2018/19 QUALITY IMPROVEMENT PLAN. Markham Stouffville Hospital Indicators Posted: April 1 st, 2018

Transcription

1 2018/19 QUALITY IMPROVEMENT PLAN Markham Stouffville Hospital Indicators Posted: April 1 st, 2018

2 Overview of Markham Stouffville s - Quality Improvement Plan 2018/ /19 Quality Improvement Plan Quality in Action Our Quality Improvement Plan (QIP) outlines the hospital s priorities in key area in the upcoming year and sets the stage for establishing MSH as an organization committed to achieving a fully functional culture of safety and quality across the organization. Our areas of focus have been chosen to demonstrate our commitment to improving safety for staff and patients, fostering patient centeredness and delivering high quality services. This plan highlights key initiatives and builds on earlier plans to further improve our performance. With this in mind, the theme for our 2018/19 QIP is Quality in Action 2

3 Overview of Markham Stouffville s Quality Improvement Plan 2018/19 Effective 1. Readmission for stroke 2018/19 Indicators: 2018/19 Quality Improvement Plan Patient- Centred 2. Would you recommend? (ED) Efficient 3. Alternative level of care rate 4. Implement two choosing wisely recommendations in selected programs/specialities every fiscal year until FY20/21 5. Rate of hospital acquired cases of Clostridium Difficile infections 6. Medication reconciliation (discharge) for all patients Safe 7. Overall incidents of workplace violence Timely 8. High Alert Medication Errors with harm 9. Number of patient falls which caused harm (mild, moderate) 10.Repatriation of MSH patients from Sunnybrook Health Science Center within 2.5 days 3

4 2018/19 Quality Improvement Plan Issue 1 Effective Transitions 1. Risk-adjusted 30-day all-cause readmission rate for patients with stroke (QBP cohort) back to MSH Goal: Reduce 30-day all-cause readmission for patients with stroke (QBP cohort) 8.5% 7.6% The measuring unit of this indicator is an admission for stroke, as defined for the QBP. Results are expressed as risk-adjusted all-cause 30-day non-elective readmission rate among patients admitted back to MSH. 1. Improve timely follow-up of all patients with stroke in MSH's stroke clinic with clear understanding & follow through of each readmitted case 1.1 Standardize, Plan, Do, Study & Act (Reflect) on referral, delivery and quality of patient followup in MSH stroke clinic 1.2 Develop a process to follow-up with each readmitted stroke patient to understand gaps in current process 1.3 Establish a task force to Plan, Do, Study & Act on identified gap(s) in short duration, high interval 'meet ups' 4

5 2018/19 Quality Improvement Plan Issue 2 Patient & Family Experience 2. Improve patient experience in the Emergency Department (ED) Goal: Improve patient experience - "Would you recommend this Emergency Department to your friends and family?" 67.0% 64.2% 2. Improve timely and empathic communication with our patients & family members 2.1 Develop and implement standardize staff training on patient relation/customer service, de-escalation skills & application 2.2 Develop a process to embed purposeful patient rounding' at set frequencies Percentage of respondents who responded positively to the following question from the Ontario Emergency Department Patient Experiences of Care Survey (EDPEC): "Would you recommend this emergency department to your friends and family?" 5

6 Issue 3 Access to Right Level of Care 3. Reduce Alternate Level of Care (ALC) rate Goal: Reduce unnecessary time spent in acute care 2018/19 Quality Improvement Plan 12.7% 15.6% This indicator measures the total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed census data. 3. Improve the delivery of timely restorative care support and have a consistent management process for our ALC cases 3.1 Launch of the Restorative Care Center (RCC) with timely restorative care services to support transition of patient back home 3.2 Pilot the role of an ALC Co-ordinator to manage a) timely service delivery, b) liaison with other hospital programs in the transition of ALC patients to the next care destination. 3.3 Standardize the criteria for ALC designation with the formulation of an consented ALC algorithm 6

7 2018/19 Quality Improvement Plan Issue 4 Efficient Use of Resources 4. Implement two Choosing Wisely recommendations every fiscal year until FY 2020/21 Goal: Adopt two Choosing Wisely recommendations in selected programs/ specialities every fiscal year until FY 2020/ Reduce unnecessary tests, procedures, medication or treatment by implementing two Choosing Wisely recommendations every year until FY 2020/ Establish a physicians champion and a dept./unit leader to co-lead each of the two recommendations 4.2 Thorough analysis of current gaps and countermeasures based on the scientific method 4.3 Establish a task force to Plan, Do, Study & Act on identified gap(s) in short duration, high interval 'meet ups' Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective care choices. Developed by professional societies, these recommendations identify tests and treatments commonly used in each specialty that are not supported by evidence, and could expose patients to harm. 7

8 2018/19 Quality Improvement Plan Issue 5 Effective and Consistent Practices (Safe) 5. Reduce hospital acquired infection rates Goal: Reduce Clostridium difficile Infection (CDI) rate Establish a consistent discharge cleaning protocol and clean equipment tagging process in Clostridium difficile (C. diff) hot-spot areas of the hospital 5.1 Consistent discharge cleaning protocol in selected areas in the hospital with high C. diff cases 5.2 Clean equipment tagging process in selected areas in the hospital with high C. diff cases. Number of hospital acquired Clostridium difficlie infections / Number of patient days in a defined period, standardized by Establish a task force to Plan, Do, Study & Act on identified gap(s) in short duration, high interval 'meet ups' 8

9 Issue 6 Medication Safety (Safe) 6. Improve the rate of medication reconciliation at discharge 2018/19 Quality Improvement Plan Goal: Increase the proportion of patients leaving the hospital with a best possible medication discharge plan 80.0% 6. Phased approach to improve medication reconciliation process in five key area/ specialties; surgery, childbirth & children's services, palliative, psychiatry, and Uxbridge 52.4% Percentage of patients discharged with medications reconciled (in the Meditech Discharge Summary Writer) as a proportion of the total number of patients discharged home (reviewed quarterly). 6.1 Utilize a phased approach to engage physicians in education and embedding medication reconciliation into their discharge planning process 6.2 Consult and collaborate with each specialty to deploy medication reconciliation into existing workflow through the utilization of a structured feedback/monitoring process 6.3 Incorporate medication reconciliation report/review into existing communication venues 6.4 Establish a task force to Plan, Do, Study & Act on identified gap(s) in short duration, high interval 'meet ups' 9

10 Issue 7 Safe Environment (Safe) 7. Decrease the overall incidents of workplace violence Goal: Reduce the number of incidents of workplace violence 2018/19 Quality Improvement Plan Improve our staff's knowledge and application of crisis prevention intervention in focused areas 7.1 Increase the level of a) crisis prevention intervention training (CPIT) for staff and b) mock codes in focused areas to ensure knowledge from the training translates into application 7.2 Establish a timely process for review and reconciliation of reported cases with escalation protocol at all level of management This indicator measures the number of reported workplace violence incidents by hospital workers (as defined by OHSA) within a 12-month period. 10

11 2018/19 Quality Improvement Plan Issue 8 Medication Safety (Safe) 8. High alert medication errors which caused harm Goal: Reduce percentage of High alert medication errors which caused harm 6.0% 8.5% 8. Improve the consistency of understanding, delivery, and review of gaps in the medication administration of high alert medication (as defined in MSH's policy) 8.1 Standardize the process of administering, timeliness & communication of (stat) high alert medication in our emergency departments This indicator measures the percentage of reported high alert medication error incident (as defined in the MSH policy) which caused harm (level 2+) to the total number of reported medication errors incidents in the same reporting period. 8.2 Reoccurring training for nurses of the practical medication administration of high alert medications (list of medication, independent double checks, administration process) 8.3 Standardize scanning protocol of pharmacy orders to ensure timely delivery of medication before administration 8.4 Standardize training module for reporting of medication errors for all staff 11

12 2018/19 Quality Improvement Plan Issue 9 Minimize Harm to our Patients (Safe) 9. Patients falling at MSH which caused harm Goal: Reduce the percentage of patients falling in MSH which caused harm 26.0% 37.5% This indicator measures the percentage of reported falls incidents which caused harm (level 2+) to the total number of reported fall incidents in the same reporting period. 9. Pro-active management of fall prevention tactics, gaps identified, and timely follow-up on each incident with our patient, family, and staff 9.1 Pro-active monitoring of falls prevention strategies in high occurrence areas 9.2 Pilot of falls prevention 'meet-ups' in high occurrence areas to a) review the data & environmental factors & b) test countermeasures to address specific gaps 9.3 Standardize a timely follow-up process (after the occurrence of a fall) to address gaps and communicate next steps to the patient, family and staff 12

13 2018/19 Quality Improvement Plan Issue 10 Timely Transition 10. Improve repatriation of MSH patients from Sunnybrook Health Science Center (SB) within 2.5 days Goal: 90% repatriation of MSH patients from Sunnybrook Health Science Center (SB) within 2.5 days 90.0% 85.0% This indicator measures the percentage of MSH patients repatriated from SB within 2.5days started after initial contact to the SB repatriation office. 10. Improve transfer of accountability (TOA) between Sunnybrook and Markham-Stouffville Hospital, timely communication with patients & family along with a documented understanding of their experience 10.1 Standard guideline for repatriation, role clarity and documented understanding by physicians 10.2 Staff educational outreach to ensure retention of repatriation process 10.3 Patient & family designed information package and timely capture & review of patient experience information 13