2018/19 Quality Improvement Plan (QIP)

Transcription

1 2018/19 Plan (QIP) Measure MSH MSH MSH Evaluate the effectiveness of SmartCells flooring. Evaluate the effectiveness of SmartCells flooring % of falls with serious injury/death in CB () across 26 beds (13 units). the rooms with SmartCells flooring Falls with injury (levels 3,4,5) per 1,000 patient days % from 17/18 Target % Partner with Redevelopment to determine potential areas for SmartCell flooring installation within Phase3A. (MSH) Implement and evaluate falls monitoring technology - video monitoring (SHS) Determine potential areas for installation Determine areas for pilot, implement and evaluate at both and MSH % of falls prevented/intervened in the rooms where the technology is being used to monitor at risk patients milestone milestone >80% Safe Zero falls with serious injury or death Develop and implement a targeted mobility/walking program (SHS) Implement a mobility/walking program to ensure early and increased mobilization (1 unit at MSH + 1 unit at ) TBD - balancing measure TBD Falls with serious injury/death (number of patients) Theoretical Best 0 Theoretical Best Explore the opportunity to implement a falls prevention clinic (SHS) Sustain and spread safe prescribing of sedatives on targeted units (SHS) Explore and develop a business case for a falls prevention clinic Implement non-pharmacological sleep hygiene practices, staff education, and order set revisions to remove sedatives in Surgery (MSH) and in 1 unit at. Business case developed & submitted % staff educated on targeted units completion 80% full/part time staff educated Implement a recruitment and staffing strategy for Engage with HR to develop an ES recruitment Environmental Services (ES) that's aligned with PIDAC and staffing plan to fill vacancies best practice standards (MSH) Fully implement a quality auditing program to ensure best practice standards for cleaning are met # of vacancies filled # of quality audits completed 80% filled 300 quality audits Safe Zero incidence of nosocomial cases of C. Difficile Infection C.Difficile - nosocomial (rate per 1,000 patient days) Elsewhere 0.03 Elsewhere Improve hand hygiene adherence (SHS) Participate in multi centre hand hygiene study using a bundled approach w performance feedback + huddles (3 units at MSH) Complete review of access to hand rub at point of care () % adherence to hand hygiene Point of Care hand sanitizer placement review completed () MSH - overall 42% e- monitoring, 55% on study units, >90% direct observation for units without e-monitoring devices - 93% direct observation

2 C.Difficile - nosocomial (number of patients) MSH MSH MSH Reduce prolonged antibiotic exposure post surgery Explore and develop a plan to audit current milestone (MSH) surgical prophylaxis practice and reduce prolonged antibiotic exposure post surgery

3 MSH MSH MSH Implement pressure injury best practices and Perform root cause analysis, determine and milestone advance SHS' comprehensive pressure injuries implement pressure injuries prevention prevention program with priority in targeted high interventions that are unit specific risk areas (SHS) Create an automated Braden report and implement during regular safety huddles Safe Zero incidence of hospital acquired stage II or greater pressure ulcers including the neonatal population Hospital acquired pressure injuries stage 2 and above (% of eligible patients) 3.1% NA 3.5% 5.1% 2.6% 25% 4.6% *New KPI for 2018/19* 10% Relaunch of policies and pressure injuries bundle kit with the use of the e-learning module Enhance existing pressure injury assessment by revising the ED Nursing Care Record. Hospital acquired pressure injuries stage 2 and above (number of patients) 31 NA Explore innovative solutions to flag high risk patients using results beyond the Braden in the EMR () Create an automated flag in Meditech for high risk patients based on the Braden, lab results, nutrition status etc. Continue to implement closed-loop medication management system (SHS) Complete RFP process and select vendor. Work redesign in pharmacy prior to pharmacy automation in 2019/20 (MSH) Complete implementation of emar and bedside medication verification on 14 units () Ensure appropriate storage and dispensing in selected high risk ambulatory care areas (MSH) Review current state of storage and dispensing practices in ambulatory care settings and redesign as per best practice guidelines Redesign and implement in 4 ambulatory care areas (Eye Clinic, ENT, Fertility, Dentistry) 4 areas Safe Zero serious harm or death associated with high risk medications High risk medication incidents (includes opioids) causing serious harm/death (# of incidents) Theoretical Best 0 Theoretical Best Implement technological solution for monitoring of Develop criteria/protocol based on respiratory status in high risk patients (surgical units - technological solution, educate staff, and narcotic use) (MSH) implement on 1 pilot unit OPIOID STRATEGY Adopt Health Ontario opioid quality standards (SHS) Develop recommendations for safe initial opioid naïve doses (SHS) Develop policies and procedures for clinical interpretation of opioid dose range medication orders and opioid monitoring post administration Using best practices, develop recommendations to CPOE morphine and hydromorphone orders that adhere to general principles for safe initial opioid naïve doses

4 MSH MSH MSH Establish a multi-year SHS workplace violence Establish a governance and accountability strategy structure to monitor and advance workplace violence in accordance to the recommendations from the Public Services Health & Safety Association (PSHSA). Create driver diagrams, workplan, and key performance indicators Effective Workplace Violence # of Workplace Violence Incidents (Q2) *NEW Indicator* Collecting Baseline in 2018/19 across SHS Increase workplace violence incidence reporting Streamline incident reporting process by enhancing and upgrading electronic workplace violence reporting system, communicate and educate staff. Implement standard incident response process by developing standard incident response tools and educating managers in selected high risk areas # of incidents reported # of managers educated in selected high risk areas Collecting Baseline Evaluate Universal Precautions initiative for spread (MSH) Evaluation methods as set out in the project plan s th Roll out 10 level, 9S, 14S, 11S Develop Safe patients/safe staff community of practice forum (SHS) Web site development in collaboration with Communications and Marketing to create a repository of resources s Content development and web site designer identified Pilot BPSD screening approach for identified patients (MSH) Select and trial use of an evidence-based tool for all patients referred to geriatric psychiatry consultation liaison team with a diagnosis of dementia Number of identified patients with dementia with tool completed 80% screening completion Adoption of Standards in the management of behavioral and psychological symptoms of dementia Adoption of HQO standards NEW Adopted 2 quality statements *NEW Indicator* % Reduction in BPSD Symptoms among Diagnosed Patients Collecting Baseline in 2018/19 across SHS Define care pathway for identified BPSD patients (MSH) Trial supplementary standardized behavioural discharge summary (MSH) Develop and trial use of an evidence-based pathway for all patients referred to geriatric psychiatry consultation liaison team who are identified as BPSD patients Trial use of previously developed behavioural discharge summary and explore EMR access for all patients referred to geriatric psychiatry consultation liaison team with BPSD and who are discharged to an institutional setting Number of identified patients with BPSD with pathway used Number of patients with BPSD discharged to institutional setting with behavioral discharge summary completed 80% of identified patients have pathway used 80% of identified patients have behavioural discharge summary completed. Implement recommendations from the Transitional Care Unit review () Develop work plans associated with recommendations related to BPSD and implement change ideas

5 Pain management (did everything to control pain) MSH MSH MSH Complex medicine 64% 63% 62% 74% 66% 81% Standardize pain re-assessment practices post-prn Standardize and implement re-assessment % completion of pain-re-assessment 80% medication (SHS) practices including documentation post-prn post-prn medication medication on targeted units (ortho, medicine, WIH) and develop a plan for spread Effective Be a top 10% performer in pain management for post partum, complex medicine, and orthopedic populations including high risk populations with chronic pain issues (IBD, oncology) Orthopedic 74% 70% 72% 66% 77% 68% 5% improvement 5% improvement Women's & Infants 76% -- 77% -- 82% Develop a patient education tool that include pharmacological and non-pharmacological pain management options () Enabling patients to self-manage pain (MSH-WIH) Co-design with patients an educational tool that will show the various options for pain management. Increase staff awareness for nonpharmacological pain management options Spread self medication program to enable patients to have more control over their pain management. Implement proactive regular rounding to monitor patients for pain Orthopedic QBP Length of Stay Explore the opportunity to pilot a self-management app for primary hip/knee population (MSH) Build pre and post surgical modules/protocols for primary hip/knee that are aligned with best practices and launch app Hip/Knee: Maintain acute care LOS and improve rehab LOS 3 / 3 14 / 15 3 /3 14/14 3/3 Internally 11/11 20%/25% Ensure convalescent and LTC applications are processed through various stages in a timely manner (MSH) Develop and implement a pathway for convalescent and LTC applications with CCAC that is aligned to the escalation policy to maximize patient flow Timely Achieve top 10% QBP performance benchmarked against peers for average length of stay for Orthopedics Schedule unilateral hip and knee patients to be seen in Pre-Admit Unit 2-3 weeks prior to surgery (MSH) Map current state of process and develop a future state process for administrative assistants to ensure PAU appointments are booked 2-3 weeks prior to surgery % of unilateral hip and knee patients having their PAU appointments 2-3 weeks prior to surgery 90% Hip fractures: improve acute care LOS and maintain rehab LOS Internally 23 Internally Use clinical criteria on rehab program switches to ensure patients are admitted into the appropriate program () Develop a decision tree to guide clinical decision making to switch patients from high intensity rehab to reconditioning program and designation of service interruptions % staff educated on decision tree inclusive of physician Discharge patients as appropriate to conserve inpatient days and improve patient flow () Develop and implement a tracking tool to track days conserved for patients who are ready to go prior to their expected discharge date. # of days conserved CB

6 MSH MSH MSH Fully implement Oculys bed management system and Re-design and optimize workflow to support use # of units with electronic performance TBD the unit-based electronic performance measurement of the Oculys bed management system and the boards boards (MSH) unit-based electronic performance measurement boards. implemented Timely Decrease conservable days to become a top 10% performer for complex medicine patients at MSH and sustain LOS reductions at Conservable days for complex medicine (% of days without ALC days) 26.7% % % 15% Explore and implement geographic cohorting for GIM patients (MSH) to enable accountable care unit design principles Explore the development of an automated algorithm to generate estimated discharge date (EDD) based on most responsible diagnosis and implement on GIM units (MSH) Examine and design processes related to geographic cohorting including bedside rounding with patients and families, standardization of discharge planning, and appropriate staffing (MD, RN, Allied) ratios that meet variation in demand to ensure team balance. Engage with IM to explore the development build of an automated algorithm that will convert admission diagnosis into an estimated expected discharge date to facilitate and support flow and LOS. # of units implemented geographic cohorting # of GIM beds located on off-service units TBD # of patients with an EDD assigned 80% patients assigned an EDD within 24hrs of admission Implement and evaluate Home (MSH) Identification and enrolment of patients with CHF, COPD, CAP who fit defined program inclusion criteria. Complex rehab medicine: maintain LOS % improvement Sustain continence screening and implement continence management plan of care () Customize and implement integrated care plan and key messages on admission related to goal setting and discharge planning () Work with IT to build continence management plan of care in the EMR Co-design the integrated care plan with patients/families and implement on medical rehab units, and sustain on orthopedic units % screened 90% % of appropriate patients with a plan of 80% care # of units Implementation on 2 medical rehab units Spread and sustain the Transition Planning Risk Assessment Screening (TPRAS) tool (SHS) Implement the early risk identification tool to help with complex discharge planning # of units spread at % of patients screened with tool 3 neuro rehab units 80% Determine resources at MSH that can be shared with to improve patient care and increase flow across both sites by matching resources (e.g. geriatric psychiatry) (SHS) Identify key services that patients require and engage with key stakeholders to identify whether relevant resources at MSH can be shared and determine/recommend the model for shared resources Timely Decrease the overall percentage of ALC days for Medicine and Complex Continuing Care to less than 20% ALC Rate (medicine and complex continuing care) 34.7% 25.9% 23.3% 25.8% 22.0% Internally 23.2% 10% Implement relevant change ideas from the TCU Review related to effective transitions () Identify relevant change ideas that will support care to facilitate effective transitions, particularly for those with responsive behaviours

7 MSH MSH MSH Strengthen partnerships with external stakeholders to enable effective transitions (SHS) Develop and strengthen partnerships with TC LHIN, LHIN Home & Community Care, LOFT, and other stakeholders to explore innovative opportunities to transition patients to the community

8 MSH MSH MSH Ensure capture of the Clinical Decision Unit (CDU) for Optimize the CDU process to ensure all % total ED volume designated CDU <8% the right patients at the right time (MSH) appropriate qualifying patients are being captured for CDU CDU Admit Rate <30% Timely Be a system leader in Emergency Medicine by ensuring top 10 standing in "Performance Rank" in the Ontario Performance Rank Top 10 P4R ranking system for access and flow Internally Explore Circle of Care options related to transportation for ED patients (MSH) Pilot bedside ultrasounds in the ED (MSH) Partner with Circle of Care to explore and Business case developed develop a business case for readily available and accessible transportation options for ED patients Trial bedside ultrasounds with an ultrasound technician in the ED # of ultrasounds completed per shift Turnaround time from test order to completion completion Collecting Baseline Optimize physician workflow in the ED with the use of portable personal electronic devices with powertouch capbilities (MSH) Work with Informatics to acquire 30 portable devices such as ipads to enhance physician workflow and enable efficiency in the ED Physician initial assessment (PIA) time TBD Timely Be a system leader in Obstetrical wait times by ensuring Obstetrical Triage Acuity Scale (OTAS) priority 1-3 patients meet best practice times for assessment and disposition % patients within best practice target from triage arrival to medical assessment for OTAS 1-3 % patients within best practice target from medical assessment to disposition for OTAS % -- 27% % % -- *NEW Indicators* % meeting OTAS wait time level 3, 4,5 Collecting Baseline Develop and implement an enhanced nursing model to increase patient flow in triage (MSH) Enhance patient flow by continuing to combine the triage area and obstetrical day unit (MSH) Develop medical directives in which nurses are taking on a role to set discharge disposition for the appropriate patient population (e.g. move appropriate patients into labor and delivery or discharge home) Re-design workflow to optimize patient flow. Develop policies and procedures to support a combined unit of L&D and ODU staff. Educate all new triage staff to triage processes and OTAS scoring tool. completion completion Patient and Family Centred Achieve 90% in patient overall patient experience Overall patient experience (would recommend) 77% 79% 76% 81% 80% 5% 86% 5% Enact year 2 work plan for Cultivating Care: Caregiver Friendly Hospital and Community Hub: C- communication, A- caregiver assessment, R- caregiver recognition, E- education and resources (SHS) Implement Service with Heart training integrating PFCC principles (SHS) Spread and Sustain: Better Together Pledge - Family Presence Policy (SHS) Develop and implement workplans for stroke, palliative workstreams in partnership with WoodGreen and evaluate. Spread project to 2 other key populations. Trial caregiver experience measurement tool in target populations (SHS) Incorporate PFCC principles into Service with Heart training (live and elearning). Refresh training for MSH site and spread to. Full implementation of overnight visiting hours at site. Review and revise current family presence policy at MSH. completion % staff trained 80% full time staff? Experience of Staff, Patients Survey: % positive experience with expanded family presence policy Staff: >75%; Patient: >80%

9 MSH MSH MSH Ensure discharge summaries are sent to family Explore Cerner capabilities to enable discharge physicians post-discharge (MSH) summaries be sent to family physicians post discharge Re-design workflow to ensure family physician information are captured accurately during the admission process, in order for discharge summaries be sent to the patients' physicians Implement a self-management app for colorectal surgery patients to enhance continuity and transition and patient experience (MSH) Build the PAU module for the colorectal surgery program Spread PODS discharge tool and explore bundling Spread PODS to additional populations (MSH - PODS with follow-up phone calls post discharge (SHS) GIM; - Ortho and Stroke) % discharged patients given discharge tool Patient and Family Centred Achieve 85% in patient experience for Continuity and Transitions Continuity & Transition 66% 60% 66% 62% 69% 5% improvement 66% 5% improvement Create a self management strategy that encompasses the use of teach back and motivational interviewing methodologies (SHS) MEDICATION RECONCILIATION Fully implement admission BPMH and medication reconciliation in WIH and roll out Cerner discharge medication reconciliation tool (MSH) Explore and implement process in which the clinical team will follow up with patients within 7 days of discharge on selected units Train clinical staff on the teach back and motivational interviewing methodologies Determine current state and re-design future state workflow with the WIH clinical teams. Explore the use of pharmacy technicians to perform BPMH as part of the process for complicated, identified patients. % discharged patients received followup phone call on selected units 75% % of clinical staff trained 80% full/part time staff % of Admission BPMH and medication reconciliation completed on antenatal units 70% BPMH & med rec (WIH) Re-design workflow to ensure the tool is used and medication reconciliation is completed on discharge. % of discharge medication reconciliation completed for eligible patients (exclude WIH) 70% medication reconciliation completion (exclude WIH) Spread BPMH and medication reconciliation to the remaining ambulatory care clinics () Engage with the ambulatory care team to redesign workflow to ensure BPMH and medication reconciliation are being completed as appropriated based on selected criteria Implement in all appropriate ambulatory care clinics % BPMH and medication reconciliation completed 4 ambulatory care program areas (outpatient rehab as appropriate, internal medicine, psychiatry, physiatry) 70%

10 Patient and Family Ce ntred Achieve 85% in patient experience for "informed" MSH MSH MSH Informed care 53% 44% 52% 46% 54% 5% 49% 5% Spread access for MyChart Patient Portal through Create workflow to enable patient enrolment # of patients enrolled into patient 25% improvement from Q4 MSH. Explore spread to. across MSH in alignment with electronic health portal baseline 2017/18 card validation availability. Define policy for caregiver access to Patient Portal. Determine value for having MyChart at. Operationalize Caregiver Resource Centre () Co-design contents of Caregiver Resource centre. milestone and Family Centred Ensuring 80% of all corporate quality initiatives will have patient and family engagement Patient and family engagement in quality initiatives 40% 56% 70% (40% ) Fully implement and sustain foundational activity Implement, sustain and evaluate support using the Moore Foundation Roadmap for Patient mechanisms that prepare patients and families Engagement to ensure patient and family and staff to partner including a) recruitment preparation, clinician and leadership preparation and and interview processes, ongoing identification organizational partnership. Develop strategies to and selection of effective patient and family ensure broader reach in engagement for diverse advisors b) processes to match patients and populations (SHS) families with opportunities of interest that make use of their skills. Devise and trial creative engagement strategies for diverse populations. # patients and families matched to initiatives 25% improvement from baseline year 2017/18 Patient Ensure sustained partnership with patient and family advisories. Create 2 additional patient and family caregiver advisories.