Quality Improvement and Patient Safety Portfolio Annual Report 2013/14 Report to the Board Quality Performance Committee October 29, 2014

Transcription

1 Quality Improvement and Patient Safety Portfolio Annual Report 2013/14 Report to the Board Quality Performance Committee October 29, 2014 September 2014 Respect Caring Trust 1/35

2 Table of Contents Executive Summary... 3 Vision and Organizing Structure for Quality and Safety... 5 Quality Improvement and Patient Safety Portfolio... 7 Review of Quality Improvement and Patient Safety Accomplishments... 9 Improve Care Transitions... 9 Improve Patient Safety Culture Support, Standardize and Spread Evidence-Informed Practices Improve the Patient Experience FH Infrastructure to Support Organization-Wide Accountability Glossary of Acronyms Respect Caring Trust 2/35

3 Executive Summary The Quality Improvement and Patient Safety (QI/Patient Safety) portfolio is comprised of a network of specialists to promote the integration of evidence-based, patient-centered principles and practices with Fraser Health s operations. The portfolio is comprised of four streams: Clinical Improvement, Accreditation, Patient Care Quality Office (PCQO) and Organization-wide Initiatives and works closely with leadership at all levels (local, Program, and organization-wide) to ensure our services are aligned with Fraser Health's priorities. In addition to internal partnerships, the QI/Patient Safety portfolio also actively participates in provincial, inter-provincial and national networks and working groups to advance shared goals, such as the BC Patient Safety and Quality Council, BC PSLS, Canadian Patient Safety Institute (CPSI), Provincial Quality and Patient Safety Directors Network, Patients as Partners/Patient Voices Network, Western Canada Patient Safety Working Group, educational institutions, and numerous other external partners. This Annual Report provides an overview of activities undertaken by the QI/Patient Safety portfolio during 2013/14 to support Fraser Health s organizational priorities with a focus on the following areas: Improve care transitions; Improve patient safety culture; Standardize and spread evidence-informed practices; Improve the patient experience; and FH Infrastructure to support accountability for quality and patient safety throughout the organization. To improve management of care transitions, an initiative called Releasing Time to Care was introduced in Fraser Health in Spring, 2014 with the launch of a pilot at Mission Memorial Hospital. Objectives to improve patient safety culture centered around continuing to embed the Accreditation Canada Required Organizational Practices (RoPs) with Clinical Program operations and improvement initiatives, fostering patient-provider partnership for patient safety, proactively analyzing potential for harm (human factors engineering), supporting the reduction of nursesensitive adverse events (NSAE), and learning from patient safety near-misses, patient harm, and complaints as drivers for improvement. The QI/Patient Safety portfolio coordinated Fraser Health s involvement with the BC Clinical Care Management strategy, designed to standardize and spread evidence-informed practices in key areas identified as needing improvement province-wide. The portfolio worked closely with Clinical Programs during 2013/14 to support their overall improvement of key patient care processes through redesign through 48/6 evaluation, Medication Reconciliation and Venous Thromboembolism (VTE) prevention. In addition, the Fraser Health Patient Advisory Committee participated in Seamless Care planning to ensure the patient perspective is incorporated with care delivery redesign, implementation and evaluation. The QI/Patient Safety portfolio contributed to improving the patient experience through initiatives to obtain patient feedback and engage Clinical Programs in incorporating the patient s perspective in improvement activities. These included planning for implementation of the Real-Time Patient Experience Survey (RTPES), as well as the BC Patient Experience Measurement Survey (PREMS) for BC Acute Inpatient Care, Outpatient Cancer Care and ER. The Patient Care Quality Office (PCQO) also promotes patient-provider partnership by offering a formalized complaints Respect Caring Trust 3/35

4 management system for patients, residents and clients in compliance with requirements of the Patient Care Quality Review Board Act (PCQRB Act) and BC Ministry of Health Directives. The Fraser Health Patient Advisory Council, established in April, 2011, is comprised of patient members of the BC Patient Voices Network as well as Fraser Health staff. During 2013/14, the Patient Advisory Council played an active role in a number of key Fraser Health initiatives, such as Keeping Patients Safe and the Seamless Care Patient Experience stream. Development of FH Infrastructure to support accountability for quality and patient safety throughout the organization continued to be a major focus for the QI/Patient Safety portfolio in 2013/14. This included the revision of the complaints management and patient safety event management processes, as well as systems to enable monitoring and accountability within Fraser Health s operations for continuous improvement, such as the Patient Safety and Learning System (PSLS) and the Quality Performance Management System (QPMS). Respect Caring Trust 4/35

5 Vision and Organizing Structure for Quality and Safety The Quality and Safety structure is guided by and framed within the context of Fraser Health s Vision, Purpose, Values and in alignment with the organization s top priorities. The Fraser Health Quality Performance Committee (QPC) structure, established in 2009, has a key leadership role in supporting the achievement of Fraser Health s objectives. Reporting to the Board through its Quality Performance Committee, the overarching purpose of the Fraser Health Quality Performance Committee is to provide strategic leadership, oversight and stewardship for quality and patient, client and resident safety across Fraser Health (FH) and advise on regional system-wide issues impacting on care and quality outcomes. The FH QPC provides oversight and direction to reporting committees with specialized areas of focus as follows: Medication and Therapeutics, Infection Prevention and Control, Quality Performance Management System (QPMS) and Health Technology Assessment, as well as Program Quality Performance Committees for each Clinical Program. The QPC structure is designed to create effective linkages with Fraser Health s operations through oversight and stewardship for quality improvement, evidence-based practice, and performance measurement and evaluation organizationwide. Respect Caring Trust 5/35

6 Fraser Health Quality Performance Committee Reporting Structure Respect Caring Trust 6/35

7 Quality Improvement and Patient Safety Portfolio: Supporting Fraser Health s Vision and Strategic Imperatives The Quality Improvement and Patient Safety (QI/Patient Safety) portfolio is comprised of a team of consultants whose role is to promote the integration of evidence-based, patient-centered principles and practices with Fraser Health s operations. The QI/Patient Safety staff work closely with leadership at all levels (local, Program and organization-wide) to ensure our services are aligned with Fraser Health's priorities. In addition to internal partnerships, the QI/Patient Safety portfolio also actively participates in provincial, inter-provincial and national networks and working groups to advance shared goals such as the BC Patient Safety and Quality Council, BC PSLS, Canadian Patient Safety Institute (CPSI), Provincial Quality and Patient Safety Directors Network, Patients as Partners/Patient Voices Network, Western Canada Patient Safety Working Group, educational institutions, and numerous other external partners. The QI/Patient Safety portfolio functions as a network of internal consultants. Its operations are based on the following quality improvement principles: Recognize the Individual Foster Strong, Cooperative Team Relationships Apply Quality Improvement Methodology Consider the System as a Whole To bring these principles to life in everyday practice, the QI/Patient Safety team must work in partnership with customers at all levels of the organization as well as external bodies. Evidence and experience show that to successfully implement, sustain and spread healthcare improvement, an effective partnership needs to exist between operational (administrative), clinical (content), and process (quality improvement) leaders, with clear sponsorship at the Executive level. Real improvement requires a shared vision, will, ideas and execution. This is only by establishing a clear understanding of each partner s contribution to the aim from the outset of an initiative and as it progresses. Efforts to make improvements without balance between these key stakeholders fall short of performance expectations. The portfolio is comprised of four streams: Clinical Improvement, Accreditation, Patient Care Quality Office (PCQO) and Organization-wide Initiatives (Patient Safety Learning System, Human Factors Specialist, Quality Performance Management System, Patient Advisory Council). With the introduction of Program Management in 2009, the portfolio service delivery model was structured to align its Consultant resources with the Clinical Programs through their Quality Performance Committees. In early 2013, the Clinical Improvement stream was redesigned in response to the Corporate deficit and transitioned to a centralized approach supporting Program and cross-program initiatives, effective April 1, 2013 (please see organizational chart below). A service request process was developed to enable timely response to organizational needs as well as prioritization and monitoring of staff workload, and evaluation of customer experience with the new model. The following organizational chart shows the staffing resources within the Quality Improvement and Patient Safety portfolio as of March, Respect Caring Trust 7/35

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9 Review of Quality Improvement and Patient Safety Accomplishments in 2013/14 This report provides an overview of performance objectives addressed during 2013/14 by the QI/Patient Safety portfolio in support of Fraser Health s top priorities, focusing in the following areas: Improve care transitions; Improve patient safety culture; Standardize and spread evidence-informed practices; Improve the patient experience; and FH infrastructure to support accountability for quality and patient safety throughout the organization. Improve Care Transitions The effective management of care transitions is fundamental to the quality and safety of patient care. An evidence-based approach to teamwork and process redesign can help eliminate inefficiencies that steal time from direct care and effective communication as patients move from one phase of care to the next. Releasing Time to Care Releasing Time to Care (RT2C), originating in the UK and also known as the Productive Series, is an internationally renowned program that empowers frontline staff to come together to analyze their work environment and develop ways to improve the quality of care for their patients. This program is comprised of modules for integration of lean principles and quality improvement methodology with everyday work in the clinical setting. In Spring, 2013, the BC Patient Safety and Quality Council launched a province-wide education program for health authorities, along with a process to coordinate and support implementation, measurement and reporting as the RT2C modules are implemented at each participating site. Results of implementation on the inpatient units at Richmond General Hospital (Vancouver Coastal Health) have demonstrated the value of RT2C in improving direct patient care time for clinical staff as well as patient safety, patient experience, staff well-being, and efficiency. Learnings from Vancouver Coastal s experience were used to identify a pilot site in Fraser Health. The Medicine unit at Mission Memorial Hospital was selected to participate, sponsored by the VP, Clinical Operations and Executive Director, Medicine, with support from Professional Practice and QI/Patient Safety. Next Steps 2014/15 The provincial RT2C Collaborative was to be launched in June, Learnings from the MMH pilot will be shared with the Medicine Program and Executive as it progresses to ensure appropriate support for implementation and sustainment, as well as potential for spread to other areas across Fraser Health. Respect Caring Trust 9/35

10 Improve Patient Safety Culture: Strategies to Prevent, Manage and Learn from Harm Fraser Health is committed to monitoring and continuously improving patient safety. This requires a comprehensive, multi-pronged strategy comprised of measurement systems, processes and tools to support effective management of patient safety and harm and embedding patient safety into the organization s culture at every level of service. Fraser Health s Patient Safety Event Management policy as well as processes and tools for reporting and analysis define accountabilities for patient safety and action on recommendations for improvement. The Program Management structure has enabled local, case-specific learnings and improvement efforts to be spread across Clinical Programs and the organization as a whole. The QI/Patient Safety portfolio has continued to focus its efforts in a number of key areas as highlighted below. Patient Safety & Learning System (PSLS) One of Fraser Health s most significant patient safety strategies has been organization-wide implementation of the Patient Safety and Learning System (PSLS). The web-based Patient Safety Events module is used by providers throughout the organization. The PSLS is an important enabler of accountability for patient safety throughout the organization, notably the improvement of processes that contribute to patient harm and documentation of followup action. The PSLS is also an important data source for the safety dimension of the Quality Performance Management System (QPMS) scorecards for each Clinical Program. Only data from the final approval category are included in the QPMS PSLS indicator; therefore, timely completion of follow-up documentation in the PSLS is essential. Excerpt from BC PSLS Blog: We all recognize that patient safety is the gold standard of quality care. Every day, thousands of pieces of medical equipment and devices are used by healthcare providers all over the Lower Mainland. It s our job to make sure this equipment is working properly, staff know how to use it and it s replaced at the end of its lifespan. We re using BC PSLS to learn and improve the way we do our work so our patients and their families feel safe. Charles Xiao, Biomedical Engineer. Strategies to Engage Leaders in PSLS A major focus for 2013/14 was on supporting accountability within and across Clinical Programs for timely follow-up and documentation of actions in response to harm in the moderate, severe and death categories (Levels 3-5), by operational and clinical leaders, as well as review of no harm events for proactive improvement. This was continuously reinforced through distribution of monthly PSLS profile reports to Program leaders, along with education, coaching and support by the PSLS Coordinator. Regular bi-weekly reporting to the Executive Committee was continued from 2012/13 on the status of overdue patient safety events under each VP s areas of responsibility. This has helped strengthen accountability for patient safety learning and improvement organization-wide, and has provided positive recognition for the sharing of improvement stories within the organization and on the BC PSLS blog, which has world-wide readership. Ongoing monitoring by senior leadership has also resulted in reducing the volume of overdue events from several thousand to just a few hundred each month, with a goal to eliminate overdue events altogether. Respect Caring Trust 10/35

11 Excerpt from BC PSLS Blog: When I looked at our PSLS data I could see we had a lot of mislabelled lab specimens, says Deljit. If you mislabel a lab specimen it delays the process of care and delays treatment. Many of our patients are recovering from open heart surgery so there s no room for that kind of preventable error. It s not about having enough people to do our job, it s about the work we re doing and how we engage each other in quality of care, says Deljit. The CSICU team is very focused on patient safety and I would say they feel a strong sense of ownership when it comes to our PSLS data. The system has brought a lot of positive change for our team and our organization. Deljit Bains, Manager, Cardiac Services Sustainment of the PSLS system is key to its effectiveness. This includes a help desk, managed by the PSLS Coordinator, and ongoing online and in-person education. Three two-hour sessions are provided each month throughout the Health Authority for PSLS follow-up users / Handlers: A series of Vimeo tools was also developed and implemented across the Health Authority for handlers and follow-up users to refresh their skills in various aspects of the follow-up process. Data Highlights In the fiscal year 2013/2014, 29,855 safety events were reported in PSLS, an increase of 2,486 reports from fiscal 2012/2013. One percent related to severe harm (283 events) and 0.04% related to death (135 events). Sixty-nine percent of all safety events reported across Fraser Health were reported and confirmed with no harm. The information captured in these events presents a vital opportunity to learn and predict where harmful events may occur. We continue to review the data in the aggregate which illuminates where prevention efforts can be focused. All Safety Events No harm 2 Minor harm 3 Moderate harm 4 Severe harm 5 Death % 21% 4% 1% 0.4% The top 10 patient event categories are also provided to the Executive, Clinical Integration Executive Committee, HAMAC, and the Clinical Programs to support improvement priority-setting. Of the top 10 categories of patient safety events, the top 3 categories have been consistent year over year: Falls, Medications, and Clinical Processes and Procedures (early recognition and management of deteriorating patients; and behavior, specifically suicide in clients of the Mental Health and Substance Use Program). These continued to be priorities for harm reduction within the Clinical Programs, reinforced by Accreditation Canada s Required Organizational Practices. Efforts within individual Programs were brought closer together through Clinical Integration Executive Council (CIEC) and development of Shared Work Teams to address safety issues which cross multiple Programs. Respect Caring Trust 11/35

12 The Provincial bubble chart below illustrates Fraser Health s safety reporting volume/average days to review and average days to complete the follow-up relative to the other organizations across BC using the PSLS. These results are a testimonial to the engagement of leadership in PSLS. FHA Average days to Review = 3.6 FHA Average days to Final = 11.8 FHA Respect Caring Trust 12/35

13 The Executive Committee has also been presented with data (426 events) where handlers/follow-up users have completed the analysis of their safety events and designated them as preventable. The level of harm for these patients/clients/residents was either moderate, severe or death. Each Program reviews the Preventable Events and uses this information to mitigate patient harm. Top 10 Event Categories Deemed by Handlers as Preventable 3 Moderate harm 4 Severe harm 5 Death Total Clinical process / procedure Medication / IV fluid / biological (includes vaccine) Fall Documentation Clinical administration Laboratory Equipment / product / medical device Resources / organizational management Behaviour Neonatal care Inter-disciplinary Patient Safety Reviews Patient safety events are routinely reviewed by a handler who is assigned to assess and document level of severity of harm and follow-up actions in the system prior to placing events in the Final Approval category for closure. Some events are the result of complex processes for which the contributing factors need to be better understood so they can be either eliminated or mitigated. In such cases, a formal inter-disciplinary process review is undertaken, usually with the support of a QI/Patient Safety Consultant as facilitator. Over the past few years, significant effort has been made by QI/Patient Safety to improve the patient safety event management process, including education, tools and resources to guide Programs in the decision to commission an inter-disciplinary process review. During 2013/2014, the QI/Patient Safety team received requests for facilitation of 21 patient safety reviews. Patient Safety Review Activity: a Two-year Comparison 2013/ /2013 # Patient Safety Reviews Avg. # of days from date of event, to date of completion of review Forty percent reduction in the number of reviews conducted in 2013/14 (21 reviews); compared to 2012/2013 (35 reviews). Respect Caring Trust 13/35

14 Completion times for patient safety reviews remained relatively the same in 2013/14 (113.2 days) compared to 2012/2013 (111.9 days) which is a slight increase of 1%. This suggests a need to further strengthen the commissioning process (formal request for review by an Executive lead), including early identification of the need for a formal process review and activation of the process as soon as possible after events are reported in PSLS. The commissioning Executive also needs to be kept informed about status of reviews to ensure timelines for completion are met and that key stakeholders are available to participate. Patient Safety Reviews Cases - Program Areas The top three Program areas for the Patient Safety Reviews Cases for the last two years are: 2013/2014 1) Maternal/Infant/Child/Youth 29%; 2) MHSU 19%; and 3) Surgery 14% 2012/2013 1) Maternal/Infant/Child/Youth 43%; 2) Surgery 20%; and 3) Medicine 11% Figure Program Areas involved in Patient Safety Figure Program Areas involved in Patient Safety Reviews (2013/14) Reviews (2012/13) Patient Safety Event Management Consultation (PSEM) In addition to the above Patient Safety Reviews, the QI/Patient Safety Consultants also completed 45 Patient Safety Event Management Consultations: Patient Safety Event Management Consultation 2013/2014 # of Consultations 45 Avg. # of days from date of event to date of close Respect Caring Trust 14/35

15 Next Steps 2014/15 Quality Improvement & Patient Safety Annual Report During Fall, 2014, an updated Patient Safety Event Management (PSEM) toolkit will be completed and shared with the Clinical Programs. Ongoing PSEM education will be provided by the QI/Patient Safety Consultants; clinical Leaders can register online using the Course Catalogue Registration System (CCRS). Management of Recommendations The QI/Patient Safety Consulting team has led the development of the new provincial PSLS Recommendations module for implementation across the BC Health Authorities. This tool enables documentation, monitoring and analysis of recommendations from various sources (ie Patient Safety Reviews, PCQO Reviews, Coroners Reports, Accreditation) and status of implementation. The Recommendations module supports Program Leaders in closing the loop on learnings arising from in-depth reviews and in developing implementable recommendations by use of a scoring algorithm to assess the strength of each recommendation (based on human factors principles of hierarchy of effectiveness). During 2013/14, the Recommendations module was fully implemented for two Programs: the Mental Health and Substance Use Program, and the Maternal /Infant/Child/Youth Program. Early in 2014, both Programs were surveyed to obtain feedback on the implementation process and the use of the module. The new module was very positively received by both Programs and suggestions were made on ways to improve functionality and user experience. This information was incorporated in the updated Recommendations Module education for 2014/15 and a toolkit set for release in Fall, Next Steps 2014/15 The following Programs are preparing to implement the Recommendations Module during the fall of 2014: Critical Care, Renal, Emergency, Trauma, Older Adult, and Rehabilitation (Rehab). The remaining Clinical Programs will begin implementation during 2015 through a phased approach based on readiness. Support Cross-Program Partnership to Address Systemic Patient Safety Issues The QI/Patient Safety portfolio provided expertise to targeted patient safety initiatives during 2013/14 by: providing leadership on the use of the Model for Improvement and incorporating the Plan-Do- Study-Act (PDSA) cycle to guide tests of change; facilitation of key performance measures to determine if the change is an improvement; and promoting the standardization of clinical processes and clinical practice guidelines for improved outcomes. Two examples of targeted initiatives supported by the QI/Patient Safety Consultants were: 48/6 Model of Care, a pro-active, integrated approach designed to prevent functional decline and in-hospital comorbidity, helping patients return home sooner at the level of independence they Respect Caring Trust 15/35

16 had prior to admission. This evidence-based strategy addresses 6 care areas through patient screening and assessment within 48 hours of admission to care: Nutrition and Hydration, Cognition, Medications, Pain, Mobility, and Bowel/Bladder; and Nurse Sensitive Adverse Events (NSAE), an improvement initiative which focuses on reduction of harm related to 4 nurse sensitive clinical areas: hospital acquired pneumonia, urinary tract infections, pressure ulcers and in-hospital fractures. Five Clinical Programs are involved in Fraser Health: Critical Care, Emergency, Medicine, Older Adult, and Surgery. Other activities during 2013/14 included a Fraser Health Patient Safety Symposium and participation in Keeping Patients Safe. Patient Safety Symposium: How safe are your patients... How do you know? In November, 2013, at the request of Dr. Nigel Murray, President and CEO, the QI/Patient Safety portfolio hosted a one-day Patient Safety Symposium. This was designed to bring together Fraser Health s clinical management team to learn, be inspired, and take away innovative concepts and tools to embed a focus on patient safety into everyday practice. Participants were provided with practical hands-on tools, techniques, and resources to support them in the use of PSLS to its fullest capacity in improving patient safety. Real-life examples of patient safety in action were shared from within Fraser Health and other safety-critical industries to inspire and educate participants on the characteristics of an organization committed to safety and how to use the PSLS and other tools/techniques to create a safety culture. The Symposium received very positive feedback and was an excellent forum for connecting leaders in their passion for improving patient safety across the organization. Keeping Patients Safe The QI/ Patient Safety portfolio provided support to an initiative sponsored by the Fraser Health President and Chief Executive Officer to explore innovative ways to improve patient safety, by strengthening partnership between front-line healthcare providers and patients and their families. During 2013/14, a task group worked in partnership with the Health Design Lab of Emily Carr University of Art and Design (ECUAD) to engage Fraser Health leaders and Patient Advisors as well as members of the public to co-create prototypes for enhancing provider-patient information. These included the design of patient-centered whiteboards, public smartboards, and processes to encourage shared responsibility between providers and patients or safety practices such as hand hygiene, falls prevention and medication error prevention. Each prototype was assessed with respect to feasibility and prioritized for implementation as part of the Seamless Care strategy in 2014/15. Application of Human Factors Engineering to Improve Patient Safety Human Factors is an area of psychology and engineering that seeks to promote a culture of safety by optimizing the relationship between technology, the work environment and people. Human factors science has been effectively applied in prospective activities such as procurement of new medical devices, infrastructure and software requirements, and risk assessment and mitigation. Human factors also supports retrospective quality initiatives launched in response to critical incidents and near-misses to identify and close systemic gaps that impact patient safety. Since its addition to the QI/Patient Safety portfolio in 2011, the role of human factors engineering in Fraser Health has evolved and become embedded into a growing number of patient safety initiatives. Respect Caring Trust 16/35

17 Procurement of Medical Devices The Human Factors Specialist supported and informed Fraser Health and provincial procurement decisions by providing formal clinical evaluations of medical devices during the RFP process, including defibrillators, transport monitors and automated external defibrillators (AED), large volume infusion pumps, patient-controlled analgesia (PCA) pumps, automated medication dispensing cabinets (ADC), blood-glucometers. The Human Factors Specialist provided expertise through usability testing and heuristics analysis on the following procurement projects: implementation of Epidural infusion pumps; blood glucose meters (provincial RFP); defibrillators, transport monitors and automated external defibrillators (RFP); automated medication dispensing cabinets (provincial RFP); large volume infusion pumps (RFP); PCA infusion pumps (RFP); and hemodialysis machines (provincial RFP). Process Re-design The Human Factors Specialist was consulted during 2013/14 by several Fraser Health Programs for process redesign to provide expertise in task and workflow analysis, environmental assessment and process mapping. Examples included: standardization of Vitamin K concentration; management of obstructed sleep apnea; mass immunization clinics; physical layout of clinical space; standardized crash cart drug tray configuration; Code Blue RMH Switchboard re-configuration; and drug change cards in crash carts (eg change in Magnesium Sulphate concentration). Support, Standardize and Spread Evidence-Informed Practices Clinical Care Management Clinical Care Management (CCM) Inspired by Intermountain Healthcare, Utah and launched in 2010, the BC Clinical Care Management program is a provincial collaboration between the BC Ministry of Health, regional health authorities and the BC Patient Safety and Quality Council (BCPSQC). The purpose of CCM is to improve the quality, safety and consistency of care for patients by creating and sustaining the necessary structures, processes and behaviors that support the implementation and delivery of evidence informed, multidisciplinary, clinical care guidelines across British Columbia. The CCM strategy aligns with the Ministry of Health s goals as outlined in the health system strategy document Setting Priorities for the BC Health System, which commits to establishing a guideline driven clinical care management system to improve the quality, safety and consistency of key clinical services and improve patient experience of care building on the work undertaken to date in this area. To date, CCM has focused on 11 clinical care areas for system-wide improvement: hospital care for seniors (48/6), antimicrobial stewardship, stroke, sepsis, surgical site infection, surgical checklist, hand Respect Caring Trust 17/35

18 hygiene, heart failure, venous thromboembolism, medication reconciliation, and critical care related to glycemic control. During 2013/14, the QI/Patient Safety portfolio continued to support the CCM initiatives across Programs through application of the Model for Improvement to test practice changes in the clinical setting to assist the designated Program leads in achieving provincial performance targets. Steady progress has been made towards improvement targets throughout 2013/14 and will continue through 2014/15. In addition, QI/Patient Safety has supported the coordination of Fraser Health s CCM initiatives and reporting to the MoH through: facilitation of quarterly meetings of FH clinical and data collection leads to discuss issues, learnings and opportunities to improve data collection and adoption of CCM practices; and liaison with BC Measurement and Coordination Working Group, Sepsis Case-Finding and VTE Working Groups to promote standardization of data collection practices and share leading practices. Next Steps 2014/15 The provincial focus for 2014/15 is development of a CCM framework for decision-making related to the continuation of support and reporting requirements by MoH for each current CCM initiative, as well as the introduction of up to 15 new CCM topic areas. Within Fraser Health, support for each of the current topic areas will continue in order to meet and sustain improvement targets. Improve the Patient Experience The focus of the QI/ Patient Safety portfolio with respect to improving the patient experience has been on enhancing internal and external partnerships for better health. The primary vehicles for this have been the Fraser Health Patient Advisory Council, development and use of patient experience survey feedback, and the Patient Care Quality Office (PCQO) complaints management process. Fraser Health Patient Advisory Council Fraser Health is committed to involving patients and their families in informing and guiding decisionmaking about matters which make the greatest difference to their experience of the quality and safety of our health care services. The Patient Advisory Council (PAC) is valued as a key strategy to bring a stronger focus to patient/provider partnership at the governance and organizational level. Since 2011, Fraser Health has collaborated with Impact BC and Patients as Partners/Patient Voices Network to support effective partnership between patients and families and the healthcare system. The overarching purpose of the PAC is to work with the Board and Executive to strengthen the relationship between Fraser Health and the public, promoting an exchange of learning, idea-sharing, and information flow related to: policy development, implementation and evaluation; health service planning; initiatives to improve quality and patient safety; and building capacity for engagement of patients and families at all levels of care delivery. The PAC has had a key leadership role in strengthening the relationship between Fraser Health and the public to promote two-way exchange of learning, idea-sharing, and information flow. The PAC develops an annual work plan to promote its vision to improve our experience of our health care Respect Caring Trust 18/35

19 together which includes reaching out to various stakeholder groups to build partnership in improving the patient experience, consultation on organizational and Program initiatives. The PAC s activities during 2013/14 included Patient Advisors : participation in development of the Fraser Health Research and Evaluation Department strategic priorities; consultation on a successful research proposal focused on patient-oriented research (SPOR); participation in the November, 2013 Patient Safety Symposium; co-presentation with the Director, Quality Improvement and Patient Safety on a Impact BC national webinar on patient engagement; participation in the Keeping Patients Safe initiative; participation in the Patient Experience stream of the Seamless Care initiative; and consultation on recruitment of new patient advisors for the PAC. Next Steps 2014/15 Key areas of focus for the PAC s 2014/15 workplan will include building capacity for patient engagement with Clinical Programs, sites and local initiatives. Patient Experience Survey Feedback Real-time Patient Experience Survey (RTPES) Respect Caring Trust 19/35

20 Patient Experience Survey Feedback Real-time Patient Experience Survey Real-time patient feedback is becoming increasingly recognized by healthcare organizations as a valuable mechanism to address patients concerns during their healthcare experience and promote partnership with the patient and family in care planning, service delivery, and evaluation. Seeking feedback and patient-provider communication at the point of care is integral to providing the best possible patient experience. Leadership commitment is essential to the survey process, in the use of results to 1) address patients needs and concerns during their care experience, 2) evaluate the impact of improvement efforts in real time and 3) use aggregated patient feedback for system-wide improvement. A real-time patient experience survey (RTPES) pilot, sponsored at the Executive Committee level, was undertaken in 2012 at Ridge Meadows Hospital in the Rehabilitation and Medical units. Key success factors associated with the real-time survey identified through the pilot include the following: Operational leadership engagement in the real-time survey on a day to day basis (Site Director, Manager and Patient Care Coordinator); a dedicated resource with appropriate interpersonal skills to administer the survey at each site; and a consistent training plan to ensure that there is standardized delivery and can be adopted across sites. Avenues to build on the pilot were explored during 2013/14 and Executive Committee endorsement received to implement the RTPES strategy across Fraser Health as an integral component of Seamless Care/Patient-Centered Care. Agreement was reached by the Executive Directors group and the Seamless Care/Patient-Centered Care Steering Group to launch the RTPES at Ridge Meadows Hospital site-wide as part of 48/6 implementation. In addition, work was initiated to coordinate this initiative with a RTPES initiative underway in the ER Clinical Program. Next Steps 2014/15 Implementation of the RTPES strategy across Fraser Health will be integrated with existing initiatives, starting in Fall, 2014, by: building capacity and capability for real-time surveying as a core competency of front-line managers; and introducing RTPES to 6 other sites or improvement initiatives for which patient-reported experience is a key metric and organizational readiness is demonstrated. BC Patient-Reported Experience Measures Survey (PREMS) The mandate of BC PREMS is to develop and implement a provincial strategy for the measurement of patient satisfaction AND patient experience of care to: enhance the public accountability of BC s health system; and support the quality improvement initiatives of health care providers and the Health Authorities. Respect Caring Trust 20/35

21 Fraser Health is committed to seeking continuous feedback from our patients, clients and residents about their experience with care and services. Patient experience survey results are an important source of feedback about our patients experience and how to improve public confidence in the health care system. Fraser Health results for each sector survey are provided for the organizational overall, as well as by Program, site, and unit as applicable. Results reports are disseminated to leaders to inform improvement activities. The following healthcare sectors have been involved in BC PREMS surveys: Acute Inpatient Care (point-in-time: 2005, 2008, 2011/12) Emergency Care (continuous since 2007) Long-term care (point-in-time: 2004) Mental Health and Substance Use (point-in-time: 2008) Outpatient Cancer Care (point-in-time: 2005/06; 2012/13) During 2013/14, the PREMS survey strategy reported on two sectors: ER and Outpatient Cancer Care. Highlights from these surveys are provided below. Emergency Care The table and graphs below provide an organizational overview of annual results of the BC PREMS ER survey for Fraser Health which shows a decrease in positive experience before 2012/13 and 2013/14. Detailed action plan reports are available for the organization overall as well as a drill down for each Fraser Health ER; these are distributed each quarter to the ER Clinical Program help guide and monitor improvement. Fraser Health Emergency Department Patient Experience Overall: April 1, 2013-March 31, 2014 (n=2795; Response Rate=24.6%) Measure Apr- June/13 July- Sept/13 Oct- Dec/13 Jan- Mar/14 FH 2013/14 BC 2013/14 FH 2012/13 FH 2011/12 Overall Quality * of Care All Dimensions * Combined Would def recommend * Fraser Health Large Facilities April 1, 2012-March 31, 2013 (n= 2111; Response Rate= 24.5%) Overall Impressions All Dimensions * Combined Would def recommend * Fraser Health Medium Facilities April 1, 2012-March 31, 2013 (n=570; Response Rate=24.9% Overall * Impressions All Dimensions * Combined Would def recommend * Denotes statistically significant difference between HA average and BC HA average and/or BC top 3 facilities average % positive scores. Respect Caring Trust 21/35

22 Next Steps 2014/15 Planning is underway by the BC PREMS Steering Committee to implement the continuous ER survey in conjunction with the Acute Inpatient survey, with a focus on care transitions. Consultation with key stakeholders, including patients, will be undertaken to inform development of custom survey questions related to continuity of care transitions. Outpatient Cancer Care This survey, undertaken in 2012, included patients in active treatment receiving radiation+/or IV chemotherapy as well as an additional population patients receiving non-iv treatment, between June 15 and December 15, All BC Cancer Agency regional, satellite, full-service and basic community chemotherapy centres participated. The survey also included new made in BC Emotional Support/Emotional Distress and non-iv treatment questions. The overall BC response rate was 48.7% (6, 385 patients). Fraser Health had a response rate of 41.6% (373 returns, of which 172 were from patients receiving radiation+/or IV chemotherapy and 201 were from patients receiving non-iv treatment). At the provincial level, results show high levels of overall satisfaction with care: 97.5% of respondents said the quality of outpatient cancer care was excellent, very good or good. A statistically significant improvement was noted in the Overall Quality of Care percent positive score from 2005/06 to 2012, as well as the number of radiation and chemotherapy patients who rated their Overall Quality of Care as excellent. While BC scores are lower in 5 of 6 dimensions compared to the Canadian comparator, the dimensions of Coordination and Continuity, and Emotional Support scores show statistically significant improvement from 2005/06 to However, only 46.7% of patients surveyed across BC gave positive ratings to questions on Emotional Support. Non-IV patients rated Physical Comfort (pain control) significantly less positively than the IV and Radiation Treatment population. Respect Caring Trust 22/35

23 Summary of Results: Fraser Health - Health Authority Level Fraser Health maintained an overall positive rating for outpatient cancer care of 94.9% from 2005/06 to 2012, with a slightly lower rating for all dimensions combined as noted in the summary below. Fraser Health Outpatient Cancer Care Patient Experience: n=373 Response Rate=41.6% All Treatment 2005/ BC CDN BC High Groups Combined Average Average Performer Overall Impressions 94.9% 94.9% 97.5% 98.0% 100% All Dimensions Combined 63.1% 62.3% 63.8% 68.7% 71.5% Within Fraser Health, Respect for Patient Preferences remained the dimension receiving the highest percentage of positive ratings very slightly lower than results in 2005/06 (73.6% vs 76.1%) and Emotional Support accounted for the lowest scores in 2012, very slightly higher than in 2005/06 (44.3% vs 42.8%). Respect Caring Trust 23/35

24 The top performing question for Fraser Health in all treatment groups combined was identity confirmed before care provided (eg medications) at 95.4%, which was above the BC Outpatient Cancer Care average of 94.7%. The lowest performing question was put in touch with providers for anxieties/fears in past 6 months at 21.6%, which was below the BC average of 26.9% 2. 2 These questions were added to the 2012 survey and have no 2005/06 baseline comparator. Respect Caring Trust 24/35

25 Outpatient Cancer Care survey results are displayed to show any differences in patient experience for the purpose of improvement. The chart below shows a notable difference between the % positive ratings of patients receiving IV+Radiation therapy and patients receiving non-iv treatment for Fraser Health s lowest performing question. These results indicate an opportunity for improvement for both treatment populations, with a focus on factors which may contribute specifically to the experience of non-iv treatment patients. Respect Caring Trust 25/35

26 Interpretation of Results Quality Improvement & Patient Safety Annual Report Maintaining similar results over time (2005/06; 2012) can be viewed as positive in the context of increasing demands on the health care system; however, the results identified opportunities for improvement in targeted areas which continue to be important to patients, most notably in the dimension of Emotional Support, with particular focus on patients receiving treatment at home or in their physician s office. In-depth analysis of the qualitative results of this survey by the BC Cancer Care leadership highlighted significant improvement opportunities within key dimensions of quality. Access to cancer care: gap between the diagnosis of cancer and start of cancer treatment - long waiting time with lots of anxiety; need emotional support at time of diagnosis. Information: lack of discussion about alternate therapies. Communication/empathy: lack of sensitivity and reluctance to address concerns/impersonal/ignored spouse. Need more counseling: Build counseling and/or palliative care into treatment plan. Next Steps: 2014/15 A BC Outpatient Cancer Care group, including leaders from Fraser Health, will develop an improvement strategy to address key opportunities for improvement across the BC Cancer Agencies. Patient Care Quality Office (PCQO): Complaint Resolution Fraser Health established its Patient Care Quality Office (PCQO) with the enactment of the Patient Care Quality Review Board Act in October, The PCQO is responsible for providing Fraser Health patients, residents and clients with a formalized complaint system, while ensuring that the process for complaints resolution is aligned with the requirements of the Patient Care Quality Review Board Act (PCQRB Act) and the procedures enforced by the Ministry of Health. The PCQO is held accountable on behalf of Fraser Health for coordinating complaint resolution and response to complainants, the Ministry of Health and the PCQRB. Fraser Health s complaints policy sets direction for complaints management in accordance with our Values of Trust, Caring and Respect. The purpose of the policy is: to ensure a consistent, transparent and timely management process for any patient, client, resident, or family member with care quality complaints, requests for information and compliments, in accordance with Fraser Health s Values of Trust, Caring and Respect; to ensure Fraser Health Patient Care Quality Office (PCQO) operations are aligned with the requirements outlined in Ministry of Health Directives for each BC Health Authority; and Respect Caring Trust 26/35

27 to ensure the FH PCQO complies with provincial legislation including the Patient Care Quality Review Board Act (2008) and Regulations to manage and process care quality complaints. The complaints management process requires that complaints brought to the PCQO from any source receive an initial acknowledgement within 2 business days and a formal reply to the complainant within 40 business days. Extensions to the closure timeframe are permitted under the MoH Directives with agreement by the complainant. The volume of complaints increased 38% between 2012/13 and 2013/14 (from 1071 to 1474) and requests for information increased 21% (from 433 to 524). The PCQO undertook a significant service delivery and complaints management redesign during 2013/14 in order to meet MoH requirements and fulfill Fraser Health s commitment to welcoming feedback for improvement. An operations engineer was engaged in Spring, 2013 to analyze the PCQO s workflow and performance indicators and validate the proposed changes. The PCQO service delivery model subsequently transitioned from alignment with Clinical Programs to a centralized case management approach which assigns a PCQ Officer to a patient/client/family member for all aspects of their complaint regardless of Program(s) to which it relates. The complaints management/resolution process was also revised to escalate attention to follow-up actions at the most appropriate level of operational leadership as required when Fraser Health responses to complainants are overdue. These changes are expected to significantly improve the timeliness and quality of complaints follow-up in accordance with Fraser Health s Vision and philosophy of patient-centered care. The following are highlights of PCQO activity during 2013/14, in comparison with 2012/13. Respect Caring Trust 27/35

28 Next Steps 2014/15 Significant effort will continue through 2014/15 on redesign and improvement of the PCQO service delivery model and processes for complaints resolution and reporting to the MoH and Fraser Health leadership. Actions underway or planned include: reporting to Executive Committee of actions taken to close overdue complaints; change management and education plan to engage front-line leaders in resolving complaints at the point of care whenever possible (commencing August, 2014); daily reports to Executive Committee and Board QPC Chair on incoming complaints (effective as of June, 2014); distribution of monthly complaints profile reports to Clinical Programs to inform improvement initiatives (commencing September, 2014); and consultation with customer service leaders in private industry to establish best practices in written responses to complaints. Input will also be sought from Fraser Health patient advisors and this work will be done in collaboration with other members of the provincial PCQO Working Group (September, 2014). FH Infrastructure to Support Organization-wide Accountability for Quality and Patient Safety The QI/Patient Safety portfolio provides leadership on systems and processes to support accountability for quality and patient safety throughout Fraser Health s operations. In addition to areas previously highlighted in this report, the portfolio has an ongoing responsibility for leading the Accreditation process and implementation and sustainment of the Quality Performance Management Respect Caring Trust 28/35

29 System. The portfolio has also established a new service request process accessible via QI/Patient Safety@fraserhealth.ca to support timely, appropriate response to Fraser Health requests for quality improvement and patient safety consultation. Accreditation During 2013/14, planning was undertaken to prepare for the April, 2014 Accreditation Canada Survey visit. This visit was focused on 4 programs (Cardiac, Renal, RCAL, Surgical), using 7 sets of standards. Surveyors evaluated 36 applicable Required Organizational Practices (ROPs) and 676 applicable criteria during the visit. This was the 3 rd and final visit of a complete accreditation cycle under Q mentum and Fraser Health was awarded Accredited status which lasts until the end of the next cycle in 2018/19, when a new decision will be awarded. Program Results by Standard High Priority Criteria Met Other Criteria Met Total Criteria Met RCAL Long Term Care 100% 97% 98% Renal Ambulatory Care 100% 97% 98% Cardiac Medicine 100% 97% 98% Diagnostic Imaging 93% 98% 95% Surgery Surgical Care 100% 99% 99% Operating Rooms 93% 93% 93% Reprocessing & Sterilization 92% 95% 94% All Teams Total 96% 97% 96% Thirty-two out of 36 applicable ROPs in the standards were fully met. Of the 4 unmet ROPs, 2 related to falls prevention, 1 related to the client and family role in safety and 1 related to infusion pump training. 92% (79/86) major tests of compliance were met and 86% (19/22) minor tests of compliance were met. Results by Quality Dimension Criteria Met Population Focus (Working with communities to anticipate and meet needs) 100% Accessibility (Providing timely and equitable services) 100% Safety (Keeping people safe) 94% Worklife (Supporting wellness in the work environment) 97% Client-centred Services (Putting clients and families first) 97% Continuity of Services (Experiencing coordinated and seamless services) 100% Effectiveness (Doing the right thing to achieve the best possible results) 96% Efficiency (Making the best use of resources) 93% All Dimensions Total 96% The surveyors congratulated Fraser Health on the implementation of Medication Reconciliation across all sites within the Renal and RCAL programs. The organization was required to follow-up on the 4 unmet Required Organizational Practices and to submit evidence of compliance by October In addition, Fraser Health was required to follow-up on 3 high priority criteria and to submit evidence of compliance by October During 2013/14, 2 progress reports were submitted to Accreditation Canada relating to improvements around ROPs and high priority criteria from the Managing Medications Standards following the 2012 survey visit. Respect Caring Trust 29/35

30 Other work during the year included: realigning the Survey Visit schedule for the next Accreditation cycle; piloting a tailored approach to online self-assessment surveys; developing and delivering training on how to conduct practice tracers; carrying out mock tracers to prepare RCAL sites for the visit; liaison at provincial and national accreditation advisory and working groups. Additional work to integrate Accreditation standards and RoPs included: design and delivery of the Fraser Health Patient Safety Symposium; delivery of a QI/Patient Safety module for the supervisory skills training; and developing and delivering a QI/Patient Safety education day for Patient Care Coordinator orientation. Next Steps 2014/15 Pilot at Ridge Meadows, followed by implementation of the Accreditation Canada Patient Safety Culture Survey across Fraser Health; Support Mental Health, Medication Management, Infection Prevention and Control, Cancer Care Clinics, Emergency and the Executive Leadership Team to carry out self-assessments, improvement plans and preparations for their Accreditation visit in April, 2015; Plan and coordinate the April, 2015 Accreditation Canada supplementary onsite survey visit; Coordinate the submission of follow up reports to Accreditation Canada in October, 2014; Continue to add to the suite of QI/Patient Safety tools and education modules ; and Continue to participate in the Seamless Care Patient Experience Steering Group and Patient Advisory Committee. Quality Performance Management System (QPMS) The QPMS is a strategic system designed to promote accountability for quality and patient safety in alignment with Fraser Health s model of accountability for financial performance, ultimately to create an organizational culture of quality and safety and enable public reporting. The deliverables of the QPMS include: an interactive, web-based scorecard tool which enables a balanced view of performance using 5 quality dimensions - acceptability, effectiveness/appropriateness, access/activity, safety, and efficiency/affordability; a set of outcome-based indicators for each Clinical Program; and an accountability framework and mechanism for reporting to the Fraser Health Board and public. Program Adoption and Use of QPMS The Clinical Program Quality Performance Committees has been reporting quarterly from their QPMS scorecards to the Fraser Health and Board Quality Performance Committees since Fall, 2012, with a focus on analysis and actions to address unmet priorities. The focus of the QI/ Patient Safety portfolio during 2013/14 was on supporting the Clinical Programs in the use of their QPMS scorecards to monitor and guide improvement, as well as the development and revision of key performance indicators (KPI). A change request toolkit was designed to guide Program leadership through a robust process ultimately resulting in thoughtfully selected, patient- Respect Caring Trust 30/35

31 centered KPI. A QPMS work plan tracks each Program s activity to enable appropriate support by QI/Patient Safety and HBA at each step in the process. Next Steps 2014/15 QPMS User Evaluation In order to continuously improve the functionality, support and value of the QPMS, users will be invited to participate in a survey in Fall, Case for Change The User Groups and their Executive Leaders have identified the need to upgrade the QPMS. A proposal for QPMS support enhancement within HBA and QI/Patient Safety has been submitted to the Executive Committee with an aim to leverage QPMS v. 1.0 (developed and implemented from ), as the basis for a second version (QPMS v. 2.0). This version will incorporate significant changes in the current selection of indicators, the addition of new Program scorecards to the system, and improvement to system functionality. This project proposes the renewal of 30% of the KPI included in the current QPMS system, 2-3 new Program scorecards requested by VPs, minor changes (wording, logic-simple, target, deletions, etc.) in ~50% of the indicators, and some improvement of system functions and features over the term of the project (2 years). Quality Improvement and Patient Safety Portfolio Consultation Between 2009 and 2013, the QI/Patient Safety portfolio was primarily aligned with the Clinical Programs. In April 2013, the Clinical Improvement stream was transitioned to a centralized model in response to the Corporate deficit and accommodate the reduction of 5.5 FTE. During the first year of implementing the centralized service, an Online Request for Service Form was introduced and a dedicated phone line implemented to support requests from Clinical Program leaders and other stakeholders. The portfolio committed to providing the same core QI/Patient Safety consulting services as prior to the new model, and to responding to service requests within two business days. The Request for Service Form is utilized to provide monthly data on the number and type of requests by Clinical Program. Monitoring of service request activity consistently shows timely response to requests. The data also shows that the QI/Patient Safety Consulting service is being utilized appropriately, and that over the past year, there has been an increase in the use of the online form rather than and telephone, which facilitates needs assessment and QI/Patient Safety resource assignment. Through the new service delivery model, the portfolio has also standardized its systems and processes. The Managing Consultant, QI/Patient Safety has created task teams with each QI/Patient Safety Consultant assuming a key lead role for organizational initiatives such as the Quality Performance Management System, Patient Safety Event Management, and the PSLS Recommendations Module. (Please see p.16.) Service Request Intake Profile Sixty-two percent of requests for service were received via communication. The s were received from Clinical Programs and sent to QI/Patient Safety Consultants, Managing Consultants, and Director, Quality Improvement and Patient Safety. However, the data shows a downward trend Respect Caring Trust 31/35

32 in requests with each quarter, with 35% of the requests for service received via online form completion. The data trended upwards with each quarter data reported, showing increasing awareness and use of the online form to request service. Three percent of requests for service were received via telephone calls. Next Steps for 2014/15 The data identifies the need to continue to promote the use of the online form. This form provides information (i.e. contact person, deliverables, time required to complete the request), which initiates needs assessment and assists in priority-setting as well as the appropriate QI/Patient Safety Consultant assignment. Status of Requests: Resource Management and Prioritization New requests for services were received for each month of the year. Thirteen percent of new requests were closed in the same month; 35% of new requests remained active during the month. Ninety-eight percent of requests received were assigned to the QI/Patient Safety Consultants. Two percent of the new requests were referred out to other appropriate services (i.e. Human Factors, PSLS Coordinator). Respect Caring Trust 32/35

33 Type of Requests - Top 3 type of requests: The top 3 types of requests during 2013/14 were: 1. Patient Safety Event Consultation 2. Quality Performance Management System (QPMS) 3. Consultation /Education on QI Principles and Tools Respect Caring Trust 33/35

34 Next Steps for 2014/15 Currently the data tracks new requests for each month. In 2014/15, data collection will be enhanced to track both the new requests for each month and the requests that are carried over from the previous month. This change will show the total number of requests that the QI/Patient Safety Consultants are supporting each month to more accurately reflect workload distrtibution and facilitate efficient and effective service by the portfolio to the organization. Respect Caring Trust 34/35