2017/18 Quality Improvement Plan "Improvement Targets and Initiatives"

Transcription

1 2017/18 Quality Improvement Plan "Improvement Targets and Initiatives" St. Mary's General Hospital 911 Queen's Boulevard AIM Measure Quality dimension Issue Measure/Indicator Unit / Population Source / Period Organization Id Current performance Target Target justification Effective Coordinating care Percentage of % / Patients Hospital collected 699* CB CB Hospital Wide patients identified meeting Health data / Most with multiple Link criteria recent 3 month conditions and period complex needs (Health Link criteria) who are offered access to Health Links approach Effective transitions 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? % / Survey respondents CIHI CPES / April - June 2016 (Q1 FY 2016/17) Discharge Planning Review Project will be conducted during the 2017/18 fiscal year. Referrals of complex patients to Health Links will be incorporated 699* CB CB This into discharge survey tools is not utilized by St. Mary's.

2 Percentage of acute hospital inpatients discharged with selected HBAM Inpatient Grouper (HIG) that are readmitted to any acute inpatient hospital for nonelective patient care within 30 days of the discharge for index admission. % / Discharged patients with selected HIG conditions CIHI DAD / July June * Readmission rate meets current target. Monitoring indicator Percentage of patients discharged from hospital for which discharge summaries are delivered to primary care provider within 48 hours of patient s discharge from hospital. Rate of psychiatric (mental health and addiction) discharges that are followed within 30 days by another mental health and addiction admission % / Discharged patients Rate per 100 readmissions / Discharged patients with mental health & addiction Hospital collected data / Most recent 3 month period CIHI DAD,CIHI OHMRS,MOHTLC RPDB / January December * 699* CB X CB 0.00 Once a Hospital Discharge Summary is dictated and transcribed, an autofaxing system is in place to send the Discharge Summary to the Family Physician automatically. An Not assessment applicable of

3 Risk-adjusted 30-day all-cause readmission rate for patients with CHF (QBP cohort) Rate / CHF QBP Cohort CIHI DAD / January December * QBP Order Set adopted in Monitoring indicator. Risk-adjusted 30-day all-cause readmission rate for patients with COPD (QBP cohort) Rate / COPD QBP Cohort CIHI DAD / January 2015 December * QBP Order Set implemented in Monitoring indicator. Risk-adjusted 30-day all-cause readmission rate for patients with stroke (QBP cohort) Rate / Stroke QBP Cohort CIHI DAD / January December * X 0.00 All Stroke Patients are cared for at the Regional Stroke Centre.

4 Efficient Access to right level Total number of Rate per 100 WTIS, CCO, BCS, 699* Current of care alternate level of care inpatient days / MOHLTC / July performance is (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 All inpatients September 2016 (Q2 FY 2016/17 report) better than target for 9.46% for WWLHIN Average length of stay Days / All patients Hospital collected data / April March * % reduction. This is the second year for this indicator. The average length of stay was reduced year 1 from 6.7 to 6.2 days. The purpose is to sustain the gains and monitor this indicator.

5 Patient-centred Palliative care Percent of palliative care patients discharged from % / Palliative patients CIHI DAD / April 2015 March * SMGH is hospital with the discharge status "Home with Support". Person experience "Would you recommend this emergency department to your friends and family?" % / Survey respondents EDPEC / April - June 2016 (Q1 FY 2016/17) participating with the WWLHIN Collaborative QIP on Palliative Care. Indicator is the Percentage of People with access to a palliative approach to care in the last year of 699* Data is from NRC Patient Satisfaction Survey from April- June Current ED Performance Q1 2016/17 is 63.3% n=30. Target for improvement is greater than 85% of patients would recommend the ED.

6 Safe "Would you recommend this hospital to your friends and family?" (Inpatient care) % / Survey respondents CIHI CPES / April - June 2016 (Q1 FY 2016/17) 699* New surveying methodology is being implemented in April Collecting baseline data for first six months of fiscal year. Current data is 89.4% n=47 for fiscal Q1 2016/17 Medication safety Medication Rate per total Hospital collected 699* Data is not reconciliation at number of data / Most admission: The total admitted patients recent 3 month number of patients / Hospital period with medications admitted patients reconciled as a proportion of the total number of patients admitted to the hospital collected on this indicator

7 Medication Rate per total reconciliation at number of discharge: Total discharged number of discharged patients / patients for whom a Discharged Best Possible patients Medication Discharge Plan was created as a proportion the total number of patients discharged. Hospital collected data / Most recent quarter available 699* Data is not collected on this indicator at the current time. Safe care Percentage of patients receiving complex continuing care with a newly occurring Stage 2 or higher pressure ulcer in the last three months. % / Complex continuing care patients CIHI CCRS / July - September 2016 (Q2 FY 2016/17 report) 699* 0.00 Not applicable

8 The number of hospital patients who were physically restrained at least once in the 3 days prior to a full admission assessment, divided by all patients with a full admission assessment in the reporting period. % / Mental health patients CIHI OMHRS / October September * 0.00 Not applicable Hospital Acquired Clostridium Difficile Infections Number / All acute patients In house data 699* 16 collection / April 2016-March Reduction in current number of infections by 25% Staff Blood and body fluid exposures Number / Staff In house data collection / April 2017-March * Reduction by at least 10% in current performance

9 Timely Timely access to care/services Total ED length of Hours / Patients stay (defined as the with complex time from triage or conditions registration, whichever comes first, to the time the patient leaves the ED) where 9 out of 10 complex patients completed their visits CIHI NACRS / January 2016 December * Focus in the Emergency Department will be to reduce the Provider Initial Assessment by at least 20% from 3.75 hours to 3 hours by March 31, 2018.

10 Change Planned improvement initiatives (Change Ideas) Methods Process measures 1)Hospital Wide Discharge Planning Project Utilizing our Lean Management System, a rapid improvement event will be held. An A3 will be developed documenting current state, future state and an implementation plan. A3 developed incorporating implementation plan Target for process measure Comments A3 is completed and implementation plan with timelines and deliverables is documented. Standard work is developed for hospital wide discharge planning. 1)This indicator is not collected currently at St. Mary's. Our Patient Experience Survey through NRC and our own survey methodology. St. Mary's Survey methodology Patient Experience Indicators are provided on the Quality Scorecard Improvement is on Quality Scorecard

11 1)Monitoring indicator Indicator is monitored on the Quality Scorecard Quality Scorecard is reported quarterly to the Board Quality Committee WWLHIN wide readmission rate 1)Evaluation of Information System technology to monitor this indicator Current IT system involves autofaxing of discharge summary as dictation is received and authenticated. Review ability to collect this data Achieve target as described. 1)Not applicable to St. Mary's Not applicable to St. Mary's Not applicable to St. Mary's Not applicable

12 1)Monitoring Indicator Indicator on Quality Scorecard Monitoring Indicator Monitoring indicator 1)Monitoring indicator Monitored on Quality Scorecard Monitored on Quality Scorecard Monitoring 1)St. Mary's is a collaborative partner with Grand River Hospital who is the Regional Stroke Hospital Not applicable Not applicable Not applicable

13 1)Revised approach to ALC See average length of stay action plan management within the organization in collaboration with CCAC. Integrated Discharge Planning agreement has been signed with CCAC. A3 will be developed to identify current state, future state, improvements, implementation plan, cost/benefit and evaluation. Completion of project by March )Integrated Discharge Planning Model in Collaborative with the Integrated Care model established at St. Mary's and the WWCCAC A3 will be developed for corporate strategy related to discharge planning, transitions in care, alternate level of care and enhancing the integrated care model. Completion of Strategic A3 with identified improvements. Value stream map is completed. Implementation plan is developed. A3 is completed Value stream map is completed Implementation plan is developed and initiated 2)Senior's Friendly Emergency Department An assessment by representatives from the St. Joseph's Hospital System will be conducted in the spring The assessment will then provide the framework for an implementation plan. To be determined in the development of a A3 related to Seniors Friendly. To be determined.

14 1)WWLHIN Collaborative Participation in Collaborative Project QIP Project for Palliative Care Common approach and language across SubLHIN. Substitute Decision Maker(SDM) identified on palliative care patients. Substitute Decision Maker Project is implemented Percentage of patients 50 years = who have a SDM discussion and documentation on the chart. Percentage of patient records that contain SDM. 90% 1)Management of surgical admitted patients waiting transfer to Grand River Hospital. 1. Tracking board updated to indicate patients waiting for transfer with no booked Operating Room time. 2. Quality improvement Project led by Surgeon to enhance the patient experience related to acute surgical intervention. 1. Tracking Board indicator in place and monitored. 2. Utilization of Nurse Practitioner in care of surgical patients waiting for transfer. 3. Surgeon Quality Improvement Initiative to MAC April Implementation of recommendations for Surgical Improvement Initiative. A3 documented to support change initiaves. 2)Implementation of A-I-D-E- T method of communication to patients in the Emergency Department. Project plan for implementation to be developed 100% of staff participate in education and training for A- I-D-E-T Staff utilize tool in communication with patient >80% of the time. 100% of ED Nurses attend training session Tool is utilized greater than 80% of the time when communicating with patients.

15 3)Extended CCAC hours in Expand CCAC hours in the ED 7 days per week the ED 7 days a week to improve transitions in care and discharge planning from the ED Extended hours are in place. Patients are better prepared for discharge with resources. Patient satisfaction survey indicate improvement in "did you receive enough information from hospital staff on what to do it you were worried after discharge". Collecting baseline measure for discharge question. 1)New survey methodology is being implemented for inpatient bedside surveying. Electronic survey tool auditing by Volunteers Paper based anonymous survey tool available to all patients, families and visitors effective April 1,2017 Implementation of survey tool methodologies Survey tools are implemented and being used by patients, families and visitors. 1)Medication Reconciliation Refresh Project An interprofessional working group will be developed to evaluate the current state and prepare an A3 on Medication Reconciliation. Development of A3 for Medication Reconciliation identifying gaps in current processes, current state, future state, contributing factors, strategies for improvement, implementation plan, cost/benefit and evaluation march 2018

16 1)see Medication Reconciliation on admission for plan see above see above see above 1)not applicable not applicable not applicable not applicable

17 1)not applicable not applicable not applicable not applicable 1)Strategic A3 is developed for the corporate approach. Sub A3s are developed in focused areas related to hand hygiene, vectors for transmission and environmental cleaning. 1. Promote a culture of staff awareness around hospital acquired infections and the role every staff member, volunteer and physician has to prevent infections. 2. Focus on hand hygiene compliance through education, communication of department results and auditing. 3. Assess, address and mitigate vectors of transmission across the organization. 4. Continued focus on environmental and equipment cleaning. A3 developed Sub A3s developed Hand Hygiene Audit Results 100% Improve hand hygiene by at least 25% before patient contact. Year 2 of this intiative. 1)Strategic A3 is developed to identify focus areas and contributing factors. Sub A3s are developed in focus areas related to practice. 1. Promote a culture of staff safety through awareness, A3 developed for Corporate Strategy 3 Sub A3s safety promotion and communication strategies. 2. developed in focus areas Percentage of new staff Focus area: Cardiovascular Operating Room-- trained in Orientation compliance with neutral zone, double gloving, physician education and awareness, separation of sharps. 3. Focus area: Medical Device Reprocessing--compliance with best practices related to sharps handling in the Surgical Suites, standard work development for instrument handling in MDRD, staff certification updates, staff awareness program 4. Focus area: Surgical Inpatient Care Area--handling of sharps, improved injection techniques, education by supplier on management of 100% Project is led by Occupational Health & Safety in collaboration with Patient Services, Quality & Risk Management.

18 1)Utilizing lean methodology the Emergency Department will conduct a value stream map to identify areas of opportunities. 1. Value stream map 2. Identified process improvements. 3. Site visit to high performing emergency department 4. Redesign of emergency patient flow Reduction in Provider Initial Assessment by 20% from 3.75 hours to 3 hours 20% reduction in PIA Provider Intial Assessment indicator is linked to Executive Compensation 2)Increased availability of ultrasound hours Additional ultrasound technician hours 4 hours/evening to support ED patient testing Improved time to ultrasound for ED patients. Improved patient flow--reduced ED length of day for patients Implementation of hours. Monitor impact on ED Length of Stay