2017/18 Quality Improvement Plan

Transcription

1 2017/18 Improvement Plan Aim Change Enough information at discharge. Readmissio ns CHF Readmissio ns COPD Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? Risk-adjusted 30- day all-cause readmission rate for with CHF (QBP cohort). Risk-adjusted 30- day all-cause readmission rate Survey respondent s CHF QBP Cohort COPD QBP Cohort /CPE S/ Quarter April-June 2016 (QI FY2016/1 7) DAD/Janu ary December 2015 DAD/Janu ary % (7C Surgery) 72% 5% % 17.7% 10% 16.72% 15% 10% Planned t initiatives 1. Implement practice of posting monthly data for enough information when you left the hospital indicator. Pilot on 7C Surgery. This will include a minimum of a weekly focus at unit Huddle. 2. Develop Discharge Instruction Package for surgical. (Focus: general and orthopedic surgery). 3. Develop process to ensure discharge instructions are prepared and given 2-3 days in adv. 1. Implement pilot Navigator role for CHF. Role to develop follow up phone calls program post discharge. 1. Develop new patient education materials for COPD. 1. Create working group on pilot unit. 2. Identify lead to post unit level monthly. 3. Include metric in daily huddle discussion. 4. Utilize forum to identify t strategies and action planning. 1. Working group to conduct literature review of best practices related to discharge instructions for surgical. 2. Conduct focus group with to identify key areas of interest & concern. 3. Draft discharge Instruction materials. 4. Pilot new tools & gather input. 5. Evaluate Change, Spread approach & model. 1. Working group to map current state related to discharge teaching. 2. Identify barriers and opportunities to earlier teaching opportunities. 3. Identify triggers to cue staff to discharge education date. 4. Evaluate, Change. Spread. 1. Program team to develop role profile. 2. Recruit staff member. 3. Orient individual, define responsibilities and roles. 4. Define measures 5. Evaluate role. 1. Create working group of include internal stakeholders, COPD Coordinator, Pulmonary Rehab, % of staff who are aware of indicator and their contribution to improving unit. % implemented and evaluated. % of discharges where instructions/dischar ge teaching done >2 days in adv % pilot role implemented. % New COPD Handbook & reference for 1

2 Aim Change Access to right level of care Readmissio ns Mental Health Alternate level of Care for with COPD (QBP cohort). Rate of psychiatric (mental health and addiction) discharges that are followed within 30 days by another mental health and addiction admissions. Total number of alternate level of care (ALC) days contributed by ALC within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed 100 readmissio ns 100 inpatient days/all In December 2015 OMHRS /DA D WTIS, CCO, BCS, MOHLTC /Quarter/ July Septembe r 2016 (Q2 FY 2016/17 report) 13.5% 12.8% 5% Improvemen t Planned t initiatives 1. Conduct analysis of mental health readmission data to determine key patient populations most at risk of readmission. 2. Develop Patient Discharge Passport and family care plan % Budget 1. Evaluate Short stay transitional care programming. Patient & Family Advisors 2. Conduct external scan & literature review of best practices in COPD discharge resources. 3. Draft materials in collaboration with & families. 4. Educate teams to new resources. 5. Evaluate & update as required. 1. Mental Health Program Team to conduct analysis of discharge diagnosis, 2. identify most common/high risk diagnoses categories, 3. Prioritize list based on risk. 4. Develop focused program to address needs based on analysis. 1. Establish Mental Health Readmission working group, 2. Conduct external scan related to discharge information tools & resources. 3. Draft passport in collaboration with all stakeholders, and families. 4. Implement & evaluate. 1. Participate in established LHIN Based Committee. 2. Co-design model. 3. Collaborate in developing systems and processes for access to beds. 4. Implement solution. 5. Evaluate program. materials developed & implemented. % analysis complete % Discharge Passport Completed. # of Halton Healthcare referrals to program. # of who successfully transitioned to Short Stay Beds. for 10% t 25% reduction 2

3 Aim Change Patient Centered Patient Centered Palliative Care Person Experience census data Percent of palliative care discharged from hospital with the discharge status "Home with Support". "Would you recommend this emergency department to your friends and %/Palliative %/Survey Responden ts /DA D/Fiscal Year April March 2016 ED PEC/Quar ter April- June 2016 (Q1 FY 87.34% 91% 5% 56.9% 58.6% (3% t) NRCC Planned t initiatives 2. Participate in the successful integration of the new LHIN Behaviour System Navigator (BSN) Role. 3. Evaluate new Daily Bed Meeting process and updated Patient Flow Navigator role. 1. Validate current data capture and ensure indicator available to care teams at all three sites. 2. Conduct environmental scan to describe services available in each community. 3. CCAC Coordinators to be present at Discharge Planning team rounds across all acute and rehab areas. 1. Evaluate recently established Volunteer Check In role at OTMH and consider for spread at MDH & GH. 1. Introduce role to Halton Healthcare. 2. Delineate processes with new role and existing discharge planning processes. 3. Collaborate with the BSO (Behavioral Supports Ontario) team and other service providers to ensure success of role. 1. Patient Flow Subcommittee group to evaluate current bed meeting model. 2. Identify opportunities to standardized agenda and scripts. 3. Identify tools to track barriers to discharge, 4. Follow up with care teams. 5. Evaluate. 1. Leverage current Palliative Care Committee to act as steering committee. 2. Explore current data capture in coding process. 3. Identify mechanism to identify cases not correctly coded. 4. Validate. 5. Share unit level data with teams. 1. Palliative Care Steering Committee to collaborate with CCAC to conduct and analyze external scan. 2. Participate in the Regional Palliative Care Network structure to develop care delivery models. 1. Internal working group to evaluate current participation of CCAC. 1. Assemble working group from Volunteer Services and ED. 2. Create evaluation framework. 3. Conduct evaluation and implement adjustments as required. # of where BSN involved, successfully placed. Average daily discharge time. % validation exercise completed. % complete of scan. % of units with CCAC care coordinator present at rounds. % complete evaluation. for Average discharge time 1 hour earlier. 3

4 Aim Change Patient Centered Safe Person Experience Safety family?" 2016/17) National Average. 60.2% "Would you recommend this hospital to your friends and family?" (Inpatient care) reconciliation at admission: The total number of with medications reconciled as a proportion of the total number of %/Survey Responden ts total number of admitted /Ho spital admitted CPES/Qua rter April- June 2016 (Q1 FY 2016/17) Hospital Collected data/quar ter 70.2% 72.2% (3% t) 71% (Oct 2016) NRC National Average 70.9% 78% 10%. Planned t initiatives 2. Evaluate existing ED Dashboard available to internal hospital stakeholders and consider implementation of a Public Wait Time Dashboard. 1. Introduce Staff Driven Code of Conduct- Patient Experience Best Practice. Implement on 1 unit at each of the three hospital sites. 2. Evaluate Bedside Handoverprogram to ensure compli across all clinical areas. 3. Evaluate Hourly Rounding- Program on 3S and 5S and develop plan for spread. 1. Establish clear roles, responsibilities and accountabilities in the Reconciliation Policy and Procedure for various care providers (including but not limited to, nursing, charge nurse, pharmacist, and prescriber). 4. Recommend for spread as appropriate. 1. ED Dashboard working group, to conduct evaluation of current internal view. 2. Conduct external scan of Public Facing ED dashboards, Identify and validate quality indicators. 3. Identify technical and communications solutions. Publish. 4. Evaluate. 1. Establish unit level working group. 2. Using existing best practice tools, conduct a series of engagements with staff to define unit based code of conduct. 3. Pilot, publish on unit, and evaluate impact. 4. Spread. 1. Reassemble implementation group. 2. Conduct current state analysis of practice. 3. Identify barriers & implement changes. 4. Monitor and complete implementation to all appropriate areas. 1. Reassemble implementation group. 2. Conduct current state analysis of practice. 3. Identify barriers & implement changes. 4. Monitor and complete implementation to all appropriate areas. 1. Establish small working group with stakeholders involved. 2. Draft a set of roles and responsibilities. 3. Embed into revised policy. 4. Educate all team members. 5. Implement policy & practices. 6. Evaluate & monitor. % implementation complete of public ED Wait Time Dashboard. % implementation complete % compli to practice. % compli to practice for 4

5 Aim Change Safety admitted to the hospital reconciliation at discharge: Total number of discharged for whom a Best Possible Discharge Plan was created as a proportion the total number of discharged. total number of discharged /Ho spital admitted Hospital Collected data/quar ter Collecting Baseline 10% from 10% t from Planned t initiatives 2. Explore and pilot the use of Visibility software to help indicate and communicate medication reconciliation status for in a select care area. 3. Evaluate Pharmacy Technician Model implemented in Define model to audit discharge medication reconciliation. 2. Launch new electronic discharge medication reconciliation form. 1. Reconciliation Committee with identify key steps in the medication reconciliation process 2. Embed key steps of medication reconciliation in Visibility 3. Determine a pilot unit/department 4. Educate and implement the use of Visibility for identifying medication reconciliation status for each patient 5. Evaluate success of pilot over a 2 month period using compli reports available through Visibility 6. Revise process as necessary and spread across organization. 1. Pharmacy team to create evaluation tool. 2. Conduct review& analyze results. 3. Implement changes to role based on evaluation. 4. Consider for spread. 1. Conduct external scan for audit framework. 2. Evaluate models. 3. Select framework. 4. Implement & evaluate. 1. Utilizing existing med rec working group develop new electronic form, 2. Pilot new tool in one area. 3. Evaluate and change as required. # of BPMHs collected by tech per day % audit framework developed. % new form implemented. for 5

6 Aim Change Timely Timely access to care/service Total ED length of stay (defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED) where 9 out of 10 complex completed their visits Hours/Pati ents with complex conditions NACRS/C alendar year Corp 7.1h OTMH 9.7h MDH 6.62h GH 5.87h 7h Below Provincial Planned t initiatives 1. Implement Physician Directed Rounds Program on three inpatient medical units. Evaluate and consider for spread. 2. Optimize triage to disposition. Process flow at OTMH ED. 3. Implement and Evaluate New Crisis Nurse Role at MDH. 4. Spread. 1. Establish Patient Flow Subcommittee- Bullet Rounds. 2. Complete current state analysis. 3. Identify barriers to participation, 4. Develop framework for rounds. 5. Implement changes to model. Evaluate & consider for spread. 1. Assemble ED working group, 2. Conduct current state process map, 3. Identify opportunities for t, 4. Implement & change, 5. Evaluate & monitor. 1. Create role profile. 2. Recruit to position. 3. Implement role 4. Evaluate. % of off-servicing of. Baseline. Avg time from Triage to Disposition # of Crisis Nurse consultations. for 6