2017/18 Quality Improvement Plan Improvement Targets and Initiatives

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1 2017/18 Quality Improvement Plan Improvement Targets and Initiatives AIM Measure Change Effective Effective Care for Patients with Sepsis % Eligible Nurses who have Completed the Sepsis Education Bundle (ilearn + Case Reviews + Simulation + Skills Competency Assessment) % / All Eligible Nurses (inpatient areas) 0 80 Match Internal Benchmark. The target reflects the level of saturation required to impact practice. It is also based on an internal benchmark associated with other comprehensive education initiatives and takes into consideration the constant flux of staff throughout the organization. 1) Standardize & Optimize Care. A sepsis early recognition & management pathway and implementation toolkit was developed for the inpatient units. The pathway was initially tested on four inpatient units to ensure applicability to different patient populations and work environments. Improvements and revisions were made based on clinician feedback. 2) Skills Development & Training. A vital component of implementing the sepsis pathway is training frontline nurses. Previous analysis of sepsis events and our early experiences with the pilot unit have led to the development of an education bundle consisting of (a) an introduction to sepsis e-module, (b) case reviews, (c) simulation, and (d) competency assessment of two identified skills gaps (push-pull fluid bolus administration and direct IV antibiotic injection). Education is not considered complete until all four components have been achieved. We are also investing in unit-based coaching to support frontline nursing staff during implementation. Expert members of the implementation team attend inpatient units to help assess patients for possible sepsis and activate the new pathway. An implementation roll-out schedule has been developed. Progress is monitored monthly at the Sepsis Steering Committee which includes senior medical and nursing leadership. Unit managers are provided with regular updates on the progress of implementation to allow for their support in addressing any barriers or issues encountered. 2.5 hours of nursing education time has been allotted for each eligible nurse, representing significant organizational commitment to this initiative. Sepsis education has been integrated into the orientation program for new nurses. The sepsis implementation team is able to electronically track completion of the e- module and manually tracks attendance of the remaining three components of the education bundle. Managers are tracking education rates at a unit level, with some areas posting rates in staff areas. Implementation team members will manually track coaching conversations on "go-live" units. Education bundle compliance is also reported monthly to Quality Management Council. % of eligible units (CCCU, PICU, NICU & ED are excluded) that completed implementation % nurses completing the education e-module (by unit); % nurses attending the mandatory in-person education for the remaining three components (by unit); number of coaching conversations per unit during the first month of "go-live" implementation The pathway will be implemented on 100% of eligible units by August 31, % of eligible nurses on all units will have completed all components of the education by June 30, 2017; we aim to complete at least 20 coaching conversations per unit during the first month of "go-live" implementation (to be completed by August 31, 2017) We continue to focus on the effective management of sepsis, evolving from our initial efforts to screen for sepsis in the ED last year, to rolling out a new inpatient sepsis recognition and early management pathway. The long term goal is to monitor effective care delivery for this high risk population facilitated by a new clinical information system to be implemented over the next year. As a result of feedback from the pilot units, revisions and improvements were made to the education. These additional components must now be delivered to the pilot areas to ensure completion of the full bundle. The implementation team is small, which could limit the number of coaching conversations in the face of unforeseen absences. However, area Quality Leaders, Paraprofessional Education Specialists, and Clinical Support Nurses will be encouraged to also engage in coaching conversations. Interprofessional team training simulation sessions related to the management of sepsis are now offered. Sepsis education will also be provided at various medical trainee forums. The next phase of development includes modifying the algorithm and process for the critical care areas. 3) Create Awareness. We will develop a sepsis awareness campaign that aligns with World Sepsis Day. The campaign will target the public, patients and families as well as SickKids frontline staff. In collaboration with our Communications & Public Affairs team, a comprehensive plan will be developed to raise awareness around sepsis. Key messages for staff, patients/families and the public will be established as well as the most appropriate platforms. We will also engage members of our Family Advisor Network in our 2017 World Sepsis Day awareness efforts. # of articles published on the Daily News (on the hospital's intranet site); # of social media posts by SickKids; # of World Sepsis Day messages delivered to all staff A minimum of 3 sepsis The Sepsis Steering Committee will stories will appear on build upon the previous work of the the SickKids Daily News Work Sepsis Day campaign. by September 13, 2017 (World Sepsis Day); a minimum of 4 tweets about sepsis by SickKids by September 13, 2017; 1 panhospital message on World Sepsis Day which is September 13, 2017 Page 1 of 7

2 Efficient Reduce unnecessary time spent in acute care Average LOS for the Lowest 99% of Inpatient Stays Days / Lowest 99% of Inpatient Stays CIHI DAD / Match Previous Rate of Improvement. We continue to focus on reducing unnecessary time spent in inpatient beds. Shifting our improvement efforts to the lowest 99% of inpatient stays eliminates the very small number of patients whose extended LOS is immune to local change plans. With a narrowing margin for improvement, we are aiming for a 1% reduction. As patients with lower LOS move to outpatient care, we expect hospital ALOS to increase. 1) Standardize & Optimize Care. Building upon our previous work, we will identify opportunities to develop new clinical pathways as well as revise and strengthen existing pathways. Clinical pathways define the evidence-based care for a particular population and thus reduce unnecessary variation. 2) Standardize & Optimize Care. We will review and standardize the care coordination processes on each unit, ensuring there is an effective mechanism to assess individual patient needs. Efforts will focus on unit rounding and other coordination methods including the process for identifying an estimated date of discharge (EDD) for each patient. A thorough analysis of the current state of existing clinical pathways will first be carried out. Templates and timelines will then be developed to aid in development and adoption of new and revised pathways. Each pathway developed will have a corresponding implementation plan. Progress will be monitored at the LOS Committee. # of new clinical pathways developed and implemented We conducted a point prevalence study in % of new LOS pathways that January 2017 and established that include establishing an EDD approximately 50% of inpatients have an EDD assigned to them. First we will determine how and why EDDs are currently being utilized in order to develop effective strategies that applicable to all units. We aim to develop and implement 7 new clinical pathways by We aim to include EDDs in 80% of new LOS pathways by Typically clinical pathways take 6-12 months to develop. Once we have a better understanding of how EDDs are currently being used and which strategies can be successfully spread, we will develop more specific targets. 3) Standardize & Optimize Care. To ensure a seamless and timely transition for patients moving throughout the hospital, we will develop a transition pathway for the NICU to surgery patients. This initiative will build upon the lesson learned from our previous work with our NICU to paediatric medicine population. This will be a joint multidisciplinary initiative involving the NICU and the surgical inpatient areas. Physician champions and Nurse Practitioners from both clinical areas will collaborate to develop pathways to ensure transition coordination. Establishment of NICU to surgery transition pathway; ALOS (MOH definition) of surgical NICU inpatients We aim to have the NICU to surgery pathway completed along with the identification of associated indicators by ; we aim for a 1% decrease in the average LOS of the surgical NICU patients by 4) Process Redesign. In order to optimize the care for select populations, we will expand our Short Stay Surgical Unit (SSSU). The co-location of patients with lower acuity allows for more efficient processes including timely discharge. Expansion will involve reviewing whether there are patients that (a) meet existing criteria but are not yet using the SSSU, or (b) do not meet current criteria but might benefit from the SSSU. Once identified resources will be aligned to meet expansion needs and booking processes will be modified accordingly. % SSSU utilization We are aiming for an 85% SSSU utilzation rate (from our baseline of approximately 65%) by Page 2 of 7

3 Patient-centred Person Experience Inpatient Communication (Guardian) - Dimension % Top Box Responses / Survey Respondents NRC Picker / Q1, Q2 (Apr-Sep ) Match Previous Rate of Improvement. Based on previous patient satisfaction efforts, a 3% improvement represents an ambitious but achievable goal. Results from the first two quarters of the new Child survey indicate an improvement opportunity for Inpatient Communication in that this dimension is highly correlated with overall satisfaction and has lower scores. Improvement plans can therefore be targeted and actionable. 1) Standardize & Optimize Care. An analysis of results for all questions in this dimension revealed that scores were lower for the item about whether "providers discussed how to report mistakes". Our work plan will consist of (a) an internal and external communication plan about how and when to "speak up", (b) standard processes to encourage patient/family voicing their concerns such as embedding key messages within Family Presence at Nursing Shift Handover, Inpatient Family Orientation, Patient Rounding, etc., and (c) refreshing existing information materials for patients/families as well as developing new ones. 2) Skills Development & Training. Effective communication with families is a skill that requires training and practice. We will identify opportunities to integrate key principles within existing staff education forums, as well as develop new education initiatives. We will capitalize on the widespread reach of Error Prevention training (part of the Caring Safely initiative) with its strong foundation in effective communication techniques. The work will be led and monitored by the Patient and Family Experience Advisory Committee which includes two active Family Advisors. Opportunities to update materials and training as well as reinforce best practices will be examined and implemented. A complete review of existing education/training offered will first be undertaken to identify new or enhancement opportunities across the SickKids context. The work will emphasize the importance of timely updates to families about their child's care, capitalizing on previous work such as the recent "Talk With Me" video. Oversight will be provided by the Patient and Family Experience Committee. % top box responses to "providers discussed how to report mistakes" question of the inpatient survey We aim to see the % of top box responses for this question to be at least 25% by December 31, 2017 (representing a 69% improvement) % top box responses to "providers We aim to see the % kept parents informed about child's top box responses for care" question of the inpatient this question to be at survey least 70% by December 31, 2017 (representing a 2% improvement) Currently the baseline for "providers discussed how to report mistakes" is 14.8% Currently the baseline for "providers kept parents informed about child s care" is 68.5% 3) Patient & Family Engagement. We will engage patients and families in the development and delivery of communication initiatives, in particular as it relates to education and awareness. Building upon the strong foundation established last year with our Family Advisors Network, we will expand their involvement in all aspects of this work. Oversight will be provided by the Patient and Family Experience Committee. # of patient/family advisors involved in the delivery of staff education initiatives; # of digital stories featuring patients and families sharing their experiences around communication We aim to have 5 patients/families involved in delivering staff education about communication and at least 5 digital stories featuring patients/families by Page 3 of 7

4 Safe Reduce Acquired Infections Central Line Associated Blood Stream Infections (CLABSI) - for PICU, CCCU, NICU, 4D, 6AE, 8AE Rate per 1,000 central line days / PICU, CCCU, NICU, 4D, 6AE, 8AE Match Previous Rate of Improvement. We have expanded the number of units included in this indicator to align with what we are reporting to Solutions for Patient Safety (SPS) as part of our Caring Safely initiative. The SPS Network mean of 1.53, is considered one of the best available benchmarks. The target represents a 23% improvement which takes into account the impact of including additional units in the overall hospital rate, as well as our rate of improvement previously experienced in the critical care areas. 1) Audit & Feedback. Audits of bundle compliance not only ensure the reliable application of evidence informed care bundles, but also allows for reflection and coaching as a result of peer feedback. The critical care areas (NICU, CCCU, PICU) will double the number of CLABSI audits on the calendar, from 20 to 40 per month. Inpatient areas that have recently implemented the CLABSI bundles will start to conduct regular audits using K cards (audit tool). 2) Skills Development & Training. In order to ensure a more consistent application of the CLABSI care bundles, we have developed standard work and will implement annual competency training. Unit personnel (Quality Leaders, Education % compliant audits (green K cards) We will aim for 90 % Specialists, Managers, Safety Coaches) will compliance in all areas be trained to conduct CLABSI audits using by standard work. We will expand the number of CVL auditors in the critical care areas and establish a core group for the onboarding inpatient areas. The Caring Safely Steering Group monitors the progress of each identified Acquired Condition. Annual nursing education days will include an objective structured clinical examination (OSCE) of CVL care. The nursing education content is currently in development, taking cues from the CVL audit results (areas that are most frequently missed or completed incorrectly). % eligible nursing staff who have completed the annual CLABSI training; % eligible nursing staff who have have passed the annual CLABSI training We aim for 100% compliance with the education by Carrying out the audits can be challenging during times of high acuity and/or high census. Expanding the number of CVL auditors will create more flexibility but also makes it more challenging to maintain consistency in the coaching provided. 3) Standardize Process & Create Awareness. In the critical care areas (NICU, CCCU, PICU), the leadership team will conduct daily rounds on all children with CVLs to reinforce the application of the bundle elements, promote accountability for CVL practice and use the "My CVL Plan" template. A member of the leadership team will % daily CVL rounds completed in round daily on all children with CVLs to critical care areas review competencies and accountabilities. They will also role model safety behaviours and reinforce the importance of prevention efforts. The process will facilitate identifying barriers to best practice as well as individuals who may require more support and coaching. A leader schedule and process is in development. We aim to complete daily CVL rounds 75% of the time by 4) Process Redesign. In order to facilitate compliance with the bundle elements by providing ready access to all of the tools required, we will roll out CVL dressing and cap change kits hospital-wide. The kits were recently revised in order to align with an updated policy and procedure. A roll out plan has been developed for all units involved in the CLABSI work (NICU, CCCU, PICU, 4D, 6AE, 8AB). # kits used (compared to number of central line days per unit and predicted usage calculated during planning); % CVL audits reporting appropriate use of the kits We aim for widespread Final approval of the kits is pending usage of the kits by September 30, 2017; 100% of CVL audits will report kit usage by Page 4 of 7

5 Safe Reduce Harm Events Serious Safety Event Rate Rate per 10,000 Adjusted Patient Days / All Patients Incremental Improvement with Long Term Goal. The target represents a 29% improvement which is good progress towards our Caring Safely goal of reducing the SSER by 2/3 by the end of FY2017/18. The target represents 4 fewer SSEs than in assuming a relatively stable number of adjusted patient days. 1) Skills Development & Training. Conduct Error Prevention and Leader Methods training for all staff as part of our Caring Safely initiative. These interactive in-person sessions impart the principles of high reliability as well as practical strategies proven to prevent adverse events and support a culture of safety. 2) Standardize & Optimize Process. Building upon the implemenation of our SSE review process, we will optimize learning to identify trends across events that can be addressed at an organizational level thus further reducing errors and improving care. The development of an SSE database will faciliate the common cause analysis process, which ultimately helps to leverage change by integrating identified themes into organizational planning. The structured sessions are based on the proven methods employed by Solutions for Patient Safety. All staff learn the expected safety behaviours and leaders are also trained to use advanced tool and strategies to build accountability and find & fix problems in their areas. Leaders from across the organization are involved in delivering the sessions as well as a dedicated Education Specialist. Progress is reviewed at the Caring Safely Steering Committee. We will develop an easy-to-use database to track all SSE reviews and their associated recommendations. Once in place, it will be populated with past SSE review data and processes will be established to capture data on go-forward basis. The SSE Review Committee will monitor the progress of the database development and the common cause analysis work. Results will be reported to the Quality Management Council. % eligible staff who completed Error Prevention training; % eligible staff who completed Leader Methods training Database developed and in use; # common cause analysis reviews completed We aim to have 90% of eligible staff trained for both Error Prevention and Leader Methods by December We aim to have the SSE database developed and one common cause analysis review completed by Reducing the rate of Serious Safety Events (SSEs) by 2/3 by the end of 2017/18 fiscal year is one of the four key objectives of our Caring Safely initiative. SSEs are defined as a deviation from generally accepted practice standards that reach the patient and that result in moderate to severe harm or death. Caring Safely is our ambitious patient/staff safety campaign that aims to eliminate preventable harm through a number of proven strategies. The four key objectives of Caring Safely are to reduce the incidence of seven identified hospital acquired conditions (HACs), reduce the incidence of Serious Safety Events (SSEs), enhance our safety culture by adhering to the principles of High Reliability Organizations (HROs), and reduce the frequency, severity, and rate of staff lost-time injuries. 3) Create Awareness & Share Lessons Learned. We will share stories of individual SSE reviews with staff, highlighting how error prevention techniques and resulting system-level recommendations can prevent similar events in the future. This strategy will harness the power of storytelling for learning. We will build upon earlier work to share safety stories at various forums using a successful template (summary of event, why did this happen, how can prevent it, how can we support the culture of safety). In order to capture a larger staff audience, we will share more stories creating a library of resources on the SSE intranet site. Progress will be monitored at the SSE Committee. # of SSE stories posted on the Daily News hospital intranet site; % of SSE reviews with a safety story posted on the SSE intranet site 6 SSE stories will be posted on the Daily News by December 31, 2017; 75% of SSE reviews in 2017 will have a safety story posted on the SSE intranet site Page 5 of 7

6 Timely Timely Access to Care/ Services % Patients Admitted from the ED that Exceed the 12hr Service Standard % / ED Admitted Patients Match Previous Rate of Improvement. The target represents an ambitious 24% improvement and is based on our previous experience with similar initiatives. 1) Process Redesign/Create Awareness. Unit leaders will conduct "breach reviews" for all patients who have an ED LOS >12 hours. The reviews will identify root causes for the extended admission waits in order to drive improvement efforts. The process will simultaneously provide rapid feedback on the frequency and contributors of these bottlenecks, as well as lead to a deeper understanding of the associated system issues to inform potential process changes. Capability to identify these patients in real time has been built into our widely accessible Business Intelligence platform to support the process. A Clinical Director provides leadership and oversight. Issues, trends and resulting improvements are brought forward to the Clinical Managers and Directors groups. The % of Admitted ED patients that exceed the 12 hour Service Standard is reported monthly to Quality Management Council. % breach reviews completed 80% of ED patients waiting longer than 12 hours to be admitted will have a breech review completed by September 30, 2017 Establishing a service standard for ED patients waiting to be admitted that is meaningful and easy to understand serves to more actively engage staff in improving timely access to care: No more than 13% of admitted patients in the ED will wait longer than 12 hours for an inpatient bed. 2) Drive Situational Awareness. In addition to monthly progress reports at Quality Management Council, this metric will be included on the agenda of every Clinical Operations Council and weekly VP & Director meeting. How often the ED LOS Service Standard metric, and its associated improvement work, is included on the agendas and discussed will be tracked for both Clinical Operations Council (COC) and weekly VP & Director meetings. % ED LOS Service Standard is on the COC agenda and discussed; % ED LOS Service Standard metric is on the VP & Director meeting agenda and discussed In 2017, we aim to have the ED LOS on the agendas of both of these venues 90% of the time 3) Process Redesign. Units where more than 13% of their patients admitted via the ED wait longer than the 12 hour service standard will include the ED LOS Service Standard as a "Driver" metric on their unit scorecard. Action plans are developed for Driver metrics and thus will drive more timely improvements at the unit or program level. % units who exceed the ED LOS Service Standard with action plans We aim for 80% of Competing improvement priorities at these units to have the unit level could impact decisions action plans developed around whether ED LOS is designated a by May 1, 2017 "Driver" metric. 4) Standardize Process. Understanding that delayed dispositions are often not escalated in a timely and appropriate manner, we will develop an escalation protocol based on the current ED consultation policy. The metrics to evaluate compliance with the protocol will be embedded within the algorithm. An actionable and clearly defined escalation protocol will be developed and rolled out. Key stakeholders and internal experts will be engaged to ensure the protocol is integrated into the current workflow. The long term goal is track compliance at the program and hospital levels. Development of escalation protocol; protocol and compliance measures piloted The protocol will be developed by May 1, 2017; pilot (including compliance measures) will be completed by Missed opportunities to escalate delayed disposition decisions requires clear and objective definitions and is contingent on a reliable mechanism to track consultation calls, responses and arrivals. Currently this process is largely manual. Page 6 of 7

7 Timely (continued) 5) Process Redesign. Some patients require additional time and reassessments to better inform the best disposition decision. In order to establish a care environment that supports the unique needs of these patients, we will create a Clinical Decision Unit (CDU). A multi-disciplinary and interdepartmental working group is currently in the process of defining CDU criteria. In order to achieve official designation as a CDU, an application must be submitted to the TCLHIN that includes a mechanism to report compliance metrics. Establishment of CDU criteria; methodology for reporting compliance metrics established; CDU application submitted to the TCLHIN We aim to have the criteria established, measurement methodology and application submitted by April 1, ) Match Resources with Demand. Many variables impact availability of nursing resources including acuity, seasonal patterns and back fill needs. Nursing availability in turn is one of the identified root causes for long admission waits in the ED. The nursing resource group (NRG) model establishes a flex component for each program. Using mathematical modeling and trend data, work is currently underway to define the ideal number of NRG shifts for each program in order to optimize staffing to more effectively meet needs. Once the analysis is complete, recommendations will be made related to NRG levels for each program. A comprehensive action plan will then be developed and implemented. Development of an NRG action plan with implementation dates The plan will be developed by August 31, 2017 Page 7 of 7

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