Sunnybrook Health Sciences Centre Quality Improvement Plans (QIP): Progress Report for 2016/17 QIP. Target as stated on QIP 2016/

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1 Sunnybrook Health Sciences Centre Quality Improvement Plans (QIP): Progress Report for 2016/17 QIP ID Measure/Indicator from 2016/17 1 % of patients who have delirium recorded in their health record ( %; General Internal Medicine patients; Q1 15/16; EMR/Chart Review) Change Ideas from Last Years QIP (QIP 2016/17) Enhance physician and resident education Audit & feedback to physicians and residents as stated on QIP 2016/ idea implemented as intended? Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Resident education occurs monthly. In addition, interprofessional staff across General Internal Medicine units continually reinforce with physicians and residents the importance of recording delirium in the chart. Delirium rates are included in the resident education. More emphasis on feedback is recommended going forward. Patient / family involvement Two Patient Family Partners have been working with us. In addition to attending regular meetings, they have co-presented with the Senior Friendly Team, have been involved in the creation of a video on our work with Toronto Paramedic Services (see below) and have reviewed our / 18 QIP submission. Develop interprofessional delirium prevention & management protocols Optimize knowledge of patient s pre-hospital condition Continue to focus on the accurate assessment, identification, prevention and management of A Delirium Order Set is in development with input from an interprofessional team comprised of a Physician, Nurse Practitioner, Occupational Therapist, Advanced Practice Nurse and a Pharmacist. In-house experts have provided input to the drafts developed. The final document is nearing completion. Optimize knowledge of patient s pre-hospital condition Y Toronto Paramedic Services ambulance staff have received education with respect to the importance of collecting information of patients pre-hospital condition and a template has been integrated within their work processes. Evaluation of impact is ongoing. A specific ACTION project through the Regional Geriatric Program has been aligned to this work, with weekly staff education that includes quality improvement methodology. Data over time has improvement due to the

2 delirium. intervention. ID Measure/Indicator from 2016/17 2 % of patients with a QBP hip fracture discharged to rehabilitation services within 7 days of admission (Defined as the number of patients with a QBP hip fracture discharged to rehabilitation within 7 days of admission divided by the total number of patients with a QBP hip fracture discharged to rehabilitation.) ( %; patients with a QBP hip fracture; Q2 2015/16; Hospital data) Change Ideas from Last Years QIP (QIP 2016/17) Enhance discharge planning and early referral to rehabilitation services Standardize management of hip fracture patients across inpatient units Engage patients and families/caregivers idea implemented as intended? as QIP 2016/ Q1 16/17: 46.4% Q2 16/17: 62.9% Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Daily bullet rounds were utilized as key venue for prioritizing discharge planning. Learnings included the importance of dedicated time for rehab referral completion, balancing early rehab referral with clinical readiness, and considering clinical workflow when setting targets for referral completion. Considering strategies to create visual cues of rehab referral completion as a next step. Hip fracture care pathway and admission and post-operative order sets revised, and currently in final stages of approval. Clinical judgement determined to be the best method for determining need for consult by other clinical service teams. Strategies planned for ensuring adoption of best practices across inpatient units include leveraging expertise through new partnerships, and defining roles and responsibilities for newly created Physician Assistant role in Orthopaedics. Planning for patient engagement through patient shadowing, interviews, and post-discharge surveys in progress.

3 3 Overall, how would you rate the care and services you received at the hospital? (inpatient), add the number of respondents who responded Excellent, Very good and Good and divide by number of respondents who registered any response to this question (do not include non-respondents). ( %; All patients; October 2014 September 2015; NRC Picker) Change Ideas from Last Years QIP (QIP 2016/17) Continue targeted implementation of the Person Centred Care (PCC) education program (consists of a 16-week cycle of called Seeking & Embedding the Voice of the Patient ). Continue broad implementation of the Person-Centred Care (PCC) approach Develop spread & sustainability plan for Person Centred Care as No baseline available idea implemented as intended? QIP 2016/ This is only the 2nd quarter of a new patient experience measurement tool and so we will continue to watch and in order to determine a reasonable target in the future. Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? The education has evolved from lengthier engagements to 15 minute sessions, held on patient care units. Sessions are tri-led by unit leaders, patient and family partners and Person-Centred Care committee members. Measurement is achieved through Conversations with Patients (an in-person survey measuring patients observations of person centered care behaviours). The Person Centred Care approach of Seeking & Embedding the Voice of the Patient has been integrated in orientation, with patient / family partners co-presenting when possible. Patient / family partners are also part of committees & Person Centred Care staff champions are aligned to this work. Engaging volunteer services remains outstanding. A sustainability plan is guiding this work. The plan focuses on the following key areas: governance, targeted education & implementation, broad engagement & communication, and sustainability all of which are reporting on a regular basis to the Person Centred Care Steering Committee.

4 4 90th percentile Length of Stay all Non- Admitted patients ( 90th percentile; non-admitted; Q ; Hospital collected data) Change Ideas from Last Years QIP (QIP 2016/17) Shorten the time between when a patient is triaged and when a physician first assesses them. (This is called Physician Initial Assessment or PIA.) Shorten the time between when a patient is triaged and when a patient is seen by a specialist, also called a consultant. (This is called Consult Arrival Time.) Collaborate with Diagnostic Imaging (DI) to improve turnaround times for imaging for Emergency Department patients as stated on QIP 2016/ idea implemented as intended? Consult Community Partnership Initiative Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Chair model was expanded to reduce patient wait time. In addition, detailed analysis into factors affecting PIA indicate that patients who require lab or radiology exams (as determined by triage nurse) have a longer PIA and that reducing PIA for these patients would have a small but meaningful impact on ED LOS. Efforts are being made to shorten turn-around times for CT exams in particular, so as to reduce PIA and overall ED LOS. Monthly data for the top 7 services is discussed at the MAC each month. Greater emphasis is being placed on resident education. A pilot project with the Department of Psychiatry is presently underway using new technology to improve consult arrival times. Automated the surge protocol so that when the wait for an Emergency Department CT test is above 90 minutes, a technologist is automatically called to see if more staff need to be added or if outpatient resources can be redeployed. Improved processing time from 45 minutes to 5 minutes for whole body scans by investing in image processing to split images, enabling enable sub-specialty radiology reporting. Revised CT protocols resulting in fewer patients having to drink a contrast fluid in some abdominal CT exams and reduced turnaround times while maintaining quality. Expanded data collection to include ultrasound and plain film radiography as well as more time measures to better understand where improvements can be made. On the yearly schedule for the early fall meeting, we review data and

5 (a patient advisory group that includes previous patients) Develop Emergency Department order sets to streamline care. Increase Clinical Decision Unit (CDU) utilization (a patient flow designation during which time further diagnostics and monitoring take place). get input from the patients and family members that sit on our Community Partnership Initiative (Patient/Family Advisory Committee). We developed the order sets and will implement them over the next month. This initiative took longer than expected due to the large number of stakeholders across multiple disciplines, delays in the committee turnaround time and obtaining signatures from all the Emergency Department physicians. CDU Utilization was closely monitored with the intention of optimizing use while remaining within limits set by Ministry of Health. Further use of this designation is to be explored through a new project for low acuity patients.

6 ID Measure/Indicator from 2016/17 5 Admissions to the Toronto Central Local Health Integration Network (TC LHIN) Palliative Program ( patient referrals; all eligible palliative patients; 2014/15; TC CCAC) Change Ideas from Last Years QIP (QIP 2016/17) Increase linkages with system partners to enhance referral processes. as QIP 2016/ NA Please note that the baseline and target for this indicator were adjusted mid-year to better reflect Sunnybrook's role in this process. The original palliative indicator was measuring Step 3 in a threestep process. o Step 1 - Sunnybrook places a patient in the referral system for the Community Care Access Centre (CCAC) Home with palliative care program o Step 2 - CCAC computer automatically accepts the patient into the palliative care program o Step 3 CCAC staff assess the patient and confirm that they will be admitted into their Palliative Care program. The reasons someone might not be admitted into the program can vary from out of district", to no longer wants, to no longer qualifies etc. Sunnybrook strives to use measures that reflect the work of our staff and within our sphere of influence therefore, we chose to change the measure to be Step 1. Revised data is below: New baseline: 82 New target: 98 at Q3 = 106. idea implemented as intended? Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? We found that it was extremely valuable to partner with both the Toronto Central Community Care Access Centre (CCAC) and the Sunnybrook Palliative Care Unit. Through partnering, we were better able to understand admission criteria and what information was important in referrals. We also learned the importance of making early referrals, so that the patient could benefit from the full range of services offered in

7 Expand processes used in Sunnybrook s Odette Cancer Program for referring directly to TC LHIN Palliative Care Program to other programs. Involve patients and families in development of referral process. Implement an education program for staff about the clinical options for palliative care in the home. Palliative Care. Sunnybrook's Community Program, which includes General Internal Medicine and Nephrology, was particularly successful in adopting processes used in Sunnybrook s Odette Cancer Program for referring directly to Toronto Central Community Care Access Centre (CCAC) Palliative Care Program. There is a plan under development to achieve this by March 31,. We found that it was extremely valuable to have the Toronto Central CCAC Palliative Care Team meet with our Community Program Team to discuss the home based Palliative Care Program. Many of the Sunnybrook staff did site visits to patients in the home, and came back with a better appreciation for the level of service being delivered in the home. This learning helped with building confidence and trust, and led to an increase in referrals to the Program.

8 6 Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital ( Rate per total number of admitted patients; Hospital admitted patients; most recent quarter available; Hospital collected data) as Change Ideas from Last Years QIP (QIP 2016/17) Expand the Emergency Department Pharmacy Technician Best Possible Medication History* (BPMH) Team to increase the number of BPMHs completed to support increased completion of admission MedRec**. * a systematic and comprehensive review of all the medications a patient is taking ** MedRec consists of comparing the BPMH to admission medication orders to ensure all changes to the medications a patient is taking are intended changes and are documented clearly in the chart. Develop electronic admission Medication Reconciliation ( emedrec ) functionality in Sunnycare for limited-use release in Bayview acute care units and at Holland Centre beginning October Note: At this time, approximately 90% of admission MedRec is measured manually. For the remaining 10%, sampling and surrogate measures are used. In the future, the completion rate for all admission MedRec will be measured electronically within emedrec (Sunnycare). QIP 2016/ A drop in December s Medication Reconciliation (MedRec) rate resulted in a drop in the overall admission MedRec rate. December s drop was a result of a decrease in admissions via the Pre- Anaesthesia Clinic and increased admissions via the Emergency Department idea implemented as intended? No Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Consistent with expectations, expansion of the Emergency Department Pharmacy Technician Best Possible Medication History (BPMH) team resulted in an increase in the number of BPMHs completed which supported an increased completion of admission MedRec. The electronic admission Medication Reconciliation ( emedrec ) functionality in Sunnycare (Sunnybrook's electronic medical chart) is nearing completion and is on target to be ready in May. Develop and implement a plan to identify and address We implemented the 5 Questions to Ask about your

9 patient determined needs/areas for improvement as it relates to MedRec. It is anticipated that these may relate to: education (importance of carrying an up-to-date medication list and showing it whenever seeking care, how it s used, etc.) and development of patient and caregiver friendly features in Sunnycare (e.g. discharge medication lists printed in patient and caregiver friendly formats) Medications campaign from ISMP Canada (Institute for Safe Medication Practices), which contains information about the importance of patients sharing up-to-date medication lists. Posters were displayed in patient waiting areas and clinics. The new Sunnycare MedRec system will print medication lists in patient and caregiver friendly formats.

10 7 Number of Conversations with inpatients and their families about their experience at Sunnybrook. ( Counts; All acute patients; Q4 14/15 to Q3 15/16; Hospital collected data) as Change Ideas from Last Years QIP (QIP 2016/17) Continue staff-led Conversations with patients/families about their experience at Sunnybrook Expand initiative by adding leader-led Conversations with patients/families about their experience at Sunnybrook QIP 2016/ We are extremely pleased to have engaged with such a large number of patients in these structure feedback conversations. idea implemented as intended? Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Corporate Nursing Council, with front line nursing representatives from the organization, has provided leadership for this important initiative. Broader team members and leaders are invited to also participate. The results of the conversations are shared in the Best Practice Matters Dashboard, and include verbatim comments from patients and families. Teams are encouraged to review their results and reflect upon how to improve. Leaders have led many additional conversations with patients, with data available now for over 40 inpatient and ambulatory care areas. Expand sharing of and accountability for results. Results have been shared with leaders over the course of the year. Qualitative comments have been reviewed with key patient messages identified by Nursing Council members to discuss with peers. Within the Conversations with Patients/Families about their experience at Sunnybrook, ask about the behaviours expected of staff as part of Sunnybrook s Seeking and Embedding the Voice of the Patient approach to person-centred care. Over 40 unit based education sessions have been held, with Conversations with Patients discussed as the primary measure of SHSC s Person-Centred approach to care. Education with ambulatory areas, infection prevention and control and other service areas is slated for / 18.

11 8 Percentage of surgical cases cancelled. The percentage cancellation rate is determined by the number of patients cancelled* (data source: the OR information system, PICIS ) over the number of scheduled surgical cases on the OR list that is printed at 11 a.m. the business day prior to surgery. *A case cancellation is one where the scheduled surgical case on the OR list (includes M2 and M-Ground Operating Rooms # 1-20) does not proceed. (A cancellation might occur anytime between 11 am the previous business day and just prior to the initial surgical incision. Once an incision is made the case is no longer considered a cancellation.) ( %; see definition in Indicator definition; Jan - Dec 2015; Hospital information system) Change Ideas from Last Years QIP (QIP 2016/17) Involve the clinical programs and surgeons to reduce cancellations due to surgeon running late Involve clinical programs and surgeons to reduce cancellations due to patients that are categorized as being medically unfit for surgery Involve patients and families in reducing last minute cancellations Occupancy Executive Committee to continue to lead initiatives to reduce OR cancellations due to no bed being available. idea implemented as intended? as QIP 2016/ As of Feb 19/17. Monitored weekly. Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? The Operating Room (OR) leaders and staff have worked with surgeons to improve booking codes to more accurately reflect surgical booking time required. Physicians have been asked to review medically unfit cancellations for accuracy of code use. We provided a phone number for Patients/family member to call in the case of a last minute cancellation. Instructions given to patients & family at the time of the Pre-Anesthesia Clinic visit. Bed occupancy monitored weekly at Occupancy Executive Committee. Surge procedures (for very busy times) were put in place to open additional beds in exceptional circumstances.

12 9 Proportion of patients undergoing pancreatic surgery who develop a Surgical Site Infection ( %; Patients having pancreatic surgery; Apr Mar 2015; NSQIP) Change Ideas from Last Years QIP (QIP 2016/17) Improve rates of perioperative glycemic control. Enhance the use of wound protectors on all open pancreatic cases. Improve handling of clean and dirty instruments and equipment Pre-operative shower with Chlorhexidine 4% applied twice (for elective patients) Reduce pancreatic leak rates idea implemented as intended? as QIP 2016/ performance represents Q2 16/17 (Q1 rate= 14.3%) Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Perioperative screening compliance has been 100%. In collaboration with our Endocrinology s rapid assessment clinic, we have been able to have the newly diagnosed patients seen pre-operatively in a timely manner in order to get their blood glucose under control. As a result of this collaboration, we have learned that all our patients have access to Rapid Endo assessment clinic and they can be seen there prior to surgery if their HbA1C level (one measure to determine whether or not a person s diabetes is well-managed) is within a certain range ( >7). All surgeons have been 100% compliance with the use of wound protector in all open cases. We have introduced a separate tray when closing the fascia which carries all clean instruments. All surgeons and staff who have scrubbed (washed their hands and forearms very thoroughly) change gloves at the time of closing. All elective surgical patients are being instructed to shower with Chlorhexidine 4% (a disinfectant solution) the night before and morning of surgery. Patient use has not been consistent. Further study needs to be done to better understand the barriers resulting inconsistent use (e.g. examine practice of patients being responsible to purchase the solution from the pharmacy). All inpatients awaiting pancreatic surgery receive Chlorhexidine 4% wash in their unit. All nurses have been educated, supplies are available in the unit and the pre-op order sets are being revised in order to be aligned with this new best practice. No The intended medication (Pasireotide) is not approved by Health Canada to be used for the purpose of leak reduction in pancreatic surgery.

13 as QIP 2016/17 10 Sunnybrook's indicator for Hand Hygiene: The number of times that hand hygiene was performed during all 4 moments for proper hand hygiene, divided by the total number of observed hand hygiene moments, multiplied by 100. (The 4 moments are: Your care provider should clean their hands: 1) Before contact with you; 2) Before a procedure; 3) After a procedure; and 4) After contact with you. ) ( %; Health providers in the entire facility; Q2 15/16; In-house survey) Change Ideas from Last Years QIP (QIP 2016/17) Visible senior leadership support: Chief Executive Officer as well as Senior Leadership Team to be role models for hand hygiene. idea implemented as intended? Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Visible senior leadership support is essential to improvement and sustainability. Hand hygiene observer role Direct observations essential as in-the-moment education for improvement. Ensure accurate placement of point-of-care alcohol-based hand rub (ABHR) product Point-of-care product essential for hand hygiene compliance. Placement should be periodically reassessed to ensure it is still functioning appropriately. Education Education essential to improvement. Needs to be ongoing and re-enforced. In-the-moment education by observers is essential to continuing improvement. Enhance communication and awareness of Hand Hygiene activities Formal corporate communication heightened organization awareness. Hand Hygiene Champions Had minimal impact on the program. Difficult to have ongoing communication with the unit champions as workload prohibited time to meet as

14 Patient and family engagement Clean Hands Matter* patient empowerment campaign for in-patients; expanding to ambulatory areas, ICUs, Veteran s Centre Patient as observer for out-patient *The goal of the Clean Hands Matter campaign is to make patients aware of what healthcare providers are supposed to do to prevent the spread of infectious organisms. As well, the initiative is meant to empower patients, essentially giving them permission to ask the question Did you clean your hands? a group This had some impact on staff awareness and served to engage patients in this patient safety initiative.

15 11 Total Average Length of Stay of successfully repatriated Trauma and Neurosurgery patients. ( Total Average Length of Stay of successfully repatriated Trauma and Neurosurgery patients.; Successfully repatriated Trauma and Neurosurgery patients.; 2014/15; Hospital data) Change Ideas from Last Years QIP (QIP 2016/17) Improve communication to physicians of repatriation patients under their care Maintain or improve length of stay after repatriation desk Is called. Raise awareness among clinicians and the interprofessional team of patients eligible for repatriation Consult patients to identify new ideas for improving transfers. Use technology as a process and management tool Optimize patient/family and Sunnybrook staff awareness of repatriation idea implemented as intended? No as QIP 2016/ Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? We have a physician lead who is following up on cases and this improves the engagement. We are still working on additional physician engagement. See below for the technology improvements we are instituting. We have instituted an escalation process that we use in cases that are extending beyond the normal time frame. This seems to be working and is actually leading to other discussions that are improving relationships We will soon have a flag for potential repatriation patients in our Electronic Patient Record. This should improve the ability for all team members to identify a potential patient. The manual flag system was challenging to maintain so we think the electronic version will be better There is a bit of a delay in getting onto the agenda of the community group to get input from community members. We will proceed with this but will also need to consult other patients and families as the current patient advisory group is within our catchment and not likely to experience repatriation. This will be a priority for the spring. There has been a delay in the technology. We are nearly ready to release and then will survey groups for feedback. We have implemented a number of solutions to keep patients, families and staff aware of repatriation. Postcards are appreciated by staff and patients. There is information on the hospital website. We feed back to staff data on repatriation. We have also implemented 'standard operating procedures' related to repatriation discussions in areas with high opportunity for repatriation.

16 12 Total Margin (consolidated): Percent, by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization, in a given year. ( %; Financial; Q3 2015/16; Financial Statements) Change Ideas from Last Years QIP (QIP 2016/17) Improve operating room staffing and utilization Improve supply management Identify increased revenue opportunities idea implemented as intended? as QIP 2016/ Lessons Learned: (Some Questions to Consider) What was your experience with this indicator? What were your key learnings? Did the change ideas make an impact? What advice would you give to others? Sunnybrook achieved success in reducing turnaround time and has demonstrated improvements in utilization. Smaller changes were implemented than at first anticipated since the surgeons, independent of management s specific initiatives, significantly improved their utilization, maximizing funded case volumes, leaving less opportunity for further change. Success has been materially achieved through a focused review involving a combination of pharmacy, clinical and business personnel to review drug usage and to identify safe, quality substitutions. The reprocessing opportunity was explored but determined not to be viable, instead capacity at the Holland site has been maximized by the transfer of additional surgical cases from the Bayview site. However, increased revenue has been significantly achieved via growth in outpatient pharmacy revenues.