North Wellington Health Care April 1, 2012

Transcription

1 North Wellington Health Care April, 202 This document is intended to provide public hospitals with guidance as to how they can satisfy the requirements related to quality improvement plans in the Excellent Care for All Act, 200 (ECFAA). While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and hospitals should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, hospitals are free to design their own public quality improvement plans using alternative formats and contents, provided that they comply with the relevant requirements in ECFAA, and provided that they submit a version of their quality improvement plan to HQO in the format described herein. North Wellington Health Care of 7

2 Part A: Overview of Our Hospital s Quality Improvement Plan. Overview of our Quality Improvement Plan North Wellington Health Care is a dynamic organization that is dedicated to providing quality care close to home within a culture of performance improvement. North Wellington Health Care supports two vibrant hospital sites, the Louise Marshall Hospital in Mount Forest and the Palmerston & District Hospital in Palmerston. The mission, vision and values of the organization are supported through the Patient Safety, Quality, Performance Improvement and Risk Management Framework. The framework was adopted by the Board of Directors in January 2008 and revised in November 2009 and March 20 to incorporate the Excellent Care for All Act. The Board of Directors approves the annual Quality Improvement Plan on the recommendation of the Safety, Quality Performance Improvement Committee of the Board. Aligned with the Strategic Plan, the Corporate Balanced Scorecard and the Strategic Management Plan, the Quality Improvement Plan is the annual plan that focuses corporate and departmental initiatives with a focus on patient safety and quality. The Safety, Quality & Performance Improvement Committee of the Board receives monthly, quarterly and annual reports related to the Quality Improvement Plan, the Corporate Balanced Scorecard, Corporate Initiatives (i.e. Seniors Friendly), Departmental Quality Reports, Serious/Sentinel/Near Miss Reports, Complaints, Patient Satisfaction and Patient Safety Walkabouts. Utilizing the four quadrants of the Balanced Scorecard, NWHC is striving to provide the best patient care, in the best organization with a focus on system innovation and effectiveness and financial health. NWHC is compliant with the legislative requirements of the Excellent Care for All Act. The Corporate Scorecard reflects a comprehensive review of indicators as determined by the Board. The QIP (Part C) reflects the required indicators as well as indicators reflected in the Quality Improvement Plan. 2. What We Will Be Focusing On and How These Objectives Will Be Achieved Advancing BEST PATIENT CARE (Clinical Utilization and Patient Outcomes) Strategic Direction Provide quality care close to home by adopting best practice Participate in partnerships with other health care providers to develop a seamless continuum of care Management Plan Provide a safe, responsible obstetrical care in an environment that facilitates adoption of evidence informed decisions and the development of clinical skills. Participation of >90% of staff and physicians in the Managing Obstetrical Risks Effectively program (MOREOB) 2. Obstetrical policies & procedures are updated and implemented as needed providing evidence of MOREOB algorithms as evidenced by on line audit of policies & procedures 3. Obstetrical Ultrasound Reporting reflecting guidelines of the Society of Obstetricians and Gynaecologists of Canada standards as demonstrated through random auditing of 0 ultrasounds per month. Provide a patient environment that is responsive to infection prevention and control practices. Infection rates are below provincial comparator rates on the corporate scorecard % of staff complete the core infection control competencies 3. Annual Hand Hygiene Audits indicates an improvement > 79% for initial patient contact. Provide a medication administration environment that supports professionals to deliver medications safely, efficiently and consistently. Medication Errors that reach the patient and cause harm will be reduced by 0% North Wellington Health Care 2 of 7

3 Provide an environment that supports best practice and care close to home.. Alternate Level of Care (ALC) rates are monitored quarterly and Hospital Service Accountability Agreement (HSAA) target is met within 5% 2. Readmission rates of specific Case Mix Group (CMG) as indicated in the Provincial QIP Indicators are within benchmark 3. Emergency Department (ED) Wait Times are monitored daily and quarterly to improve length of stay for non admitted and admitted patients and reduce left without being seen to achieve a target of <%. 4. Patient Satisfaction Surveys indicate >80 85% for Inpatient satisfaction and >80% for Emergency Department satisfaction with services provided. 5. Adopt Senior s Friendly principles, develop an action plan and implement the best practice guideline for Delirium in 202. Realizing BEST SYSTEM (System Innovation and Change) Strategic Direction Provide leadership as the cornerstone of rural healthcare with vibrant sites in Mount Forest and Palmerston to advocate for comprehensive care in a campus model Partner with the Ministry of Health & Long Term Care (MOHLTC) and the Waterloo Wellington Local Health Integration Network (WWLHIN) for creative solutions to meet the communities health care needs and be aligned with the Integrated Health Services Plan Be innovative, focused on quality improvement and utilize technology to enhance the patient experience Management Plan Continue to focus on Accreditation Preparedness and provide reports to Accreditation Canada in February 202 and August 202. Improve the patient experience within the organization through the implementation of an ehealth record that provides seamless interaction with the interprofessional team. Secure capital funding for the implementation of electronic Meditech NUR through ehealth funding opportunities. Implementation of Rural Health Care of Tomorrow concepts that will facilitate the organizations ability to build capacity for the Campus Model Support and align discharge planning policies with a Home First philosophy to enable patients/clients to be discharged to a safe environment that promotes their well being. Optimizing BEST ORGANIZATION (Organizational Health) Strategic Direction Commit to patient and staff safety Implement creative solutions to meet health human resource requirements Develop a culture supporting a healthy and respectful workplace Adopt best practice in leadership development Management Plan Foster a safe, healthy and respectful environment that promotes positive interprofessional relationships thereby improving the patient s health care experience North Wellington Health Care 3 of 7

4 . Provide Non Violent Crisis Intervention training for all staff measured by the number of sessions provided and staff attendance of >80%. Provide a supportive environment that allows staff to actively reflect on their professional practice and provide them with an opportunity to participate in professional and personal development opportunities. Provide 2 annual Skills Fair Days for all nursing staff (June & November) Implementation of Rural Health Care of Tomorrow concepts that will facilitate the organizations ability to build capacity for the Campus Model Develop leadership within the organization through the adoption of Kouzes and Posner s Leadership Model. Leaders need to demonstrate their ability to challenge the process in order to improve the patient experience by using creativity, innovation and Continuous Quality Improvement (CQI) methodology. Provide 2 Leadership Retreats per year to build on leadership model with evidence of >90% participation by formal and informal leaders Conduct an annual staff/provider satisfaction survey utilizing the Work Life Pulse Survey from Accreditation Canada and establish targets for improvement based on survey results by December 202. Incorporate from the Corporate Scorecard into the QIP the indicators of Lost Time due to Workplace Injury and Complaints involving patient care. Provide LEAN education for 5 leaders across the Wellington Health Care Alliance by December 202. Ensuring BEST FINANCIAL POSITION (Financial Health) Strategic Direction Exercise responsible fiscal management and stewardship Management Plan Receive approval for a 5 year capital plan annually from the Board of Directors by March. Total Margin is in compliance with HSAA. Current Ratio is maintained 3. How The Plan Aligns With The Other Planning Processes The Quality improvement Plan is directly linked to North Wellington Health Care Strategic Plan , Waterloo Wellington Local Health Integration Network Integrated Health Service Plan, Waterloo Wellington Rural Health Network Planning, Waterloo Wellington Regional Infection Control Network, Waterloo Wellington Emergency Services Network, Waterloo Wellington Geriatric Service Network, Public Reporting of Quality Improvement Plan indicators and Ministry of Health and Long Term Care Initiatives. 4. Challenges, Risks and Mitigation Strategies The challenges identified by North Wellington Health Care are largely related to the ability to respond to the ongoing legislated and mandated requirements with limited resources. Small rural hospitals continue to be challenged with mandated requirements and limited resources. The Wellington Health Care Alliance between North Wellington Health Care and Groves Memorial Community Hospital provides opportunities for the alignment and sharing of resources to mitigate these challenges. NWHC Board of Directors has determined the Strategic Directions and Initiatives for the organization and recognizes that the initiatives as documented are the priority and will require the redistribution of resources as required to ensure success. North Wellington Health Care 4 of 7

5 Part B: Our Improvement Targets and Initiatives Purpose of this section: Please complete the Part B Improvement Targets and Initiatives spreadsheet (Excel file). Please remember to include the spreadsheet (Excel file) as part of the QIP Short Form package for submission to HQO (QIP@HQOntario.ca), and to include a link to this material on your hospital s website. North Wellington Health Care 5 of 7

6 Part C: The Link to Performance based Compensation of Our Executives The purpose of performance based related to ECFAA is to drive accountability for the delivery of quality improvement plans (QIPs). By linking achievement of targets to, organizations can increase the motivation to achieve both long and short term goals. Performance based will enable organizations to ensure consistency in the application of performance incentives and drive transparency in the performance incentive process. Manner in and extent to which of our executives is tied to achievement of targets Our executives' is linked to performance in the following way: The Executives of the hospital, which include the CEO, two Vice Presidents, the Chief Human Resources Officer, Chief Financial Officer and Chief of Staff will have performance based based on the Quality Improvement indicators as shown below: Indicator Below Floor Score = 0 points Floor level or maintenance of Quality Score = point Desired 202/3 target Score = 2 points Full Success Score = 3 points QUALITY : Hand Hygiene Below 7% 7% up to 79% 79% up to 85% 85% or higher EFFECTIVENESS: Total Margin Worse than HAPS by % or more of total revenue Worse than HAPS Obligation but within % of total revenue Meet or better than HAPS Obligation (up to % of total Better than HAPS obligation by % or more of total revenue revenue better) EFFECTIVENESS: ALC % of total Over 5% 5% down to 3% 3% down to 9.46% 9.46% or less ACCESS : ER patients Left Without Being Seen PATIENT CENTERED : Inpatient Satisfaction Overall, how would you rate the care and services you received at the hospital? PATIENT CENTERED : Overall ER patient Satisfaction 4% or more Under 4% Under 3% Under % and 3% and % Below 80% 80% up to 85% Over 85% up to 90% 90% or higher Below Prov l Avg of 85% 85% up to 90% 90% up to 95% 95% or higher While a total possible score is 8, success and continuous improvement is evidenced clearly with scores in the desired range with a 2 point value per indicator. A total of 0 points overall would provide for full performance pay entitlement. Any score over 0, would not entitle executives to any further bonus. A score under 0 would provide for a proportionate reduction of /0 of performance for every point below 0. The at risk Performance is equivalent to 2% of employment income for all executives except for the CEO. The CEO will have the equivalent of 5% of employment income at risk. Compensation at risk will be determined with each executive at the beginning of the year as a combination of dollars, vacation and any other earning entitlements. Payments or entitlement calculations will be adjusted through the year and the performance payment provided once the end of year results have been calculated. Anyone working a partial year will be proportionately affected by the year end. North Wellington Health Care 6 of 7

7 Part D: Accountability Sign off I have reviewed and approved our hospital's Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan:. Was developed with consideration of data from the patient relations process, patient and employee/service provider surveys, and aggregated critical incident data 2. Contains annual performance improvement targets, and justification for these targets; 3. Describes the manner in and extent to which, executive is tied to achievement of QIP targets; and 4. Was reviewed as part of the planning submission process and is aligned with the organization's operational planning processes and considers other organizational and provincial priorities. Al Hodgson Board Chair Mary Lou Brown Quality Committee Chair Jerome Quenneville Chief Executive Officer North Wellington Health Care 7 of 7

8 PART B: Improvement Targets and Initiatives 202/3 North Wellington Health Care, AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Current performance Target for 202/3 Target justification Priority level Planned improvement initiatives (Change Ideas) Methods and process measures Goal for change ideas (202/3) Comments Safety Reduce clostridium difficile associated diseases (CDI) CDI rate per,000 patient days: Number of patients newly diagnosed with hospital acquired Need 3d Q CDI, divided by the number of patient days in that month, multiplied by,000 Average for Jan 2/000 pte days Dec. 20, consistent with publicly reportable patient safety data <0.4 Internal 3 ) Surveillance by IP&C daily 2) Annual P&P Review Surveillance Continue to monitor Surveillance Monitoring 3) Adoption of PIDAC Environmental Standards Reduce incidence of Ventilator Associated Pneumonia (VAP) VAP rate per,000 ventilator days: the total number of newly diagnosed VAP cases in the ICU after at least 48 hours of mechanical ventilation, divided by the number of ventilator days in that reporting period, multiplied by,000 Average for Jan Dec. 20, consistent with publicly reportable patient safety data NWHC does not maintain ventilated patients. Improve provider hand hygiene compliance Hand hygiene compliance before patient contact: The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by 00 Jan Dec. 20, consistent with publicly reportable patient safety data No data yet March 202 >79% Internal ) Annual Audit March 202 2) Annual IP&C Core Competency Review for all staff June 202 Audit Annually Refresh Hand Hygiene Program through use of visual cures, video & intranet Link to executive Reduce rate of central line blood stream infections Rate of central line blood stream infections per,000 central line days: total number of newly diagnosed CLI cases in the ICU after at least 48 hours of being placed on a central line, divided by the number of central line days in that reporting period, multiplied by,000 Average for Jan Dec. 20, consistent with publicly reportable patient safety data Reduce incidence of new pressure ulcers Pressure Ulcers: Percent of complex continuing care residents with new pressure ulcer in the last three months (stage 2 or higher) FY Q3 20/2, CCRS Avoid patient falls Falls: Percent of complex continuing care residents who fell in the last 30 days FY Q3 20/2, CCRS Reduce rates of deaths and complications associated with surgical care Surgical Safety Checklist: number of times all three phases of the surgical safety checklist was performed ( briefing, time out and debriefing ) divided by the total number of surgeries performed, multiplied by 00 Jan Dec. 20, consistent with publicly reportable patient safety data st Q % Need 2nd Q data >95% Internal ) Surgical Services Committee to monitor compliance HIM Audit Action Plan Developed Reduce use of physical restraints Physical Restraints: The number of patients who are physically restrained at least once in the 3 days prior to initial assessment divided by all cases with a full admission assessment Q4 FY 2009/0 Q3 FY 200/, OMHRS Reduce MRSA Rates MRSA bacteremia rate per 000 pt. days: number of pts. diagnosed with hospital acquired MRSA bacteremia divided by the number of pt. days in that month, multiplied by 000. Average Jan December 20, consistent with publicly reported pt. safety data. 0 <0.4 Internal ) Surveillance by IP&C daily. Annually P&P review. Adoption of PIDAC Environmental Standards Surveillance Reduce VRE Rates VRE rate per 000 pt. days: number of pts. diagnosed with hospital acquired VRE divided by the number of patient days in that month, multiplied by 000. Average January December 20, consistent with publicly reported patient safety data. 0 <0.4 Internal ) Surveillance by IP&C daily. Annually P&P review. Adoption of PIDAC Environmental Standards Surveillance Effectiveness Reduce unnecessary deaths in hospitals HSMR: number of observed deaths/number of expected deaths x 00 FY 200/, as of December 20, CIHI Improve organizational financial health Total Margin (consolidated): Percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization and mortgage interest, in a given year. Q3 20/2, OHRS 20 2 Q & 2 = Meet or better 0.6% than HAPS target up to % HSAA ) Balanced budget plan with WWHLIN & HSAA Financial Statements Monthly Link to executive. 202March26 of 2

9 PART B: Improvement Targets and Initiatives 202/3 North Wellington Health Care, AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Current performance Target for 202/3 Target justification Priority level Planned improvement initiatives (Change Ideas) Methods and process measures Goal for change ideas (202/3) Comments Improve Staff Safety Lost Time Due to Injury at Work 20 2 Average Q & Q2 = 0 <.7% Industry Average 2 ) WSIB Claims Joint Occupational Health & Safety Initiatives Access Reduce wait times in the ED ER Wait times: 90th Percentile ER length of stay for Admitted patients. Q3 20/2, NACRS, CIHI 20 2 Q & 2 = 3.4 <6.0 Peer Hospital Comparator 2 ) Monitored daily by Manager & bimonthly by ER Committee NACRS ER LWBS: overall percentage of pts. who leave without being seen 20 2 Average Q & Q2 = 0.8% <.0% Peer Hospital Comparator 2 ) Monitored daily by Manager & bimonthly by ER Committee NACRS Link to executive Patient centered Improve patient satisfaction From NRC Picker Inpatient Survey: "Would you recommend this hospital to your friends and family?" IP Survey From NRC Picker: Inpatient Survey: "Overall, how would you rate the care and services you received at the hospital?" IP Survey 94.5% 93.90% >85% >80% Internal Target Internal Target ) Monitored on corporate scorecard quarterly. IP committee monitors Monitored l on l corporate scorecard f quarterly. IP committee monitors results & implements opportunities for improvement. NRC Picker NRC Picker Note: results are not statistically significant due to sample size. Link to executive From NRC Picker ER Survey: Overall Pt. Satisfaction with the ER 94.60% >80% Internal Target Monitored on corporate scorecard quarterly. Emergency committee monitors results & implements opportunities for improvement. Complaints Received Related to Patient Care 20 2 Q & Q2 = 0.04% NRC Picker < % Internal Target Continue to monitor Patient Representative Continue current complaint resolution process Note: results are not statistically significant due to sample size. Link to executive Integrated Reduce unnecessary time spent in acute care Percentage ALC days: Total number of inpatient days designated as ALC, divided by the total number of inpatient days. Q2 20/2, DAD, CIHI 20 2 = 7.2% <9.46.0% WWLHIN HSAA Target 2 ) Home First Program 2) Partnership with CCAC for all discharge planning. Continue support for GEM nurses. Advocate for continuity in rural community services. HIM Refresh Home First Philosophy Link to executive Reduce unnecessary hospital readmission Readmission within 30 days for selected CMGs to any facility: The number of patients with specified CMGs readmitted to any facility for non elective inpatient care within 30 days of discharge, compared to the number of expected non elective readmissions Q 20/2, DAD, CIHI 20 2 = 6.2% <3.8% MOHLTC Target 3 ) Unable to determine at this time FIM Website 202March26 2 of 2