QIP 2018/19 Workplace Violence Prevention

Transcription

1 QIP 2018/19 Workplace Violence Prevention AIM MEASURE Quality dimension Objective Indicator Safe Reduce harm to staff Number of workplace violence incidents (overall) reported by hospital workers within a 12 month period. Note: workplace violence incidents are reported via the incident reporting system. Note: Definitions for the terms worker and workplace violence will be those in the Occupational Health and Safety Act (OHSA, 2016). Current performance 773 (January December 2017) Target for 2018/ in calendar 2018 Target justification This reduction of approximately 10% is a stretch target given our specialized patient populations (including trauma, mental health, long-term care and alternate level of care patients with dementia and responsive behaviours) who can suffer from conditions that can lead to behaviours that put others at risk. Comments 2017 has the highest number of reported incidents in the last three years. We attribute this primarily to three changes: We launched a new Leaders Guide on responding to and reporting violent incidents. This has increased awareness among leaders and staff of the value in reporting incidents as it enables better improvement strategies to be developed. The issue has also been reported in the media recently. An increase volume of patients overall. An increase in the number of patients with conditions that can lead to behaviours that put others at risk (e.g. trauma and dementia) Sunnybrook s main focus is to reduce the number of Lost Time Incidents (most severe incidents) related to a workplace violent incidents from 8 to 7 (Jan-Dec 2017). Ideally the goal is to have zero incidents Lost Time Incidents; however this may not be attainable due to factors outside of Sunnybrook s control i.e. unpredictable patient behaviour and staff's ability to return to work. As of January 9, 2018, Sunnybrook had 6, full-time equivalent (FTE) employees, 517 active acute care beds and 472 long-term care beds. Note that our incident data includes volunteers as we consider them a type of service provider and want to learn from any events in which they are involved. February 22, 2018

2 QIP 2018/19 Workplace Violence Prevention CHANGE Change Ideas Accountability Process Measures Goal for Change Ideas Provide on-line Code White 1 / Workplace Violence Prevention training to all staff Continue to monitor staff completion of the Code White/ Violence Prevention training and increase compliance among Active Staff by keeping leaders informed of progress. 1 Code White is an emergency code for staff to notify others of an incident that requires immediate action, in particular to assist staff when interacting with person who is or who may become violent. Occupational Health and Safety will report compliance rates and progress to the following to ensure accountability in reaching targets: Managers monthly Occupational Health and Safety Committee monthly Responsive Behaviour Working Group quarterly. Percentage of Active Staff that complete the Code White/ Workplace Violence Prevention training. Denominator: Count of Active Staff as of April 1, % by March 31, 2019 Current performance (Sept 2017): 80% Provide Non-violent Crisis Intervention education with a focus on high-risk areas Ensure regularly scheduled course offerings as needed April 2018 to March Complete the roll-out and increase participation rate from 61% to 90% in high risk areas 2 and expand to staff in lower risk areas. Continue to monitor staff attendance via the Learning Management System and share results with leaders. 2 High Risk Areas are the Emergency Department, Veterans Centre units (Dorothy Macham, LGSE, LGSW, LSSE, and LSSW) and acute care units C5, D5, F2 (Mental Health) and Nursing Resource Teams (CNRT/ACRNT). The Emergency Preparedness Team will report progress quarterly to the Responsive Behaviour Working Group to ensure accountability in reaching targets. Percentage of Active Staff assigned on a regular basis in high risk areas that attend a nonviolent crisis intervention education session. Denominator: Count of Active Staff as of April 1, % by March 31, 2019 Current performance (January December 2017): 340/779 = 43% Emergency Department 62% Veterans Centre 71% Acute care C5/D5-92% Acute care F2 100% Nursing Resources Team ACNRT 51% February 22, 2018

3 QIP 2018/19 Workplace Violence Prevention CHANGE Change Ideas Accountability Process Measures Goal for Change Ideas Monitor that the Framework for Responding to Reported Violent Incidents (3 step process) is being followed. Step 1: Team huddle Run by the team that responded immediately after any violent patient incident. Step 2: Unit Debrief and Patient Safety Care Plan the Debrief is to be conducted after any repetitive incidents and/or actual/potential serious harm and the Safety Care Plan is to be developed as necessary. Step 3: Serious Incident Investigation/System Review - this is completed for actual or potential violent situations involving serious injury or if a weapon was used. It is led by Risk Management and Occupational Health and Safety. All recommendations from Step 2 and 3 will be prepared by Occupational Health and Safety for the Joint Occupational Health and Safety Committee & the Violence Prevention Committee and will be shared with the Vice President, Human Resources and senior leadership to address any barriers in implementing the recommendations. Step 3 System Reviews will be prepared by Risk Management for the Quality of Care Information Protection Act (QCIPA) - Quality of Care Committee to ensure that there is awareness of important trends at the senior management and Board level and to address any barriers in implementing the recommendations. % of Patient Safety Care Plans developed when required % of System Reviews completed Baseline: 35% (Jan Dec 2017) Target: 80% of required Patient Safety Care Plans completed 100% February 22, 2018

4 QIP 2018/19 Workplace Violence Prevention CHANGE Change Ideas Accountability Process Measures Goal for Change Ideas Continue to support practice changes to enhance violence prevention with staff. A. On two units engaged in pilot violence prevention work in 2017/18: Implement pilot Violence Assessment and Documentation Tool for admitted patients in the Emergency Department to identify o Those who have a history of, or have demonstrated behaviour that, puts others at risk and o de-escalation care strategies that can be used to address the behaviour. For the identified patients, implement unit-based care planning processes to identify triggers/ contributors to the demonstrated behaviour and more intensive care interventions to continue prevent /mitigate it. B. Apply the learnings from the Part A (above) to another priority high risk unit. Develop learnings by December 2018 and implement by March The Violence Prevention and Responsive Behaviour Working Group will report progress quarterly to the Violence Prevention Committee for the purpose of engagement and feedback. Senior Friendly Lead and the Patient Care Managers will articulate learnings. The percentage admitted patients who have had a staff assist and/or code white * called during their Emergency Department stay and who have a completed Violence Assessment and Documentation Tool in the Emergency Department. The percentage admitted patients who have had a staff assist and/or code white * called during their Emergency Department stay and who have a completed care plan on the inpatient unit. *indication of violence or potential violence 70 % 60 % February 22, 2018

5 QIP 2018/19 Workplace Violence Prevention CHANGE Change Ideas Accountability Process Measures Goal for Change Ideas Consult and collaborate with community partners to support practice changes to enhance violence prevention with staff. At Toronto Academic Health Sciences Network- Senior Friendly Community of Practice meetings, discuss opportunity to collaborate and develop common strategies. Explore risk identification and communication processes to inform the Sunnybrook electronic patient care record; Explore electronic documentation solutions for flagging behaviours that put others at risk Explore opportunities to develop common strategies to identify and communicate risk among community partners Share progress with Screening and unit-based Care Planning processes with Michael Garron Hospital. Risk Management and Senior Friendly will oversee work with community partners. All consultations initiated and at least 50% completed. By March 31, 2019 February 22, 2018

6 QIP 18/19 Suicide Prevention AIM MEASURE Quality dimension Objective Indicator Current performance Target for 2018/19 Target justification Comments Safe Development and implementation of suicide-prevention interventions Percentage of inpatients, Emergency Department patients (when indicated), and Veterans residents for whom suicide screening is completed Screening includes completion of either: Columbia Suicide Severity Rating Score (CSSRS) or Documentation of equivalent suicide risk screen at one point during their care in hospital Baseline data will be collected via sample chart audit in early 2018 Target will be set after baseline data collected Ultimately we wish to reach 100%, but we recognize that both system and patient factors make a doubling in year 1 followed by further incremental gains to be a more realistic target. Our ultimate goal is to reduce suicide attempts and deaths among Sunnybrook patients. Two key mediators for reaching this goal are screening (year 1 focus) and interventions (year 2 focus). In our year 1 work plan, we are also including work to prepare for year 2. Year 2 Draft Plan: For Mental Health, Emergency Department, Inpatients or Outpatients who screen positive for elevated suicide risk, implementation of any of the following interventions: Basic management steps and psychiatric referral where appropriate Completion of Coping Card Access to focused psychotherapy (i.e., Cognitive Behavioural Therapy, problem-solving app) Timely access to ketamine clinic services Timely access to Electroconvulsive therapy (ECT) clinic services Implementation of means restriction(s) Timely access to follow-up services for inpatients

7 Change Ideas Accountability Process Measures Goal for Change Ideas 1. Staff Training on Suicide Prevention Awareness and Training Module Preventing Suicide at Sunnybrook 12-minute Suicide Prevention e-learning training is online and registration occurs through Sunnybrook s Learning Management System (LMS) Implement broad communication strategies to improve leader and staff training rates Provide monthly reports showing completion rates to department managers and quarterly to the Suicide Prevention working group. Percentage of staff (fulltime and part-time) that complete the New Suicide Prevention Strategies Awareness and Training. Denominator: Count of permanent full-time and part-time staff as of April 1, % by end of year 1 (March 31, 2019) 2. Initiate Discussions with Sunnycare team on the creation Brain Sciences and Discussions initiated and Initiate contact with of an electronic process for documentation of screening and Department of next steps documented Sunnycare team by Apr referrals for suicide prevention interventions Psychiatry Leadership and monitored 1, 2018 and note and monitor all follow-up actions. 3. Take the Quality Improvement Plan to the Department of Chief of Psychiatry will Present the plan in Implement suggested Psychiatry Patient and Family Advisory committee for review. present the plan at an upcoming meeting. advance of March 31, 2018 changes to the plan where possible by April 30, 2018.

8 Change Ideas Accountability Process Measures Goal for Change Ideas 4. Increase external capacity and access to community services (psychotherapy and follow-up) A half-day educational event(s) on suicide screening and prevention strategies will be organized for community agencies, Local Health Integration Network and primary health care teams. Workshops will also enhance capacity for coordination with Sunnybrook services. Targeted invitations will be disseminated. Focus will be on psychotherapy services and follow-up support postdischarge from Emergency Department or inpatients Event organizers will track information on number and type of attendees, and obtain feedback on the event, including capacity for Sunnybrook patients accessing services Number of agencies that attend event > 10 agencies/ organizations/ teams per event This is preparation for Year 2

9 Change Ideas Accountability Process Measures Goal for Change Ideas 5. Increase internal capacity for delivery of suicide-prevention strategies and treatments Develop and disseminate information within Sunnybrook on key suicide prevention strategies for patients who screen positive for suicide risk This specifically includes: - Using Columbia Suicide Severity Rating Score (CSSRS) to track change in suicidal thoughts - Use of the Sunnybrook Coping Card - Access to psychotherapy resources (Cognitive Behavioural Therapy (CBT), problem-based app) - Establishment of new ketamine and neuromodulation clinics - Access to Electroconvulsive therapy (ECT) services (inpatient and ambulatory) - Restricting access to lethal suicide methods Work with hospital resources (Communications, Sunnycare) and programs (Department of Psychiatry, Brain Sciences) to build internal resources and enhance communication / access across the organization Brain Sciences and Department of Psychiatry Leadership Track usage of specific interventions/ strategies Develop ketamine and neuromodulation clinics Begin tracking Apr 1, 2018 Launch ketamine and neuromodulation clinics This is preparation for Year 2

10 AIM Hand Hygiene Quality Improvement Plan 18/19 MEASURE Quality Current Target for Target Comments dimension Objective Indicator performance 2018/19 justification Safe To improve hand hygiene performance on medical and surgical inpatient units at Sunnybrook Health Sciences Centre using electronic monitoring (Emonitoring), in order to prevent hospital acquired infections. Rate of hand hygiene performance (hand hygiene events divided by hand hygiene opportunities measured via e- monitoring). Numerator (hand hygiene events): the number of times that healthcare providers (nurses, other health professionals, residents, physicians, Environmental Services Partners, and Patient Services Partners ) clean their hands Denominator (hand hygiene opportunities): a validated number of expected number of hand hygiene opportunities based on multiple variables 47.9% Q1 17/18 (462,205 hand hygiene events divided by 964,935 hand hygiene opportunities. This is an aggregate of five pilot medical/surgical units D2, D3, D5, B4, C5.) 60% average performance across all pilot medical/ surgical units by Q4 2018/19 Few hospitals have used E-monitoring to measure improvement in hand hygiene compliance. Sunnybrook s target is based on a published study in North Carolina which demonstrated a 25% absolute improvement in E- monitored hand hygiene compliance which was associated with a significant reduction in hospital acquired infections caused by methicillin-resistant Staph aureus (MRSA). Hand hygiene compliance is a patient safety indicator of Health Quality Ontario. The traditional method of measuring hand hygiene is based on direct observation during spot audits, whereas this new indicator introduced at Sunnybrook* in 2017, measures hand hygiene compliance continuously on the unit using a built-in motion-activated censor measure against a validated number of expected hand hygiene opportunities for the unit based on multiple variables (e.g. patient acuity and unit census). It provides more accurate performance measurement than direct observation and has been validated both externally and internally. *This is part of a multi-centre initiative with four other Ontario hospitals (Michael Garron Hospital, Sinai Health System, Lakeridge Health and St. Michael s Hospital).

11 Methods Change Ideas Process Measures Goal for Change Ideas (Accountability and Responsibility) Implement provision of weekly E-monitoring Feedback Reports (contain hand hygiene compliance for the prior week) to front-line staff. All units will set a 1-month and a 3-month goal for hand hygiene compliance. Goals will be set by the unit during Quality Improvement huddles and posted on Quality boards included in Feedback Reports shared with the unit Infection Prevention & Control coordinator Monitor that a minimum of two weekly Quality Improvement huddles will occur on units to review and discuss E- monitoring Feedback Reports and identify opportunities for iterative changes* that promote better hand hygiene compliance. *Examples of iterative changes arising from huddles may include walk-arounds to identify specific physical locations where hand sanitizer location may be optimized to improve workflow, and reviewing hand hygiene data at specific times of day to correlate with patient care activities. Infection Prevention and Control will set up a system so that Feedback Reports will be automatically generated and pushed to all hand hygiene champions, Team Leaders, Advanced Practice Nurses and Patient Care Managers for the unit to share with all staff. Patient Care Managers and/or other unit leaders as assigned will ensure goals are set. Quality Improvement Huddles are organized by unit managers with the support of Infection Prevention and Control. Huddles are attended by most clinical staff on the unit. % of unit leadership receiving E-monitoring Feedback Reports on a weekly basis 1-month and 3-month goals will be tracked on monthly corporate E-monitoring reports Discussion at bi-weekly Quality Improvement huddles will be recorded by Infection Prevention & Control 100% of unit leadership >50% of the front-line staff on the pilot study unit. To set a monthly E- monitoring goal at least 10% above baseline at the start of each month. To set a 3-month E- monitoring goal at least 10% above baseline every quarter. At least 1-2 new ideas or lessons are generated on each unit every month. These will be shared with other units as applicable to drive improvement.

12 Methods Change Ideas Process Measures Goal for Change Ideas (Accountability and Responsibility) Empower patients and families to make hand hygiene an expectation of care by: 1) Providing point of care hand hygiene bottles for patients and families at the bedside 2) Formalizing empowerment of patients and families to assist with audit and feedback of healthcare provider hand hygiene E-monitored point of care bottles will be installed at the bedside by the Patient Care Managers and Infection Prevention and Control Coordinator will monitor product use. Infection Prevention & Control will work with Patient Engagement Team, and patient/family representatives to design a process that formalizes patient/family involvement in providing audit and feedback to healthcare providers about their hand hygiene. Absolute number of hand hygiene events using point of care bottles will be monitored and reported using the e-monitoring system. To increase the number of hand hygiene events of point of care bottles on the intervention units. (Target will be set with Sunnybrook s patient engagement team.)

13 Quality of Discharge Summary Quality Improvement Plan 18/19 AIM MEASURE Quality Current Target for Target Objective Indicator dimension performance 2018/19 justification Comments Effective Improve the quality of Discharge Summaries to ensure effective communication of patient information when transitioning patients to the community. Percentage of primary care physicians who responded yes to the question, Was the content of the Discharge Summary relevant and concise? 33% October % Q4 2018/19 This is a challenging stretch goal because we want to make a lot of progress this year to get to the ultimate goal of 100%. Survey was conducted in October 2017 and was responded to by nine family physicians from Sunnybrook s Family Health Team and the North Toronto sub-lhin (Local Health Integration Network) Primary Care Council. The survey will be repeated at the end of Q2 and in the fourth quarter of 2018/19 to re-measure the indicator. There were two other questions on the survey. One asked about timeliness (1/9 said yes, 6 said sometimes) and one solicited ideas for improvement. The key themes that emerged were: Timeliness Clarity of follow-up plan Completeness CHANGE Change Ideas 1. Implement changes to resident training on Discharge Summaries in line with Toronto Central Local Health Integration Network (TCLHIN) recommendations a. Implement University Heath Network tool kit which specifies best practices for Discharge Summaries b. Implement video education to support resident learning c. Corporate trainers to provide training to residents on units (units will be selected based on current performance data) d. Create Discharge Summary quick reference guide (based on University Health Network s) to inform residents on Discharge Summary best practices including Sunnybrook s focus on timeliness, completeness (required components) and clarity of follow up plan e. Modify orientation (December 2017 and further for July 2018) Methods (Accountability & Reporting) Office of Education to oversee implementation of changes to resident education. Reports progress into Discharge Summary Working Group Corporate Training Services (Director, Health Records) to conduct training and distribute quick reference guide and report feedback to Discharge Summary Working Group Process Measures Completion score on list of criteria. Health Data Records to audit completion of the Discharge Summaries using TCLHIN standard template (criteria), as well as the criteria for follow-up plan that Sunnybrook develops. Goal for Change Ideas 20% improvement in result from baseline by March 31, 2019 Baseline will be collected by June 30, 2018 if possible.

14 Change Ideas 2. Modify Discharge Summary template to align with LHIN best practice template (also used by St. Michael s Hospital and University Heath Network). a. Base modifications on learnings from i. other hospitals that have implemented the template ii. high performing physicians here at Sunnybrook iii. Quality audit e.g. Length, sections left empty, quality of follow-up section b. Implement modifications to template if required: - Consult with Sunnycare - Obtain Medical Advisory Committee approval - Obtain Forms Committee approval Methods (Accountability & Reporting) Director, Health Records and Chair Medical Advisory Committee execute action plan Reports progress into Discharge Summary Working Group Process Measures Revised Discharge Summary approved by Medical Advisory Committee. Goal for Change Ideas Paper form completed by December 31, Electronic form completed by December 31, Continue to increase timeliness (rate of Discharge Summary completion within 48 Lead (Chair, Medical Advisory % Discharge Summaries Baseline: 75% hours) Committee) continues work of QIP completed within 48 hours Target: above 80% by a. Take new target completion rate of above 80% to Medical Advisory Committee 17/18 to increase completion rate. across the hospital as per March 31, 2019 for approval Reports progress into Discharge policy requirements b. Conduct focus groups with those not meeting targets to determine barriers and how to improve rates using tools such as fishbone diagram. Summary Working Group c. Seek and share insights and strategies to overcome barriers from high performers d. Continue physician education on Discharge Summary completion (e.g. through e- learning) e. Implement a quality improvement process to make Discharge Summary process efficient for providers (without impacting quality) 4. Continue to improve fax success rate (the percentage of faxes to primary care that Health Data Records (Director) to lead % Discharge Summaries Baseline: 70% successfully go through (e.g. not rejected due to wrong number or primary care fax improvement in fax completion rate. successfully faxed to Target: 80% by March 31, turned our etc. a. Improve accuracy of documentation of patient s family physician at time of registration b. Implement fax registry maintenance (using University Heath Network s process) c. Streamline discontinuation of faxing for primary care physicians who are on HRM (Hospital Report Manager) Note 1: HRM coming fall 2017 and this will cover many Family Practitioners Note 2: College of Physicians and Surgeons of Ontario (CPSO) moving to in 2018, so will need to develop a plan to incorporate this change once it is available d. Implement Auto-fax e. Create a one page document to detail how Health Records department is trying to get Discharge Summaries out to physicians with tips to increase success rates send out to primary care physicians with Discharge Summaries Reports progress into Discharge Summary Working Group 5. Engage with patients and families to solicit and implement improvement ideas. Health Records Department (Director) to lead Reports progress into Discharge Summary Working Group Physicians included in the cc field within 24 hours of being sent to Health Records Survey patients through MyChart about their satisfaction with the Discharge Summary % improvement in result from baseline by March 31, 2019 Baseline to be collected early in fiscal 2018/19.

15 Quality Improvement Plan 18/19 Repatriation with Markham-Stouffville Hospital AIM MEASURE Quality dimension Objective Indicator Timely To create a defined model for repatriation that is safe, timely, and provides an excellent experience for patients and families. The proportion of patients repatriated to Markham-Stouffville Hospital (MSH) within 2.5 days of initiation of repatriation (Initiation of repatriation defined as when the Sunnybrook Repatriation Office is contacted by the Sunnybrook clinical team). Current performance 67% Q2 17/18 Target for 2018/19 90% Quarterly Target justification The target for improvement reflects that repatriation from Sunnybrook to Markham- Stouffville Hospital is already high performing as compared to repatriation from Sunnybrook to other hospitals, and emphasizes the 2.5 day target for repatriation process duration. Page 1 of 3

16 Change Ideas Accountability Process Measures 1. Improve transfer of accountability (TOA) between Sunnybrook and Markham-Stouffville Hospital The Transfer of Accountability Leads at Sunnybrook and Markham- Stouffville Hospital will jointly oversee the following: a. Optimize process for transfer of accountability for repatriation The Flow Steering and Utilization Committee at Markham-Stouffville Hospital and The Shared Knowledge Working Group of the Sunnybrook Repatriation Taskforce will oversee the following: b. Improve handover between sending and receiving physician i. Create guideline for Sunnybrook to determine correct receiving service at Markham-Stouffville Hospital when initiating repatriation ii. Increase understanding of repatriation principles and processes for Physicians at Sunnybrook and Markham- Stouffville Hospital. Create education package regarding repatriation for Resident orientation/education. The Transfer of Accountability Leads at Sunnybrook and Markham- Stouffville Hospital will jointly oversee a sample audit of compliance with optimized transfer of accountability process, and report progress quarterly to the Sunnybrook Repatriation Taskforce and to the Markham- Stouffville Hospital Flow Steering and Utilization Committee. Compliance with transfer of accountability process Goal for Change Ideas 100% compliance (Baseline not available as not currently tracked) c. Clarify roles and responsibilities. Develop a standard repatriation guide for staff that outlines the repatriation process, roles and responsibilities, and key contact information. 2. Improve communication regarding repatriation with patients and The Shared Knowledge Working Group Staff self-rated level of 6.5 out of 10.0 family of the Sunnybrook Repatriation understanding of (From Sunnybrook Taskforce and the Flow Steering and repatriation staff survey The Shared Knowledge Working Group of the Sunnybrook Repatriation Utilization Committee at Markham- regarding Taskforce and the Flow Steering and Utilization Committee at Stouffville Hospital will oversee a staff repatriation, Markham-Stouffville Hospital will jointly oversee the following: survey to measure retention of administered in a. Educational outreach to ensure staff are using consistent and educational outreach. Survey results 2016) appropriate terminology when discussing repatriation with will be reported to the Sunnybrook n=85 staff patients and families Repatriation Taskforce and to the respondents b. Co-design with patients and family members a comprehensive Markham-Stouffville Hospital Flow repatriation information package for patients and families. Steering and Utilization Committee. Target: 7.5 out of 10.0 Page 2 of 3

17 Change Ideas Accountability Process Measures Goal for Change Ideas 3. Understand patient and family experience of repatriation The Shared Knowledge Working Group Patient and family Target to be of the Sunnybrook Repatriation satisfaction with determined. The Shared Knowledge Working Group of the Sunnybrook Repatriation Taskforce will oversee the repatriation process Taskforce will oversee the following: measurement of patient and family Create a plan for measuring patient and family experience of satisfaction with repatriation, and will Measure of repatriation and assess patient and family satisfaction with the report results quarterly to the satisfaction to be process of repatriation. Design quality improvement initiatives Sunnybrook Repatriation Taskforce defined in alignment based on patient and family feedback. and to the Markham-Stouffville Hospital Flow Steering and Utilization Committee. with Canadian Patient Experience Survey (CPES) and National Research Council (NRC) Health standard method for displaying survey results ( top box scoring ). Page 3 of 3

18 AIM Emergency Department Length of Stay for Non-admitted Patients: Quality Improvement Plan 18/19 Quality dimension Object ive Indicator Current performance Target for 2018/19 Target justification Timely Reduce length of stay for non-admitted patients in the Emergency Department. MEASURE 90th percentile Length of Stay for all Non- Admitted patients 9.0 hours Oct 17, 2017 YTD 7.7 hours by March Since the target was not met last year, we are keeping it the same. The target is an ambitious improvement of approximately 15% from our current performance. CHANGE Change Ideas Physician Initial Assessment 1 A number of initiatives will be reviewed, tested (if necessary) and introduced when appropriate to improve flow so that new patients can be seen by an Emergency Department physician sooner after arrival to the Emergency Department: Increased nurse time in the Ambulatory area Adjusted start time for the Triage nurse(s) Process for CCL (Clinical Care Lead) to work more closely with Bed Flow staff Flowing patients more proactively from triage into the department, and from the department to the ward Improving bed sign-over times (including porter and environmental services processes) Facilitating ambulatory patients waiting in the waiting room when appropriate Moving appropriate stretcher patients into a chair Accountability Chief, Emergency Department, and associated team members will oversee the review and implementation of these initiatives. Process Measures Physician Initial Assessment 4.7 hours (Oct 17, 2017 Year to Date) Goal for Change Ideas 3.7 hours Average by Q4 2018/19 1 This indicator measures the time interval between the earlier of triage date/time or registration date/time and the date/time of physician initially assesses the patient in the emergency department.

19 Change Ideas Accountability Process Measures Goal for Change Ideas Consult Arrival 1. A. Report new consultation 2 time measures (from consultation request Director of Medical Affairs will provide Complete monthly reporting of 100% monthly reporting date/time to patient discharge home date/time) for the eight most reports on a monthly basis new consultation time frequent consulting services to the Department Chiefs measures of the eight most Director of Medical Affairs will collect the frequent consulting services 1. B. Solicit feedback from Department Chiefs feedback received from Department Chiefs. Together with the Chief of Emergency Department, the Director of Medical Affairs will consider the feedback received and Convene meeting of relevant stakeholders to further discuss the suggestions made for Present findings, recommendations for improvements and progress 2 In the Emergency Department, a consultation is when an emergency medicine explore the suggestions made for improving improving consult times and updatesto the Medical physician contacts another physician (specialist or otherwise) for advice or consult times with appropriate stakeholders. implement changes Advisory Committee at least intervention regarding patient care. twice during 2018/ A. Complete implementation of Phase 2 of HERMES 3 trial by April 30, 2018 with ability to: i. Track the following psychiatry consult time metrics Consultation request Bedside arrival Staff physician contacted Decision made, and Disposition/discharge ii. Offer a new interactive interface between HERMES and the consultant; and iii. Implement a new peak hours FAST TRACK protocol. Chief of Emergency, in partnership with the Department of Psychiatry, Psychiatry Emergency Services Director, and chief residents are leading the pilot. Emergency Department Information Technology Lead will assist with data collection. Chief of Emergency, Executive Vice President/ Chief Medical Executive and Director Medical Affairs will review and report on results. Report to the Medical Advisory Committee on the outcome of the pilot and make recommendations regarding roll-out and establishing targets for other services. Present outcomes from the pilot to Medical Advisory Committee by June 30, Develop roll-out timeline and targets for other services by October 31, B. Review and analyze the consultation data from Phase 2 and recommend changes to improve consultation times by June 30, HERMES is a pilot project using a new iphone application measuring very specific time intervals in the consultation process. The data can then be used to make improvements in time from consultation request to consultation. 3. Partner with Clinical Champions to implement improvement opportunities Chief of Emergency, Executive Vice Implement new process(es) in Other services, as appropriate, in other services. President/Chief Medical Executive, Director other services and report to to set Consult arrival time Medical Affairs and Emergency Department Medical Advisory Committee targets by December 31, Information Technology Lead will partner on results with Clinical Champions in consult services to roll-out improvements. Implement new process(es) and begin measurement by January 31, 2019 (dependent on availability of quality data).

20 Change Ideas Accountability Process Measures Goal for Change Ideas Diagnostic Imaging Complete full establishment of the Emergency & Trauma Radiology Division (ETRD) with overnight reporting by hiring the last member of this ETRD staff radiologist team by January Change led by Head of the Emergency & Trauma Radiology Division and Chief, Medical Imaging Rollout and performance metrics will be conveyed at the Emergency Department Quality Improvement Plan meetings. Percentage of finalized reports within 4 hours of exam completion between 10pm- 8am 50% improvement on weekends compared to baseline (will be measured in first half of 2018). Analyse the need to expand current on-site ultrasound technologist coverage (Monday - Friday 8:00 a.m. up to 12:00 a.m.) to Monday Sunday 24 hours a day. Analyze if change would improve patient care and total length of stay for non-admitted Emergency Department patients. The key is to analyze number of ultrasound orders on off-hours (between midnight and 8 am and on weekends and statutory holidays). Change led by Head of the Emergency & Trauma Radiology Division and Director, Medical Imaging. Progress to be shared at Emergency Department Quality Improvement Plan meetings. In July 2018, analyse 6 months of demand from January Within three (3) months of completion of analysis, develop changes ideas and times lines to support new targets. Present business case and seek approval from Senior Leadership Team to Change led by Director, Medical Imaging. Emergency Department CT 90% of CT turnaround times < increase CT (computerized tomography) technologist staffing to two staff per after-hour shift as part of initiative to improve turn-around time of Endovascular Treatment (EVT) in stroke management. Progress to be shared at Emergency Department Quality Improvement Plan meetings. turnaround times in afterhours 4:00 hours in after-hours Implement the Senior Leadership Team approved construction project of building a point-of-care radiology reading room in Emergency Department to improve radiologist support in an acute clinical setting. Explore and analyse patient transportation support for safe, timely and efficient movement of patients from Emergency Department to Diagnostic Imagining locations allowing patients for their tests and treatment procedures Change led by Director, Medical Imaging Progress to be shared at Emergency Department Quality Improvement Plan meetings. Corporate Planning and Development will assign a Project Manager to start this project. Change led by Director of Medical Imaging, Director of Environmental Services Radiologists of various applicable sub-specialties, including Emergency & Trauma Radiology Division, interpreting and consulting in the this shared reporting room Patients transports are well supported by porters on a timely basis Provide point of care radiological consult in Emergency Department. Completion date to be determined pending assignment of Project Manager. Increase alignment of Patient arrival times align with appointment times.

21 Change Ideas Accountability Process Measures Goal for Change Ideas Ambulance offload time (90th percentile Transfer of Care time baseline 82 minutes, overall goal = 45 minutes) Phase 1/Input: Improve the process for knowing when an Ambulance has arrived. Develop kiosk for Ambulance paramedics self-check-in. On arrival, the Ambulance paramedics would check-in using the kiosk and their unique Trip Number. This would alert the triage nurses to the ambulance arrival and allow them to call the crew for triaging. Triaging is the first step for the patient to be identified by the Emergency Department system and allows them to be placed in appropriate areas based on their severity. Steps for this change idea include: 1. Train Ambulance personnel on Check-in Kiosk 2. Implement Kiosk Trial Period Nursing Education 3. Rapid PDSA (Plan-Do-Study-Act) cycles to improve process Timeframe: Ambulance Kiosk Live Date: Jan 1, 2018 Kiosk Trial Period: Jan March, 2018 Time points measured: 1. Time from Ambulance Arrival to Kiosk Check-in 2. Time from Kiosk Check-in to Patient Triage Ambulance Check-in Kiosk developed by the Emergency Department Information System Administrator. Overseen by Quality Improvement staff. Leaders for Change Idea steps are: 1. Toronto Paramedic Services Stakeholder 2. Emergency Department Clinical Educator 3. Quality Improvement staff Step leaders above will report progress at every other monthly Emergency Department Quality Improvement Plan meeting. Time from Ambulance Arrival to Patient Triage 90 th percentile Source: Patient Distribution System managed by the Toronto Paramedic Services. Time from Ambulance Arrival to Patient Triage (90 th percentile): - Baseline Q1 2017/18: 25 minutes - Target Time (by June 2018): 14 minutes (45% reduction) Compliance measure: Percentage correctly inputting Trip Number Phase 2/Throughput: Transitional Zone to be Developed by the Percent of Ambulance patients Baseline Q1 2017/18: Chief of Emergency, Trauma/Emergency placed on offload delay*. 58.4% Improve the flow of Emergency Department patients to increase stretcher Department Advanced Practice Nurse and Target: 29.2% (50% reduction) availability. Maximizing the stretcher availability will improve the ability to Quality Improvement staff. transfer ambulance patients into the Emergency department as well as general flow. A. Emergency Department Transitional Zone. Develop an area for ambulance patients waiting to be transitioned into the Emergency Department, so that they will not be held on offload delay*. During offload delay, a patient will remain with the ambulance paramedics and this delays both the patient s care and the time that the paramedics remain in the hospital. This area would also serve to help bed flow and would be for eligible patients already seen by a physician and awaiting tests. *Offload delay is defined as when a patient must remain with the Ambulance paramedic after being triaged because there is not yet an Emergency Department nurse available to complete the transfer. Report progress at every monthly Emergency Department Quality Improvement Plan meeting. Source: Emergency Department Information System. Includes all patients that arrive by ambulance, excluding trauma, stroke or resuscitation patients.

22 Phase 2/Throughput: (continued) Change Ideas Accountability Process Measures Goal for Change Ideas B. Develop Transitional Protocol for nurses to help guide moving patients to the appropriate areas, including: Ambulance patients to be moved to chair/waiting area Ambulance patients to be moved to Transitional Zone Emergency Department patients in a stretcher to be moved to a chair or the Transitional Zone Transitional Protocol to be developed by the Chief of Emergency, Trauma/Emergency Department Advanced Practice Nurse and Quality Improvement staff. Report progress at every other monthly Emergency Department Quality Improvement Plan meeting. Percent compliance = numerator: number of patients moved to Transitional Zone/Chairs denominator: eligible patients based on protocol criteria Data source: audit 80% of eligible patients moved to Transitional Zone or to chairs Phase 2/Throughput: (continued) C. Registration Flow: Registration occurs after triage and is necessary for the patient to be placed in the Emergency Department information system and obtain health record information. Perform flow mapping and time analysis of the current registration process. Implement PDSA (Plan-Do-Study-Act) cycles to improve the process. Phase 2/Throughput: (continued) D. Transfer of Care for Emergency Department Admitted Patients: For admitted patients, an Emergency Department nurse must give the unit ward nurse information through a process of Transfer of Care. The goal of this phase is to perform flow mapping and time analysis of the current transfer of care process. If admitted patients have a delay to being transferred to the ward, this impacts the general Emergency Department flow as the stretcher that the admitted patient occupies is blocked for other use. Therefore there will be PDSA (Plan-Do-Study-Act) cycles implemented to improve the process and transfer of care time for admitted patients and increase the stretcher availability in the Emergency Department. Registration flow improvement led by the Emergency Department Administrative Coordinator and Quality Improvement staff. Report progress at every other monthly Emergency Department Quality Improvement Plan meeting. Transfer of Care for Emergency Department Admitted Patients developed by the Chief of Emergency, Trauma/Emergency Department Advanced Practice Nurse and Quality Improvement Report progress at every other monthly Emergency Department Quality Improvement Plan meeting. Time from Triage completion to Registration completion - 90 th percentile Ward Ready to Discharge Time - 90 th percentile. Ward ready time is defined as the time that a bed is available on an inpatient unit. Discharge time is defined as the time a patient leaves the Emergency Department and is removed from the Emergency Department Information System. Triage completion to Registration completion time (90 th percentile): - Baseline Q1 2017/18: 26 minutes - Target Time: 18.2 minutes (30% reduction) Source: Emergency Department Information System. Ward ready to discharge (90 th percentile): - Baseline (April July 2017): 2.1 hours - Target Time (by Dec 2018): 1.2 hours (45% reduction) Source: Emergency Department Information System.

23 Compassion Quality Improvement Plan 18/19 AIM MEASURE Quality dimension Objective Indicator Patient- Centred Improve the patient experience by enabling compassionate person centred care. % positive response* in the overall Respect and Dignity Dimension (made up of nine questions) from the Canadian Patient Experience Survey in the Women s & Babies, Trauma, Cancer, Community, Cardiac, and Holland programs. The Dimension is defined in four sectors: 1. Communication with Nurses - This measure is a composite measure of three questions measuring the patients' responses to whether they were treated by nurses with courtesy and respect, were listened to, and explained things in an understandable way. 2. Communication with Doctors Three questions that describe how well doctors communicate with patients. 3. Emotional Support - One question that describes the emotional support provided for anxieties, fears or worries during their hospital stay. 4. Involvement with Decision-making Two questions that describe how well patients and families are involved in decision-making. * The questions are all on a four point scale (never, sometimes, usually, always), and the % positive score is only used for the always response. Current performance Target for 2018/19 Target justification 67.9% 72% A minimum of 72% was selected because it is the 2016/17 Ontario Inpatient Academic Q1 17/18 By Q4 2018/19 Hospital average. It will be a stretch target as it is a relative improvement of 6%. As well, our results from the previous six quarters had a fairly narrow range from 66.1% to 69.0%.] The change initiatives are well aligned with Sunnybrook s Person Centred Care Strategy which is currently monitoring 4 of the 9 questions included in the Respect and Dignity dimension. Other organizational alignments include: Newly launched quarterly Quality Hub data reviews Introduction of Quality Conversations held at the local unit, to review data and create action plans Focus on the comments from patients and families in the surveys, to help staff understand survey scores Recognition that compassion for staff is as important as compassion for patients and families

24 Change Ideas Methods (Accountability & Reporting) Process Measures Goal for Change Ideas The goal of the Compassion work on the hospital s quality strategic plan The accountability of this change idea will be held 1. All job postings to reflect 1. December 2018 is to lead in valuing the humanity and vulnerability of our staff, patients by Director of Human Resources and person centred care language and families through implementing innovative initiatives promoting the Organizational Development and Leadership, 2. All Interview tools to be 2. December 2018 humane aspects of healthcare. We will accomplish this by: 1. Advance a culture of compassion 2. Support health care providers to deliver compassionate care 3. Support staff and physician wellness. Manager of Organizational Development and Director of Interprofessional Practice and will be monitored quarterly through the Person Centre Care Committee, which will include a report on the percentage completion for: Job descriptions updated with person centred care questions and language 3. Performance appraisals to include person centred care language in communication competency 4. All Sunnybrook Leadership ADVANCE A CULTURE OF COMPASSION Attract, recruit and retain a workforce committed to consistently Interview guides Institute programs to include approaching patients, residents, and family in a person centred way that Performance appraisals person centred care principles demonstrates compassion for the emotional experiences of receiving ( ) health care services. It is recognized that every Sunnybrook staff person 5. Corporate orientation to makes a difference in patient and family experiences of high quality care. include person centred care learning module, with person 1. Revise job descriptions to recruit talent committed to this values- centred language and stories based approach to care throughout the orientation 2. Revise behavioural-based interview guides to enable applicants to program. describe their strengths in this area 3. Update performance appraisals with accompanying conversation guides to enable managers to review and discuss behaviours and accountabilities to continuously improve integration of compassion in daily care 3. December March December 2018 STAFF ENGAGEMENT Engagement is described as a positive attitude held by employees towards the organization and its values. It is a two way relationship and organizations must work to develop and nurture engagement. One of the strongest drivers of engagement is a sense of feeling valued and involved. Engagement is heightened by compassion and commitment increases when staff have an opportunity to both experience and express compassion. As an organization, we wish to increase our understanding of our staff s level of engagement by measuring drivers of engagement, including compassion. The Director of Human Resources will lead the second cycle of the Staff and Physician Engagement Survey, which will be updated to include new questions regarding what, helps staff to feel valued and involved. The Director of Human Resources will lead subsequent monitoring of completed team action plans. Implementation of the updated Staff & Physician Engagement Survey by December Team Action Plans developed The new Drivers of Engagement questions will be used to create a baseline to be monitored over time. 100 % of Team Action Plans completed by March Add questions measuring drivers of engagement to the current Staff & Physician Engagement Survey. Results from the Staff and Physician Engagement Survey inform the Wellness Strategy. Additionally each leader is provided with their own results, and is required to develop a shared team action plan based on the review of the results.