2018/19 Quality Improvement Plan FINAL

Transcription

1 2018/19 Improvement Plan FINAL AIM MEASURE CHANGE dimensi transitis transitis Enough inmati at discharge. Readmissis Cgestive Heart Failure (CHF) Did you receive enough inmati from hospital staff about what to do if you were worried about your cditi or treatment after you left the hospital? Risk-adjusted 30-day all-cause readmissi rate patients with CHF (QBP cohort). Populati FOCUS # 1 MATERNAL CHILD-three hospitals Survey respdents CHF QBP Cohort /C PES/Q2 DAD/Ja nuary Decemb er % OBS 59.1% 3% 1. Strengthen & Standardize discharge planning processes within the three obstetrical programs. 14.4% 13% 10% baseline 2. Develop & standardize discharge materials obstetrical patients and leverage new DASH MD applicati to publish to mobile phes. 3. Further the implementati of DASH MD App and Discharge Inmati initiative to all Halt Healthcare Surgical Programs. 1. Evaluate use of Rapid Respse and NP STAT Nurse resources and partner with LHIN to optimize use at all sites. 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 educati date. 4. Evaluate, Change. Spread. 1. Working group to cduct literature review of best practices related to discharge instructis obstetrical patients. 2. Cduct focus group with patients to identify key areas of interest & ccern. 3. Draft discharge Instructi materials. 4. Pilot new tools & gather input. 5. Evaluate Change, Spread.approach & model. 6. Post to DASH MD Applicati. 1. Establish tri site working group to cduct internal scan of resources at MDH and GH. 2. Identify materials to be developed. 3. Develop Materials. 4. Work with DASH MD to publish materials to APP. 5. Educate Staff, surge offices. 6. Implement. 7. Evaluate and mitor. 1. Establish tri-hospital site working group with LHIN, Community Care partners. 2. Review current utilizati metrics. 3. Cduct analysis of current state. 4. Identify opportunities. Use of patient whiteboard. # of obstetrical patients Accessing Dash MD website. % spread to other surgical programs. NP STAT Utilizati Rate 90% to be determi ned post baseline. Pending. 1

2 dimensi transitis transitis Readmissis Chric Obstructive Pulmary Disease (COPD) Readmissis Mental Health Risk-adjusted 30-day all-cause readmissi rate patients with COPD (QBP cohort). Rate of psychiatric (mental health and addicti) discharges that are followed within 30 days by another mental health and addicti admissis. Populati COPD QBP Cohort Rate per 100 readmissis DAD/Ja nuary Decemb er 2016 OMHRS /D AD 22.23% 20% 10% baseline % 10% Improvem ent 2. Enhance CHF Patient Educatial Materials engage patients/families in development. 3. Revise CHF Admissi Orderset. 1. Evaluate use of COPD Patient Educati Materials. 1. Cduct an evaluati of the PODS program. 5. Implement and evaluate changes to current processes. 1. Using above group, review current educatial materials. 2. Cduct external scan of best practices. 3. Update materials. 4. Implement. 1. Using above working group, review existing CHF orderset. 2. Cduct best practice review. 3. Cduct process map of current CHF episode of care. 4. Update to reflect best practice. 5. Implement. 6. Evaluate. 1. Using existing COPD corporate working group, and patient focus groups, evaluates impact of educatial materials readmissi rate. 2. Make changes based evaluati. 3. Implement, mitor. 1. Utilize existing mental health ent team to develop evaluati framework Patient Oriented Discharge Summaries (PODS) program. 2. Cduct evaluati of current tools and resources. 3. Implement changes as a result of evaluati. 4. Ctinue to mitor process and readmit rate. % of patients receiving materials Orderset utilizati rate. Orderset utilizati rate. % of patients who received PODS 2

3 dimensi Access to right level of care Patient Centered Alternate level of Care Pers Experience Total number of alternate level of care (ALC) days ctributed by ALC patients within the specific reporting mth/quarter "Would you recommend this emergency department to your friends and Populati Rate per 100 inpatient days/all Inpatients %/Survey Respdents QTIS, CCO, BCS, MOHL TC/Qua rter/ July Septem ber 2017 Q2 ED PEC/Qu arter % Navigator 67.5% 2. Implement Phase 2 of PODS program. 3. Csider implementati of a risk readmissi scoring tool (LOCUS Tool) 14.4% HSAA 1. Develop,implement, evaluate ALC Toolkit. 69.5% 3% ent 2. Formalize Educati of ALC best practice resources. 3. Ctinue to strengthen partnership with THP and LHIN. 1. Complete ED Real time dashboard displays and messaging. 1. Utilize above team to evaluate next patient populati spread of PODS tools. 2. Develop draft tools with stakeholder group. 3. Implement new tools. 1. Using group, cduct external scan of risk assessment tools. 2. Identify tool 3. Explore implementati in small patient populati. 4. Determine assessment model. 5. Implement. 6. Evaluate. 1. Assemble tri hospital stakeholder group, including LHIN partners. 2. Catalogue existing tools and resources. 3. Cduct needs assessment. 4. Explore best practices. 5. Develop tools. 6. Implement. 7. Evaluate. 1. Using above group, create ALC best practice curriculum. 2. Test draft curriculum with all stakeholders. 3. Implement educatial tools into manager/staff orientati. 1. Partner with LHIN & THP to explore opportunities Regial ALC Roles. 1. Using existing ED Real Time Dashboard working group, cduct evaluati of current internal stakeholder view. % implementati completed % of patients who received screening assessment % ALC Toolkit complete TBD % complete TBD % Dashboard complete. # of complaints received. 3

4 dimensi Patient Centered Pers Experience Populati family?" 2. Define external indicators and labels. 3. Create ancillary resources. 4. Define technology soluti. 5. Implement new public view 6. Evaluate impact patient satisfacti scores. "Would you recommend this hospital to your friends and family?" (Inpatient care) %/Survey Respdents CPES/Q % 88% 3% Improvem ent 2. Spread Team Charter Best Practice to ED teams at all three hospitals. 1. Incorporate Experience Excellence Training into General Orientati and spread to OTMH Medicine units 5C, 6C and Georgetown Medical Surgical Unit. 2. Formalize a Halt Healthcare Patient Experience Framework, strategy and mitoring structure the Patient Experience Strategy. 3. Ctinue to evolve the Patient and family Advisor role/council. 1. Engage Team Charter working group. 2. Invite new tri-emergency Department represents to working group. 3. Share framework. 4. Implement methodology. 5. Draft new team charters. 6. Implement new charter. 7. Evaluate. 1. New working group to cduct review/evaluati of training. 2. Update materials based feedback. 3. Implement training. 1. Create new Patient Experience Steering Committee-Terms of Reference 2. Cduct external scan of PE Models and frameworks 3. Cduct internal stakeholder csultati 4. Draft new Framework 5. Solicit Feedback 6. Finalize Framework 7. Implement. & evaluate. 1. Cduct evaluati of current model, satisfacti of advisors and role of council to best support its # of EDs participating in Team Charter ent initiative. % of staff attending training from identified units. 3 % completed % complete 4

5 dimensi Safe Safe Medicati Safety Medicati Safety Workplace Violence Medicati recciliati at admissi: Medicati recciliati at discharge: Total number of discharged with a completed Med Rec at Discharge m. Number of workplace violence incidents reported within a 12-mth Populati Rate per total number of admitted patients/hospit al admitted patients Rate per total number of discharged patients/hospit al admitted patients Total number of reported WPV incidents Hospital Collect ed data/ Quarter Hospital Collect ed data/ Quarter IRS/Emp loyee Incident Quarter ly report 70.2% Collecting Baseline 70 reports per quarter Collecting baseline 78% 10% baseline. Collecting Baseline 20% increase in reporting by March % baseline. Ctinued efts establishin g a culture of reporting. 4. Ensure Standardizati & use of whiteboard across the organizati. 1. Implement Visibility Checklist across all inpatient areas Med Rec at Admissi. 2. Ctinue to evolve Pharmacy Technician Model in the Emergency Department Setting. 1. Pilot use of Visibility to support tracking of Med Rec at Discharge. 2. Define going educatial model all disciplines. 1. Add # of WPV incidents to Scorecard to ensure visibility with senior leaders and board. structure. 2. Cduct external scan of existing frameworks 3. Develop draft framework in partnership with patients and families. 4. Implement. & evaluate framework. 1. Using Patient Experience working group develop evaluati framework. 2. Implement evaluati. 3. Make changes where required. 1. Using existing med rec working group, complete implementati of visibility checklist,. 2. Cduct evaluati with stakeholders. 3. Implement changes as appropriate. 1. Create small working group. 2. Cduct evaluati of current model. 3. Create educati/orientati materials. 4. Implement, evaluate. 1. Using existing med rec working group evaluate use of visibility to track completi of med rec at discharge. 2. Ctinue to educate teams regarding roles and respsibilities. 1. Using existing med rec working group cduct external scan of educatial models. 2. Implement, evaluate. 1. Work with Occ Health and Incident Management Administrator to evaluate current electric reporting process. 2. Make changes to employee reporting to ensure ease of use and capture of % complete % Complete # of BPMH s complete per shift TBD % complete TBD % model complete. % of unit quality boards with WPV data displayed. 5

6 dimensi Timely Timely access to care/service period Total ED length of stay (defined as the time complex patients. Populati Hours/Patients with complex cditis based -Feb 2018 NACRS /C2017 calendar year 2. Develop Management Respse Toolkit. 3. Ctinue to advance the WPV Acti Plan. 4. Implement Violent Patient Identificati Policy & Procedure. 7h 8h 7hr 1. Update surge / overcapacity protocol. all WPV types. 3. Determine baseline based methodology. 4. Post corporate rate Senior Leader Scorecard. 5. Ensure unit level results available to Program Directors, Managers use at Huddles. 1. Create subcommittee of Workplace Violence (WPV) Committee. 2. Cduct external scan of best practices. 3. Develop draft toolkit and implement tool with pilot group. 5. Finalize toolkit. 1. Take draft plan out to stakeholder groups evaluati. 2. Finalize plan. 3. Publish plan. 4. Mitor progress mthly at WPV Committee. 1. Using WPV Subcommittee cduct external/best practice review. 2. Draft policy. 3. Define electric flagging processes to support policy. 4. Implement in pilot area. 6. Complete rollout across the organizati. 1. Establish a tri-site Emergency Department working group. 2. Cduct external/leading practice scan of overcapacity policies, processes. 3. Draft updated overcapacity protocol. 4. Implement. % complete % complete Year 2 deliverables % policy complete. % policy updated. 6

7 dimensi Populati 2. Evaluate current use of Emergency Department resources return DI visits. 3. Plan, implement, evaluate alternative triage models at MDH & GH sites. 1. Utilizing above a tri-site Emergency Department working group collect data return ED visits diagnostic testing. 2. Analyze results. 3. Develop plan to divert identified categories. 4. Implement. 1. Utilizing above a tri-site Emergency Department working group cduct best practice review of alternative models. 2. Define new process/flow/model. 3. Implement. % reducti of return visits diagnostic imaging investigatis % work complete 10% 7