Quality, Risk and Patient Safety Report Fiscal Year , Fourth Quarter

Transcription

1 Quality, Risk and Patient Safety Report Fiscal Year 2, Fourth Quarter Submitted to: Board of Directors June 26, 215 Contributed by Staff of the North East CCAC Date of Report: June 1, 215

2 TABLE OF CONTENTS 1. INTRODUCTION DEFINITIONS ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE... 5 a. Quality Framework and Enterprise Risk Management Framework... 5 b. Quality, Risk and Patient Safety Committee (Operational)... 5 c. Patient Services and Quality Committee of the Board of Directors... 5 d. Patient Safety Plan... 5 e. Quality Improvement Plan (QIP)... 5 f. Insurance... 6 g. NE LHIN Risk Registry... 6 h. Disaster/Emergency Response Planning... 6 i. Pandemic Influenza Planning... 6 j. Document Control (Policies, Procedures and Forms)... 6 k. Risk Events and Feedback... 6 l. Accreditation... 7 m. Internal Audit/Tracer Strategy... 7 n. Client and Caregiver Experience Evaluation (CCEE) INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT ACCESSIBLE: Wait time for CCAC services ACCESSIBLE: Access to long-term care home EFFECTIVE: Keeping people healthy in home care SAFE: Avoiding harm in home care and the community PATIENT-CENTRED: Meeting patients needs and preferences INTEGRATED: Primary Care Services APPROPRIATELY RESOURCED: Healthy work environment DATA SOURCES APPENDIX A: Patient Safety Plan Quarterly Report Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 2 of 35

3 INTRODUCTION 1. INTRODUCTION Home care is an important foundation for supporting an integrated health care system. Home care has a unique function as a key linkage point between various settings of care, such as acute hospitals, emergency departments, long-term care homes and various clinical services. Home care services are intended to meet patients needs in an individualized and comprehensive manner, and go beyond physical and mental health care to engage social supports as well. 1 To ensure that the NE CCAC is monitoring indicators across the quality spectrum, the report has been organized to link indicators to the applicable attribute of quality. The nine attributes of quality that reflect a high performing health system include: accessible, effective, safe, patient-centered, equitable, efficient, appropriately resourced, integrated and focused on population health. The report also incorporates results from the Quality Improvement Plan and the Patient Safety Plan. The report includes data to March 31, 215, the end of fourth quarter for fiscal year 2. Status reports and quality improvement strategy updates are current as of the date of the report. 1. Keep me safe 2. Heal me 3. Be nice to me in this order 26 Healthcare Performance improvement, LLC. ALL RIGHTS RESERVED. 1 Ontario Local Health Integration Networks M-SAA Performance Technical Specifications Version: December 18, 28 Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 3 of 35

4 2. DEFINITIONS Healthcare Quality Improvement: A broad range of activities of varying degrees of complexity and methodological and statistical rigour through which healthcare providers develop, implement and assess small-scale interventions, identify those that work well and implement them more broadly in order to improve clinical practice. 2 MAPLe Score: The MAPLe score was developed to prioritize patients for access to CCAC services. Patients who have been assessed and have MAPLe scores of high and very high represent the CCAC patients most in need of long term care placement. Performance Indicator: A measurement that is linked to a strategic direction. It demonstrates progress towards a stated goal and identifies areas for improvement. Performance Standard: A corridor or range around a performance target. It is established for variance reporting purposes. It takes into account expected variations such as statistical and seasonal fluctuations in performance. The Performance Standard is indicated by dashed red lines on the graphs. Performance Target: Sets a goal to achieve. It is measurable and used to demonstrate progress towards a stated goal. The Performance Target is indicated by a solid red line on the graphs. Quality in Healthcare: The nine attributes of a high-quality health system, as defined by Health Quality Ontario (HQO), are: ATTRIBUTES OF QUALITY ACCESSIBLE EFFECTIVE SAFE PATIENT-CENTERED EQUITABLE EFFICIENT APPROPRIATELY RESOURCED INTEGRATED FOCUSED ON POPULATION HEALTH OUTCOMES People should be able to get timely and appropriate healthcare services to achieve the best possible health outcomes. People should receive care that works and is based on the best available scientific information. People should not be harmed by an accident or mistake when they receive care. Healthcare providers should offer services in a way that is sensitive to an individual s needs and preferences. People should get the same quality of care regardless of who they are and where they live. The health system should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information. The health system should have enough qualified providers, funding, information, equipment, supplies and facilities to look after people s health needs. All parts of the health system should be organized, connected and work with one another to provide high-quality care. The health system should work to prevent sickness and improve the health of the people of Ontario. Risk: Anything of variable uncertainty and significance that interferes with the achievement of business strategies and objectives. Something goes wrong detracting from the organization s purpose and the quality of its programs and services. Risk Management: Risk Management is a systematic approach to identify, analyze and respond to risks. Most risks can be managed so that impact to the organization is minimized, mitigated or prevented entirely. Root Cause: The underlying or original cause of an incident or problem. 2 The Ethics of Improving Health Care Quality & Safety: A Hastings Center/AHRQ Project, Mary Ann Baily, PHD, Associate for Ethics & Health Policy, The Hastings Center, Garrison, New York, October 24. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 4 of 35

5 3. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE a. Quality Framework and Enterprise Risk Management Framework The Quality Framework outlines the NE CCAC s commitment to quality improvement in the provision of patient services and a safe, productive workplace. The Framework is aligned with the NE CCAC s vision, mission, strategic plan and operational plan as well as Accreditation Canada standards. It provides a strategic overview of the key principles and practices necessary for the effective planning, management, delivery and improvement of NE CCAC services. The NE CCAC Enterprise Risk Management Framework (ERM) supports the identification, assessment, and mitigation of risks through a standardized and documented method. b. Quality, Risk and Patient Safety Committee (Operational) The Quality, Risk and Patient Safety Committee provides a mechanism to align enterprise-wide quality improvement, risk management and patient safety efforts occurring at an operational level with the organization s strategic priorities. The Committee includes representation from a broad range of backgrounds and geographic regions to obtain regional views and perspectives, is chaired by the Director, Quality and Risk, and is accountable to the CEO. The purpose of the Quality, Risk and Patient Safety Committee (operational) is to: Support a culture of quality, risk management, and patient safety at an operational level. Identify and remove barriers to patient safety and quality of care. Analyze organizational performance data and translate this data into meaningful opportunities for improvement. Support quality improvement initiatives. Identify strategies to mitigate enterprise-wide risks. Committee meetings were cancelled in the 4 th quarter as a result of the ONA labour disruption. c. Patient Services and Quality Committee of the Board of Directors This Committee provides governance oversight related to risk management in the areas of patient services, patient safety, human resources, ethics and health system partnerships. d. Patient Safety Plan The Patient Safety Plan outlines the North East CCAC s commitment to Patient Safety and supports the mission and vision through the practice of developing and implementing a culture of safety. The Patient Safety Plan details specific objectives, activities, indicators, responsibilities, and target dates to facilitate meeting the organization s goals and objectives related to patient safety. Refer to Appendix A for the Patient Safety Plan Quarterly Report. The Patient Safety Plan was approved by the CEO in April. e. Quality Improvement Plan (QIP) The Quality Improvement Plan (QIP) is an annual plan required under the Excellent Care for All Act. This legislation currently applies to hospitals and to the primary health care sector. A Ministry of Health and Long-term Care directive requires that every CCAC shall develop, make publicly available, and submit to Health Quality Ontario an annual QIP by April 1 of each year for the fiscal year using standardized templates and guidance material. As recommended by the CCAC CEOs, the CCACspecific QIP priority indicators are: 1. Patient Experience Percentage of Good, Very Good and Excellent Client Experience Survey responses on a 5 point scale (poor to excellent) to the three patient experience KP 1 survey questions: a. Overall rating of CCAC Services; b. Overall rating of management /handling of care by Care Coordinator; Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 5 of 35

6 c. Overall rating of service provide by service provider. (Key Performance Indicator 1 CM Services) 2. 5 Day Wait Times for Nursing Services and PSW Services for Complex Patients 3. Falls Percentage of adult long-stay home care patients who record a fall on follow-up RAI-HC assessment. 4. Hospital Readmissions Percentage of home care patients who experienced an unplanned readmission to hospital within 3 days of discharge from hospital. 5. Unplanned Emergency Department (ED) Visits Percentage of home care patients with an unplanned, less-urgent ED visit within the first 3 days of discharge from hospital. The NE CCAC QIP, approved by the Board of Directors on March 7, 215, was submitted to Health Quality Ontario by April 1, 215. QIP status updates continue to be incorporated into this report. f. Insurance The NE CCAC carries insurance protection through the Healthcare Insurance Reciprocal of Canada (HIROC). g. NE LHIN Risk Registry This report alerts the NE LHIN of risks or opportunities that may influence achievement of objectives. The 4 th quarter Risk Registry Report was submitted to the NE LHIN on March 12, 215. h. Disaster/Emergency Response Planning The NE CCAC Emergency Management Plan provides a systemic response to any emergency. The Emergency Management Plan and associated Business Continuity Plan Department Profiles are currently undergoing annual review. The James Bay Contingency Plan was approved in April 215 was used as part of the response to the 215 James Bay flood season. i. Pandemic Influenza Planning The NE CCAC Pandemic Plan provides a systemic response in the case of a pandemic. The NE CCAC pandemic response plan will be updated in to align with the provincial CCAC template. j. Document Control (Policies, Procedures and Forms) The Policy and Procedure Manager software is used to manage policies, procedures and related documents developed to standardize processes within the NE CCAC. Each Senior Director of the Executive Team is accountable for the Table of Contents of their respective portfolio manual and is responsible for delegating, writing and/or editing policies, procedures and related documents to their Managers. Forms are managed and housed on a SharePoint site so that staff can readily access paper forms, electronic fillable forms, InfoPath forms and digital signature forms. The Forms Management Committee reviews all forms. Standards/guidelines for form developers and reviewers are in development. k. Risk Events and Feedback The Risk Event and Feedback System (REFS) is a database that captures patient risk events and feedback (compliments and complaints), risk events affecting employees, service providers and other third parties, general feedback, health and safety hazards, non-conformances, as well as enterprise-wide risks. A REFS e-learning intranet site ensures that training materials are available to staff throughout the NE CCAC 24/7. Risk event and complaint reporting is a challenge for many health care organizations with documented reports reflecting only the tip of the iceberg. Maximizing the overall value of the reporting system as a source of actionable data could be a helpful tool to improve patient safety and patient experience. The software system is being replaced with a solution to meet more current business and technical requirements. Intelex was the successful respondent to an RFP. Training and configuration are underway to set up the new system. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 6 of 35

7 Patient Safety Event Reports are distributed to Senior Leaders monthly to communicate about events assessed as high and very high risk by the Quality and Risk Team, the status of the investigation and preliminary recommendations for improvement resulting from the investigation. l. Accreditation The 215 version of the Accreditation standards were released in January. Updated Accreditation standards will be reviewed annually to prepare for the next Qmentum survey in 218. m. Internal Audit/Tracer Strategy An audit is a systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled. ASQ Auditing Handbook The internal audits were used to evaluate compliance to Accreditation standards and to prepare staff for participation in the Qmentum survey. In 213, the Quality and Risk Team completed internal audits at all six branch offices, resulting in 38 findings, 37 of which have been corrected and closed. To sustain the current gains and identify further opportunities for improvement, additional internal audits may be identified by the Executive Team to address specific operational areas. The focus in this fiscal year has been the provincial review of CCACs through the office of the Auditor General of Ontario and the Collaborative Capacity Assessment conducted by the North East LHIN. n. Client and Caregiver Experience Evaluation (CCEE) The provincial Client and Caregiver Experience Evaluation (CCEE) Provincial Committee oversees a coordinated approach of ongoing patient surveys to gather comparable information across and within individual CCACs about the satisfaction and experience of their patients, for the purpose of improving service and reporting to funders and the public. The surveys are currently completed by National Research Corporation Canada (NRCC) using a continuous sampling approach spread over four waves during a one year period. The survey tool has been revised and streamlined to reduce the number of questions and amount of time required for patients or caregivers to respond to the telephone survey. No new reports are available in this quarter. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 7 of 35

8 # of Days 4. INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT The nine attributes that reflect a high performing health system are: 1. Accessible 2. Effective 3. Safe 4. Patient-centered 5. Equitable 6. Efficient 7. Appropriately resourced 8. Integrated 9. Focused on population health To ensure that the NE CCAC is monitoring indicators across the spectrum of the definition of quality, the following section of the report has been organized to link indicators to the applicable attribute of quality For each attribute, from a NE CCAC perspective, there is a definition of What we want, Consequences if we don t get it and To whom does this matter?. For each indicator there is a mini-graph to indicate progress or lack of improvement over time. The actual indicator, performance corridor (range) and target are displayed on the graphs as shown in the example below: Wait Time for Patients Referred from Community Settings 25 Actual Performance Standard (range) 5 Target Fiscal Year, Quarter As applicable, to the right of each graph there is an arrow indicating which direction is better for that particular indicator. As well, there is a brief summary of the current status of the indicator along with a brief analysis and ideas for improvement. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 8 of 35

9 # of Days ACCESSIBLE 5. ACCESSIBLE: Wait time for CCAC services What we want Consequences if we don t get it To whom does this matter? Short wait times and efficient care processes for CCAC services. Long wait lists represent a barrier to accessibility for patients. In some cases a delay in providing care could result in a crisis and the need for more intensive forms of care. Patients seeking accessibility to CCAC services in north eastern Ontario. Indicators and Trends for Wait Time for CCAC Services Wait Time for Patients Referred from Community Settings to Community Home Care Value: 7 days 2 Target: 48 days 2 Performance Standard: <6 days The metric, at 7 days is still over the target of 48 days Quarter, Fiscal Year Of the 286 patients who received their first visit in and were over 48 days from the start of the referral: o 11 had personal support as the first service. One was for respite where the families decided when to use the service, and 1 was for was advanced planning. The other 9 were affected due to the delay in a home visit to assess PS needs at the time of the labour disruption. o 1 for nursing (monthly visits that were not required to start for 3 days, or pre-operative visit) o 265 patients had a therapy as the first service assigned, of which, 172 were waiting for OT (42 or 42% of these were for residents of a LTC facility) 56 were for PT o The remaining patients were waiting for the other therapy services. The number of patients on the OT waitlist has decreased by 25 patients (36%) and the median days waiting has been reduced by 19 days to 38 days. This is a 33% improvement new patients started OT services during this period which is a 33% increase from the previous quarter. The number of patients on the PT waitlist has decreased by 237 patients (72%) and the median days waiting has been reduced by 31 days to 2 days. This is a 61% improvement. 868 patients started PT services during this period which is a 34% increase from the previous quarter. Continued focus on removing long waiting patients from the wait list has continued to negatively affect this metric, especially in this last quarter where there was a dramatic decrease in Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 9 of 35

10 # of Clients # of days ACCESSIBLE Indicators and Trends for Wait Time for CCAC Services waitlist for therapy. Quality Improvement Strategy: Close monitoring of the personal support waitlist Continued focus on reducing patient wait times for therapy services, implementing guidelines, and building capacity (refer to next section) Data Source: Business Intelligence Business Intelligence > NE Reports > Indicators > Category: MSAA > MSAA - Metric 9th Percentile Wait Time from Community Setting to Community Home Care M-SAA Quarterly Progress Report result: 113 days Wait Time for SRC 92 Patients Referred from Community Settings to Community Home Care Quarter/Year Therapy (SRC 92) Waitlist Quality Improvement Strategy: The Access to Care Strategy for Therapy Services aims to provide patients and children with quick access to high quality care. Clinical Services therapy staff members are testing solutions to reduce the wait time for therapy services. Some of the quality improvement ideas include: Maximizing the use of new OHIP funded PT clinics which are becoming operational across the NE (for patients who have the strength and mobility to access the clinics) Working with partners in falls prevention to prevent the need for PT/OT referrals Reducing travel time through: o Geographic assignment of therapy staff o Use of Personal Computer Videoconferencing enabling clinicians to securely connect from a laptop to their patient in a home or school for reassessments. Access to CHRIS and templates to speed up documentation Inviting hospital therapists to spend a day with community therapists to build relationships and support collaboration Use of technology such as ipads in Speech- Language clinical treatment 2 APR MAY JUNE JUL AUG SEP OCT Month, Year NOV OT PT SW SLP Nutrition DEC JAN FEB MAR Data Source: Business Intelligence Business Intelligence > NE Reports > Indicators > 9th Percentile Wait Time from Community Setting to Community Home Care Business Intelligence > NE Reports > Patient Services > Category: Management > Service Waitlist Analysis Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 1 of 35

11 Percentage of Patients # of Days ACCESSIBLE Indicators and Trends for Wait Time for CCAC Services Wait Time (Days) from Hospital Discharge to Service Initiation 2 Value: 1 days (last available report) 2 Target: 6 days 2: Performance Standard: 6.6 days This M-SAA indicator defined by the LHIN measures the number of days from the hospital discharge date to the first non-case management service for patients whose referral source was the hospital Quarter, Fiscal Year This result does not meet the established target and performance standard for, 2, the most recent data available. Further analysis is not possible without access to the actual data sources. Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. CCAC is not able to replicate baseline numbers and identifies a large variance in referral to counts. Six month or more delay in data availability impacts reporting abilities. 5 Day Wait Time - Nursing Visits Percentage of Patients Served Within 5 Days of Service Authorization 1% 95% 9% Data Source: Ministry of Health and Long-Term Care, M-SAA Indicators, MSAA 1.1.access_wt1 Quality Improvement Plan Objective: To reduce service wait times Outcome measure/indicator: 5-day wait time for Home Care service measured from Initial Authorization Date by Care Coordinator as start time to First Service Date as the end time. Nursing Service: Result: 93.33% 2 Target: 93.% 85% 8% Quarter, Year Personal Support Complex Patient Only Result: 86.63% 2 Target: 81.4% The targets have been met for both Nursing and Personal Support Complex Patients. Data Source: Business Intelligence>Indicators>5 Day Wait Times Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 11 of 35

12 Percentage of Patients ACCESSIBLE Indicators and Trends for Wait Time for CCAC Services 5 Day Wait Time - Personal Support for Complex Patients Percentage of Patients Served Within 5 Days of Service Authorization 1% 95% 9% 85% 8% 75% 7% Quarter, Year Improvement Initiatives #1: Enhance timely patient access to CCAC services by increasing understanding of how existing processes influence our performance and identifying opportunities for improvement. Methods and Process Measures: Reports readily available for staff to review. Goal: Reports available on a timely basis Result: Local reports are available on demand at the service level, by branch and by service provider through the Business Intelligence database. The data from these reports is now available allowing for further analysis to identify areas for improvement. Improvement Initiatives #2: Care Coordination and Clinical Services managers and staff are informed about this and other QIP indicators and measurements through presentations and other communication strategies such as newsletters. This provides an opportunity to engage with managers and staff to elicit change ideas based on their experience with internal processes. Methods and Process Measures: Number of Care Coordination and Clinical Services Managers who agree that they are informed about the QIP Number of progress reports to all staff using other communication strategies Goals: 8% of managers state that they have received information about the QIP 5% of managers state that information about the QIP and progress reports are shared with their staff teams. At least 4 progress reports (quarterly) are provided to all staff through other communication strategies Result: The survey was not undertaken as a result of priorities and workload (labour disruption, OAGO reports) Same as above 3 quarterly Quality, Risk & Patient Safety Reports posted. to be posted following the June 215 board meeting. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 12 of 35

13 % of Clients Placed Number of Clients ACCESSIBLE 6. ACCESSIBLE: Access to long-term care home What we want Consequences if we don t get it To whom does this matter? Short wait times to get into a long-term care home. If the person is waiting at home, a heavy burden could be placed on loved ones who are caring for the individual. If the person is waiting in hospital, the hospital bed is used unnecessarily, which can lead to emergency department overcrowding and wasted resources. Patients in north eastern Ontario who are currently on the wait list for placement into a long-term care home, along with their families and caregivers. People get their first choice of long-term care home. Being placed in a second or third choice home may mean being placed further away from loved ones or in a home that does not specialize in meeting one s ethnic, cultural or medical needs. Residents can move to a higher-ranked choice later, but that can be inconvenient and disruptive to the residents continuity of care Indicators and Trends for Access to Long-Term Care Home Apr Total Long Stay Wait List, with Transfers May Jun Jul Aug Sep Oct Month, Year Nov Dec Jan Feb Mar As of March 31, 215, patients on wait list including transfers: 2245 The number of individuals waiting for initial placement has steadily increased since January 214 and continues to exceed the number of available beds in Long-Term Care Homes (LTCH). Fluctuations of the wait list are based on the number of applications pending for placement and the number of available LTCH beds at any point in time. New Long-Term Care Home beds will soon be available in Sault Ste. Marie. Data Source: Business Intelligence > NE Reports > Patient Services > Category: Placement > Placement Waitlist % Placed to 1st Choice of LTC Home April 214 to March 215 Average: 1 st Choice: 56.6% 7% 6% 5% 4% The percentage of patients placed into their 1st choice of LTC home remained consistent and within normal variation in the 12-month period from April 214 to March % 2% 1% % Apr May Jun Jul Aug Sep Oct Month, Year 1st Choice Nov Dec Jan Feb Mar Data Source: Business Intelligence > SSRS Report List > Indicators > Other Misc. Indicators > LT Placements by Ranking Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 13 of 35

14 % of complex clients EFFECTIVE 7. EFFECTIVE: Keeping people healthy in home care What we want How to get it Consequences if we don t get it To whom does this matter? Patients receive effective home care to improve their health, maintain it or prevent deterioration to avoid hospitalization and/or admission to long-term care homes. Promote activities to maintain health and independence (e.g. preserving bladder function and mobility, controlling pain, preserving communication ability, memory and thinking abilities and avoiding depression and weight loss). Patients experience loss of independence, reduced quality of life through admissions and/or readmissions to hospital and/or admission to long-term care home. All CCAC patients Indicators and Trends for Keeping People Healthy in Home Care 8% 75% 7% 65% 6% 55% Complex Patients Remaining in the Community for 6 Days or More Post Hospital Discharge Value (as of March 31, 215): 64.41% Target: 6% Performance Standard: 6% The percentage of complex patients who are maintained in their home exceeded the target and performance standard in March 215. Through the Integrated Discharge Program coupled with the Home First philosophy, local health service partners are creating a cultural shift in practice to reduce the number of ALC- LTC patients. 5% 45% 4% APR MAY JUN JUL AUG SEP OCT Month, Year NOV DEC JAN FEB MAR Data Source: Business Intelligence > Indicators - Other Misc. Indicators > Percentage of Complex Patients remaining in Community for 6 plus days post hospital discharge Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 14 of 35

15 # of Patients % of Patients EFFECTIVE Indicators and Trends for Keeping People Healthy in Home Care 1% 9% 8% 7% 6% 5% Patients placed in LTC Home with MAPLe SCORES High or Very High (i.e. appropriately) Value = 82% * M-SAA 2 Target: 84% M-SAA 2 Performance Standard: 75% The result for this indicator is below the M-SAA target. Most people placed into a LTC home have very heavy needs that require them to be in that type of setting; however, one in five people placed in LTC have relatively lighter needs. Ideas for Improvement: The community crisis escalation process assists with ensuring that the most appropriate patients are placed into LTC. Ongoing monitoring of MAPLe scores continues. 4% Quarter, Fiscal Year *Note: Changes were made to the calculation methodology of this indicator to align with the provincial methodology effective 2. Data Sources: Business Intelligence > NE Reports > Indicators > MSAA > MSAA - Patients Placed in LTC with MAPLe High or Very High as Portion of Total Patients Placed Patients with MAPLe scores high and very high living in the community supported by CCAC Quarter, Fiscal Year Value: 3596 patients 2 Target: 3 patients 2 Performance Standard: > 285 patients The number of patients with high and very high MAPLe scores living at home with CCAC support exceeds the established target. Data Source: M-SAA Quarterly Progress Report to the NE LHIN: ( ) Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 15 of 35

16 Average ALC Acute Rate EFFECTIVE Indicators and Trends for Keeping People Healthy in Home Care 3% 25% 2% NE LHIN ALC Acute Rate 4 Hub Hospitals average: 24.3% Target: 17% Performance Standard: 18.7% The average ALC-Acute rate for the 4 Hub Hospitals has increased and is above the performance standard for 2. Sault Area Hospital has the highest ALC-Acute rate at 41.1%. 15% 1% 5% % Quarter, Year Ideas for Improvement: NE CCAC Directors, Care Coordination, continue to work closely with all four HUB hospitals in the district (North Bay Regional Health Centre (NBRHC), Timmins and District Hospital (TDH), Health Sciences North (HSN) and Sault Area Hospital (SAH)). Regular meetings of Senior Executives have supported greater problem-solving at a system level. Strategies implemented include Weekly ALC Rounds, Executive Escalation Process and unit-specific Discharge Bullet rounds. E-Referral has been successfully implemented with Health Sciences North, Espanola Health Centre, and Manitoulin Health Center with the support of the OACCAC and the NELHIN. E-Referral has been successfully implemented with Health Sciences North, Espanola Health Centre, Manitoulin Health Center, Timmins and District Hospital, Chapleau Health Services, Sensenbrenner Hospital, and Notre Dame Hospital, with the support of the OACCAC and the NELHIN. enotification has been implemented with all hospitals in the North East that were in scope for this project. (West Parry Sound Health Centre was not in scope because they do not use Meditech.) Patient Viewer has been implemented with all hospitals in the North East. ALC Long Stay/Hard to Serve Committees have been implemented in Sudbury, North Bay and Sault Ste. Marie and Timmins. There is engagement with the Retirement Home sector in Timmins surrounding the Home First philosophy. SAH-NE CCAC-NELHIN-Cedarwood Lodge Committee initiated work towards transition of 5 additional Interim LTC/CCP beds (38 Interim LTC and 12 CCP). A work plan has Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 16 of 35

17 Percentage of home carer patients EFFECTIVE Indicators and Trends for Keeping People Healthy in Home Care been developed for transition planning. Access to Care, Access to Care (ATC), a company that provides high-quality information products and services to help improve performance and ensure accountability within health care organizations, is working with the NE LHIN to review Wait Times Information System (WTIS) consistency in ALC reporting. Note: For consistency with the M-SAA, quarterly results will be reported rather than monthly results. Data Source: M-SAA Quarterly Progress Report to the NE LHIN (H1) ( ) 2% Unplanned, Less Urgent Emergency Department Visits Within 3 Days of Discharge from Hospital Quality Improvement Plan Result: not available Last Available Result: 15.6% ( 2)* Target: 12.% 15% 1% The result for the four-quarter period from - 2 to -2 is 14.3%, an increase from the previous four-quarter result of 13.1% ( to 2). 5% % *In the Quality, Risk and Patient Safety Report, there was an error in the result reported of 4.1% that is corrected in the this report. The correct result of 15.6% is consistent with other quarterly results. Quarter, Year Data Source: Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. Delay in data availability will impact reporting abilities. Improvement Initiative: To understand the fundamental underlying cause(s) of unplanned ED visits by CCAC patients, and enable development of change ideas to prevent re-occurrence. Goal: enotification Reports clearly indicate if ED visit could have been averted. Result: enotification is in place at Health Sciences North. There are challenges to be addressed to determine which ED visits are planned vs unplanned. Goal: Completed analysis outlining reasons why patients are returning to the ED. Result: The analysis is in progress. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 17 of 35

18 Percentage of Home Care Patients EFFECTIVE Indicators and Trends for Keeping People Healthy in Home Care 22% 21% 21% 2% 2% 19% Unplanned Hospital Readmissions Within 3 Days of Hospital Discharge Quarter, Year Quality Improvement Plan Result: not available Last Available Result: 2.2% ( 2) Target: 14.% The result for the four-quarter period from - 2 to -2 is 2.5%, an increase from the previous four-quarter result of 14.9% ( to 2). Data Source: Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. Delay in data availability will impact reporting abilities. Improvement Initiatives #1: Determine baseline number and percentage of NE CCAC patients who have experienced an unplanned readmission within 3 days of hospital discharge. (enotification process would need to be improved so that unplanned readmissions of NE CCAC patients can be reported.) Methods and Process Measures: Reports available to assist with root cause analysis Goal: Measures defined and tracked; root cause analysis complete o Result: Request for report development submitted to Business Intelligence. RCA will be initiated when data is available. Improvement Initiatives #2: Improve communications among 24 hospitals and the NE CCAC through implementation of enotification. (Note: enotification will replace the term ED Notification used in the QIP. enotification is not restricted only to the Emergency Department but will also be used to notify NE CCAC when patients who have been on care with CCAC are admitted to and/or discharged from inpatient units.) Methods and Process Measures: Process implemented Goal: enotification implemented at 24 hospitals by March 31, 215 (Note: The target date in the Collaborative Capacity Improvement Plan is May 31, 215) (Excludes West Parry Sound Health Centre as they do not use Meditech.) o Result: enotification was implemented at 24 hospitals (27 sites in total) by March 31, 215. Improvement Initiatives #3: Support seamless patient care by enhancing information sharing among 52 health system partners in the NE CCAC region through Implementation of the Health Partner Gateway (HPG). (Note: The term Community Health Portal (CHP) will be updated to Health Partner Gateway (HPG) in the QIP.) Methods and Process Measures: Number of health system partners that have implemented HPG o # of hospitals o # of Family Health Teams Goal: 1% of the 52 identified health system partners implement HPG by March 31, 215 o Result: 18% of health system partners (56 of 52) have implemented HPG (hospitals, NP-led clinics, FHTs, Healthlinks, specialty clinics). Additional partners who were not in the original plan also implemented HPG. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 18 of 35

19 # of Events / # Clients (1s) SAFE 8. SAFE: Avoiding harm in home care and the community What we want How to get it Consequences if we don t get it To whom does this matter? No risk events and complete patient records to identify high risk patients Implement preventative measures to minimize risk events to the extent possible. Monitor completeness of patient records. Risk of temporary or permanent disability and death; more emergency department visits and hospitalizations. High risk patients may not get the help they need in an emergency/disaster situation All patients, caregivers and family members. Those identified as long-stay home care patients are at particular risk. Indicators and Trends for Avoiding Harm in Home Care and the Community APR Total Number of Patient Risk Events per 1 Clients R12Apr-15 to Mar-15 MAY JUN JUL AUG SEP OCT Month, Year NOV DEC JAN FEB MAR Result: 1.93 risk events per 1 patients (average) The number of risk events reported per 1 patients was lower than the normal level simultaneous to the labour disruption in February. The number of reports has risen slightly each month since. Ideas for Improvement: New state of the art software has been purchased to replace the current system for risk event and complaint reporting. It includes significantly increased capacity to speed up reporting, produce more accurate results including reports and dashboards. Processes will be updated for event investigation and analysis to support improvements that will enhance the patient experience. Data Source: Risk Event and Feedback System (Report 1-5) Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 19 of 35

20 Number of Risk Events Number of Client Risk Events SAFE Indicators and Trends for Avoiding Harm in Home Care and the Community Number Patient Risk Events by Specific Event Type (Top 5) R12, Apr-15 to Mar The top 5 patient risk events by specific type remain fairly consistent with previous reports. Ideas for Improvement: The NE CCAC will participate in a LHIN initiative to investigate efficiencies in provision of medication and pharmacy items in the community in collaboration with hospitals Service Delivery -Missed Visit Service Delivery- Other Medical Equipment/ supplies Medication/ fluid error Other Data Source: Risk Event and Feedback System (Report 6-3) Specific Event Type Severity Level Near Miss Low Risk Medium Risk High Risk APR MAY Number of Risk Events by Severity Level R12 Apr-15 to Mar-15 JUN JUL AUG SEP OCT NOV Month, Year DEC Definitions JAN FEB MAR High Risk Medium Risk Low Risk An event or deviation that is detected and remedied before an incident occurs, avoiding harm/injury/impact to the patient, CCAC, or to the service provider/organization. The event has actual, or potential for minimal harm/injury/impact to the patient, the CCAC, or to the service provider/organization. The event has actual, or potential to result in some harm/injury/impact to the patient, the CCAC, or to the service provider/organization. The occurrence has caused a delay in service or resulted in additional costs or dissatisfaction with CCAC services. The event has actual or potential for significant harm/injury/impact to the patient, the CCAC, or to the service provider/organization, has the potential for litigation and/or lack of confidence in CCAC services. Of the 97 patient risk events reported in, 25 were reported as high (25.7%), 36 reported as medium (37.1%) and 31 reported as low (37.1%). The remaining 5 reports were near miss (5.1%). The 25 reported as high were categorized as follows: Service Delivery-Missed Visit (6) Medical Equipment/Supplies (5) Medication/Fluid Error (3) Service Delivery-Other (3) Treatment (2) Fall (1) Unexpected Death (1) Unsafe Patient Environment (1) Verbal/Physical Abuse (1) Service Delivery (NSNF) (1) Other (1) Note: Missed visits causing patient harm are documented in the Risk Event and Feedback System (REFS) whereas missed visits where there is no patient harm are captured in CHRIS. Ideas for Improvement: Each patient risk event is reviewed for accuracy and appropriate follow-up when submitted. Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 2 of 35

21 Percentage of Patients SAFE Indicators and Trends for Avoiding Harm in Home Care and the Community Unresolved patient safety risk events are reviewed regularly. Follow-up with investigators and managers occurs as needed Data Source: Risk Event and Feedback System (Report 6-3) Quality Improvement Plan 5% 45% 4% 35% 3% 25% Prevalence of Falls for Adult Long-Stay Home Care Clients Objective: The incidence of falls in adult long-stay home care patients will be reduced. Outcome Measure/Indicator: Percentage of longstay patients who record a fall on follow-up RAI HC assessment. Target: 29.7% Performance Standard: 33.% Result: 37.17% The current rate of 37.17% does not meet the Balanced Scorecard performance standard. Results have remained consistently in this range since Fiscal % 15% Quarter, Year The patient population that is included in this metric has seen a significant increase in the average RAI score. It is not unreasonable that these increasingly complex patients will have a higher rate of falls even with the success of the falls prevention program. Improvement Initiative #1: Enhance reporting and follow-up of seniors' falls by improving the process for completing the Home Safety Risk Assessment. Goal: Establish baseline % of patients receiving a Home Safety Risk Assessment by December 31, 214 (YTD end ). Note: The baseline data will provide a benchmark to measure results of future improvement initiatives. Result: Work continues on the reporting mechanism for reporting the actual numbers of Home Safety Assessments completed with a pilot in the Parry Sound Branch office. The data is currently in CHRIS Notes and DMS. A report was created by Business Intelligence. Almost 51% of patients received a Home Safety Risk Assessment in. This will be used as a baseline for improvement. Improvement Initiative #2: Care Coordinators and Clinical staff complete the Falls Prevention e-learning module. Though the e-learning module is mandatory for all Care Coordination and Clinical staff, the priority is for staff working most closely with patients in the home setting. Goal: 6% of Care Coordination and Clinical staff complete the course by March 31, 215 Final Result: 78% employees have completed the Introduction to Falls Prevention e-learning module of the 497 employees assigned the module. (Note: result updated to reflect assignment to Care Coordination and Clinical Services staff only.) Data Source: Business Intelligence Balanced Scorecard Talent Development Report Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 21 of 35

22 % not reviewed SAFE Indicators and Trends for Avoiding Harm in Home Care and the Community 4.5% 4.% 3.5% 3.% 2.5% 2.% 1.5% 1.%.5%.% Percentage of Long-Stay Patients not Receiving a Medication Review Quarter, Year Quality Improvement Plan Result: 3.11% Target: 2.% Performance Standard: 2.2% Objective: Medication Safety for Long Stay Home Care Patients will be improved. Outcome Measure/Indicator: Prevalence of not receiving a medication review by a physician or other appropriate health care professional (e.g., Nurse Practitioner, Pharmacist) for long stay home care patients with a RAI Assessment completed in the last year. The current rate of 2.5% does not meet the performance standard. Further improvements are expected as both the CCAC s medication reconciliation program and the pharmacy program are utilized by more of our patients. Data Source: Business Intelligence > Indicators - Other Misc. Indicators > Medication and Falls Safety Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 22 of 35

23 Number of Complaints # Complaints / # Patients (1s) PATIENT CENTRED 9. PATIENT-CENTRED: Meeting patients needs and preferences What we want Consequences if we don t get it To whom does this matter? Patients who are satisfied with the services that they receive from the NE CCAC and our service providers. Dissatisfied patients. Potential for internal and external appeals, legal proceedings, and loss of reputation. Patients, caregivers, family members, NE CCAC staff and service providers APR Patient-Centered Indicators and Trends Total Number of Complaints per 1 Patients R12, Apr-14 to Mar-15 MAY JUN JUL AUG SEP OCT Month, Year NOV DEC JAN FEB MAR Result: 1.87 complaints per 1 patients (average) The overall rate of complaints documented per 1 patients in remained within the overall expected volume for the past 12 months for January and February, but rose sharply in March. This was likely as a result of the labour disruption in February. Ideas for Improvement: New state of the art software has been purchased to replace the current system for risk event and complaint reporting. It includes significantly increased capacity to speed up reporting, produce more accurate results including reports and dashboards. As part of the new software installation are updated approaches to investigating and analyzing events and complaints. Data Source: Risk Event and Feedback System (Report 1-1) Top 5 - Number of Complaints by Specific Type R12, Apr-15 to Mar The top 5 types of complaints in were consistent with the previous quarter. Ideas for Improvement: NE CCAC staff follow-up with patients, caregivers and Service Providers as required when investigating patient complaints. Actions are taken to reach a satisfactory resolution of the complaint and to escalate issues that require intervention by a manager or director. Most complaints are resolved by the Care Coordinator in collaboration with internal clinicians and/or external service providers. 2 1 Communication Amount of Service Competence in Service / Treatment Complaint Category Coordination Attitude / Behaviour Data Source: Risk Event and Feedback System (Report 1-2) Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 23 of 35

24 # of Complaints Number of Complaints PATIENT CENTRED Patient-Centered Indicators and Trends APR MAY JUN JUL Complaints by Severity R12, Apr-14 to Mar-15 AUG SEP OCT Month, Year NOV DEC JAN FEB MAR Major Intermediate Minor In, there were a total of 94 complaints of which 7 (7.4%) were major, 35 (37.2%) were intermediate and 52 (55.3%) were minor in nature. The 7 major complaints included the following specific types: Client Safety (2) Accessibility (1) Coordination (1) Eligibility (1) Competence in Service (1) Other (1) Classification Minor Intermediate Major Definition Resolution is straight-forward, consisting of an explanation, clarification or policy/procedure, or simply apology. Involve patient idiosyncrasies, preferences, or expectations. The issue is easily resolved. Resolution requires investigation, meeting with patient/family and other providers, minor changes to policy or procedure; requires changes to service plan or a review or policy and procedure. Resolution requires extensive investigation, meetings, follow-ups, major policy revisions or reporting of event to regulatory body or authorities; may cause litigation to the NE CCAC and/or service provider. French-Language Services Complaints Reported in Risk Event and Feedback System Data Source: Risk Event and Feedback System (Report 1-1, 1-24) Value:, Year-to-date: 3 The number of complaints about the provision of services in French remains very low with complaints reported in the Risk Event and Feedback System in. The Client Caregiver Experience Evaluation survey provides information about service provision in the patient s preferred language. There are no new survey results to report this quarter. Quarter, Year Data Source: Business Intelligence>Quality&Risk>French Language Related Complaints Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 24 of 35

25 Number of Appeals Initiated Number of Appeals # of Client Appeals PATIENT CENTRED 7 Patient-Centered Indicators and Trends Number of Internal and External Client Appeals Value:, Year-to-date: 5 2 Target 3 patient appeals per quarter 2 Performance Standard: 6 patient appeals per quarter 6 5 There were no new appeals initiated in the 4 th quarter Quarter, Year External Internal Data Source: Complaint Log (Action Line, MPP and Appeals) Note: starting with the Balanced Scorecard, the metric for internal and external appeals was combined, whereas there were separate targets and performance standards in previous reporting periods. 3 Number of Internal Appeals by Type Internal Appeals Committee Value:, Year-to-date: 4 14/15 Fiscal Quarter Number In-Process Status Resolved 2 1 Termination Amount Exclusion 1 st nd rd th Quarter, Fiscal Year Eligibility Total 4 4 Data Source: Complaint Log (Action Line, MPP and Appeals) Value:, Year-to-date: 1 2 Number of External Appeals by Type Health Services Appeal and Review Board 14/15 Fiscal Quarter Number In-Process Status Resolved Termination Amount 1 st nd 1 Exclusion 3 rd Eligibility 4 th Total 1 1 Quarter, Fiscal Year Data Source: Complaint Log (Action Line, MPP and Appeals) Quality, Risk and Patient Safety Report, Fiscal Year 2, Fourth Quarter Page 25 of 35