance with the order set and pathway to achieve 80% compliance. Reevaluate both for improvements as per evidence and best practice. 2)Enhance access to TPA. 2.1 Ongoing education to ED physicians, GIM physicians, DI, laboratory personnel, and ED nursing staff around processes in place related to decreasing the door to needle time at the HDMH site Monitor the trends for compliance with the policy and process related to TPA administration and door to needle time. Decrease door to needle time to 45 minutes or less for 80% of appropriate stroke patients. 3)Stroke Special Project 640: Dysphasia Screening for all patients with stroke symptoms, including TIA. 3.1 Stroke Nurse, Speech Language Pathologist, Ambulatory Manager to review Project 640 Dysphasia Screening tool for possible changes to MAHC current tool. 3.2 Explore CERNER EMR (Electronic Medical Record) implementation of tool. 3.3 Audit compliance of tool utilization Dysphagia Screening tool reviewed, evaluated, and updated accordingly by interprofessional team by the end of July Stroke Nurse and HDMH Inpatient and District Stroke Manager explore tool implementation through Cerner EMR (Electronic Medical Record) by end of July Monitor trends for compliance of use of dysphagia tool for a total of 80% of identified patients. With a goal of 80% total compliance of dysphagia screening on all admitted patients and a goal of 20% of patients discharged from the ED with a diagnosis of Stroke or TIA by March 4)Implement medication reconciliation upon discharge. 4.1 Ensure medication reconciliation on discharge is completed for 100% of stroke patients by January Audit to identify 100% medication reconciliation completed for stroke patients by January Increase medication reconciliation by 100% for this population.

14 Efficient Access to right level of care Total number of Rate per 100 alternate level of care inpatient days / (ALC) days All inpatients 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 WTIS, CCO, BCS, MOHLTC / July September 2016 (Q2 FY 2016/17 report) 968* This indicator is complex for MAHC and requires system improvements with multiple LHIN stakeholders. 1)Continue to collaborate with CCAC on Home First initiative. 1.1 Continue weekly interprofessional and collaborative ALC rounds with CCAC at both sites. 1.2 Meet with patients/families of at risk for ALC patients on Day 2 of admission to review options and create plan Clinical Lead and Patient Flow Navigator to attend weekly meetings with CCAC with the addition of OT, PT, and Social Work as per specific patient requirements Clinical Lead to coordinate and facilitate meetings with patients/families at risk of ALC on Day % compliance with attendance of identified staff at ALC rounds with a focus on reducing ALC days by end of March % of patients/families at risk of ALC will participate in Day 2 meeting and validated through daily bed summary report by end of October )Update MAHC ALC policy to reflect alignment with LHIN-wide ALC standardization work. 2.1 Continue daily bed meetings at both sites with front line staff, CCAC and leadership where estimated date of discharge is assessed and plan of care is reviewed. 2.1 Clinical Lead to facilitate daily bed meetings, focusing on discharge and care plans. 100% compliance with policy by end of March 3)Continue to participate/partner in LHIN system-wide service developments, including ALC Planning Steering Committee. 3.1 Implement standardized processes for ALC management and service transition resulting from collaborative interagency work emanating from the LHIN ALC Steering Committee and associated Task Forces. 3.2 Ongoing collaboration with the LHIN Lead for Specialized Geriatric Services related to quality improvement initiatives in the care of patients with concerning behaviours. 3.3 Collaborate with all partners in establishing a "Transition Protocol" that standardizes processes and practice ensuring a smooth transition from hospital to LTC home Enhanced collaboration with community partners, the LHIN, Waypoint, the District of Muskoka, CMHA, FHTs, CCAC, and LTC to develop processes for transition of ALC patients to the right environment in a timely manner Implement sustainability plan as it relates to system and process improvements developed by the Behavioural Service Agents Biannual meeting with partners to review transition successes and opportunities. Adjust system and processes to improve transition experience. Number of standard processes for transitions developed in conjunction with partners by March 4)Continue to utilize the Health Links system and process already established to facilitate discharges from hospital to home for ALC and complex medical patients. 4.1 Patient Flow Navigators and Transitional Care 4.1 Monitor the number of patients who are referred to Coordinators will continue to identify patients that meet Health Links. the criteria for Health Links. 20 patients per site that are referred to Health Links by March Patient-centred Palliative care Percent of palliative care patients discharged from % / Palliative patients CIHI DAD / April 2015 March * X hospital with the discharge status Not part of our QIP x x x MAHC has a small volume of palliative patients and so will evaluate this

15 Person experience "Would you recommend this emergency department to your friends and family?" % / Survey respondents EDPEC / April - June 2016 (Q1 FY 2016/17) 968* Patient and Family inpatient experiences are key indicators to identifying successes and opportunities for improvement through NRCC data source. 1)Elevate patient and family engagement at MAHC. 1.1 Hardwire AIDET, Leader Rounding on patients, and incorporate a refresh on patient whiteboards and bedside shift report. 1.2 Continue to support the Family Presence policy and post care calls. 1.3 Ensure that all staff receive communication and customer service training through the LMS (Learning Management System) and in person education Audit 80% compliance of clinical tactics through tracking of data from leader rounding on patients daily, starting in April Implement 2 change ideas from post care calls by end of March Managers to audit 80% compliance with customer service and communication training completion through the LMS (Learning Management System). Increase inpatient satisfaction scores by 2% by March 1.4 Engage Patient and Family Advisory Committee in projects that support patient/family engagement Committee will develop a work plan that supports elevating patient and family engagement at MAHC by end of June )Improve return rate of surveys. 2.1 Nursing staff to provide education to patients at discharge on the importance of survey completion and return, allowing MAHC to make improvements in service delivery. 2.1 Increase NRCC return rate by 5% by end of March Increase inpatient satisfaction scores by 2% by March "Would you recommend this hospital to your friends and family?" (Inpatient care) % / Survey respondents CIHI CPES / April - June 2016 (Q1 FY 2016/17) 968* Patient and Family inpatient experiences are key indicators to identifying successes and opportunities for improvement through NRCC data source. 1)Elevate patient and family engagement at MAHC. 1.1 Hardwire AIDET, Leader Rounding on patients, and incorporate a refresh on patient whiteboards and bedside shift report. 1.2 Continue to support the Family Presence policy and post care calls. 1.3 Ensure that all staff receive communication and customer service training through the LMS (Learning Management System) and in person education Audit 80% compliance of clinical tactics through tracking of data from leader rounding on patients daily, starting in April Implement 2 change ideas from post care calls by end of March Managers to audit 80% compliance with customer service and communication training completion through the LMS (Learning Management System). Increase inpatient satisfaction scores by 2% by March 1.4 Engage Patient and Family Advisory Committee in projects that support patient/family engagement Committee will develop a work plan that supports elevating patient and family engagement at MAHC by end of June )Improve return rate of surveys. 2.1 Nursing staff to provide education to patients at discharge on the importance of survey completion and return, allowing MAHC to make improvements in service delivery. 2.1 Increase NRCC return rate by 5% by end of March Increase inpatient satisfaction scores by 2% by March

16 Safe Medication safety Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital Rate per total Hospital collected number of data / Most admitted patients recent 3 month / Hospital period admitted patients 968* MAHC will monitor data collected from CERNER EMR (Electronic Medical Record), which is a hospital based documentation system. 1)Identify interdisciplinary medication reconciliation process and documentation to improve efficiency and accuracy of BPMH (Best Possible Medication History), Medication Reconciliation upon admission. 1.1 Develop policy and procedure on the medication reconciliation process at MAHC and identify the specific roles, expectations, accountabilities and functions of the various disciplines and departments. Educate all disciplines on the policy and monitor compliance. 1.2 Identify patients who require BPMH as defined by Accreditation Canada versus those who only require a list of current medications. 1.3 Provide education on medication reconciliation through the LMS (Learning Management System) education module Implement, educate policy and procedure by May On a monthly basis, measure the number of medication reconciliation completed upon admission as documented in the CERNER EMR (Electronic Medical Record) system Measure the number of staff who complete the education module on BPMH by May Implement role responsibilities by 100% of educated staff by May Increase medication reconciliation compliance on admission by 24% by March 1.4 Identify specific responsibilities according to roles by April Work with GBIN Cerner EMR (Electronic Medical Record) partner organizations to identify any additional efficiencies for medication reconciliation on an ongoing basis Ongoing collaboration with partner organizations Audit to identify 100% Medication Reconciliation completed for COPD, CHF, and Stroke patients on admission by January 1.6 Ensure med rec on admission has a 100% completion rate for COPD, CHF, and Stroke patients by January Medication Rate per total reconciliation at number of discharge: Total discharged number of discharged patients / patients for whom a Discharged Best Possible patients Medication Discharge Plan was created as a proportion the total number of patients discharged. Hospital collected data / Most recent quarter available 968* MAHC will monitor data collected from CERNER EMR (Electronic Medical Record), which is a hospital based documentation system. 1)Identify interdisciplinary medication reconciliation process and documentation to improve efficiency and accuracy of BPMH (Best Possible Medication History), Medication Reconciliation upon discharge. 1.1 Develop policy and procedure on the medication reconciliation process at MAHC and identify the specific roles, expectations, accountabilities and functions of the various disciplines and departments. Educate all disciplines on the policy and monitor compliance. 1.2 Identify patients who require BPMH as defined by Accreditation Canada versus those who only require a list of current medications. 1.3 Provide education on medication reconciliation through the LMS (Learning Management System) education module Implement, educate policy and procedure by May On a monthly basis, measure the number of medication reconciliation completed upon discharge as documented in the CERNER EMR(Electronic Medical Record) system Measure the number of staff who complete the education module on BPMH by May Implement role responsibilities by 100% of educated staff by May Increase medication reconciliation compliance on discharge at 80% by March 1.4 Identify specific responsibilities according to roles by April Work with GBIN Cerner EMR (Electronic Medical Record) partner organizations to identify any additional efficiencies for medication reconciliation on an ongoing basis. 1.6 Ensure med rec on discharge is completed for 100% of COPD, CHF, and Stroke patients by January Ongoing collaboration with partner organizations Audit to identify 100% Medication Reconciliation completed for COPD, CHF, and Stroke patients on admission by January Timely Timely access to care/services Total ED length of stay (defined as the time from triage or registration, whichever comes Hours / Patients with complex conditions CIHI NACRS / January 2016 December * X Not part of our QIP X X X MAHC is focusing on sustaining performance of ED length of stay for admitted

17 ED Wait times: 90th percentile ED length of stay for admitted patients. Hours / ED patients CCO iport Access / January 1 to December 31, * MAHC will continue to monitor gains made in ED length of stay of admitted patients. 1)Improve flow through the Emergency Department. 1.1 Evaluate the patient distribution policy. 1.2 Evaluation of time to PIA for CTAS Evaluate surgical consultant response times 1.4 Review turnaround time data from Lab and DI and work with their teams to enhance flow and patient experience in and through the ED Number of patients waiting for inpatient bed, and/or for physician initial assessment in the ED Complete at least one LEAN strategy (e.g., process flow map evaluating transfer of care and/or triage room process improvement) by end of March % of CTAS 2 patients have a PIA of less than < 1.5 hours by March 31, X 1.5 Collaborate with LHIN partners to facilitate mental health assessments and transfers of Form 1 patients Audit charts of CTAS 2 patients when time to PIA greater than 0.5 hours % of MAHC ED surgical consults have an initial response time of <1.0 hour by March 31, Complete one LEAN strategy related to the turnaround time data for diagnostics by end of March ED length of stay for admitted Form 1 patients improved by 5% by March