March 28, 2012 This document is intended to provide public hospitals with guidance as to how they can satisfy the requirements related to quality improvement plans in the Excellent Care for All Act, 2010 (ECFAA). While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and hospitals should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, hospitals are free to design their own public quality improvement plans using alternative formats and contents, provided that they comply with the relevant requirements in ECFAA, and provided that they submit a version of their quality improvement plan to HQO in the format described herein. North York General Hospital 1
Part A: Overview of Our Hospital s Quality Improvement Plan 1 Overview of our Hospital s Quality Improvement Plan for 2012-13 North York General Hospital s (NYGH) Quality Improvement Plan (QIP) is linked to our new mission of providing exceptional health care to our diverse communities and our vision to lead the pursuit of excellence through learning, innovation and partnerships. At NYGH staff, physicians, volunteers and students are committed to ensuring that patients receive the safest, highest quality, evidence-based care in a cost effective and efficient manner. We embrace a culture of quality and patient safety where collaboration among staff, physicians and volunteers is promoted. At NYGH, we recognize that patient safety and quality care are everyone s responsibility. Our commitment to quality and safety has been recognized at the national level. In February 2012, NYGH received Accreditation with Exemplary Standing, the highest designation from Accreditation Canada. We met 100% of over 1,800 standards, including all patient care services and administrative functions like strategic and operational planning, and community engagement. 2. Our objectives and how they will improve the quality of services and care at NYGH NYGH s annual Quality Improvement Plan (QIP) is based on a comprehensive assessment of our opportunities to improve quality and safety. It builds on our previous year s plan and is aligned with our annual corporate priorities. In 2011/12 we achieved the targets set for 5 of our QIP objectives and identified further opportunities for improvement where targets were not achieved. In our 2012/13 plan, 7 objectives from the previous year have been carried over. We have set a total of 8 objectives, including a new patient safety objective focused on falls prevention. This objective has been identified as a Priority 1. Patient safety objectives comprise 50% of the plan, which reinforces our commitment to improving quality. Continual performance goals associated with quality improvement supports a culture of patient safety. NYGH has committed resources to execute quality improvement, which include: Patient Experience Specialists who support clinical programs by providing patient feedback perspective, and expertise in risk management, incident reporting and patient safety Quality Improvement Specialists who use Lean management philosophy to provide expertise in project management, techniques and tools to drive performance. We continue to be leaders in embedding a Lean approach to quality improvement in hospitals A strong quality infrastructure with clinical program councils, Quality Boards and Quality Circles A corporate Quality of Care Committee that engages quality and safety at all levels of the organization North York General Hospital 2
The Board Quality Committee receiving monthly program reports and presentations on quality, safety and improvement activities. Recognition of staff and physicians for their efforts in quality improvement is also a component Support of physicians to participate in our Access to Care strategic priority, through a Physician Champion model Organizational Development s support in partnering to build quality improvement capacity at all levels. Practical Project Management workshops have been a success and engaged staff to lead improvement initiatives at the local level. Our management team is being supported through our Fundamentals of Leadership Insight The investment in an upgraded electronic reporting system that includes both incident reporting and patient feedback Our Information Technology Strategic Plan is a comprehensive, robust and future-oriented plan. It builds on the recognized success of our electronic health record, computer provider order entry (CPOE), and closed loop bar code medication administration initiatives. Medication reconciliation is a key safety driver. With our electronic system, we are achieving a high degree of compliance. CPOE is kept current and is evidence-based through ZYNX. NYGH understands that patient safety is improved through a commitment to information systems and the high level of adoption by the end users. Our 2012/13 plan sets out detailed work that NYGH will undertake to continue to improve safety, effectiveness, accessibility, integrated care and the patient experience. Specifically, we will: Improve patient safety by: 1. Reducing the rate of hospital acquired C Difficile. Our Antimicrobial Stewardship Program is working collaboratively with physicians to build capacity and understanding of antibiotic usage, which is a key contributor to C Difficile. NYGH achieved positive outcomes year 1 of the program and these outcomes will be built on in year 2 as the program expands. Best practices in cleaning of equipment and patient rooms will continue and be monitored. 2. Improving hand hygiene through our multi-year initiative that builds on our success. Though we have sustained a compliance of over 80% and it continues to increase, we believe that 100% is achievable and will work towards that goal. The target for 2012/13 is 85%. Visual management of audit results and regular discussions with staff and physicians our strategies that will continue. 3. Preventing pressure ulcers. NYGH has been a leader in reducing and preventing pressure ulcers by using a best practice strategy and building internal capacity and accountability. Our strategy will be refreshed to ensure that practices are sustained and feedback mechanisms supported. In addition our participation in the MOVE ON program through CAHO, a mobilization initiative for the vulnerable elderly, will contribute as patients who are more active have improved skin integrity. 4. Preventing falls and reducing the number of serious or moderate patient falls is a priority. Our corporate Falls Prevention Steering Committee will continue to work on standardizing best practices in risk reduction and prevention. The Child and Teen Program will implement the Humpty Dumpty Falls assessment score, as all patients should be assessed, no matter the age. North York General Hospital 3
Improve the effectiveness of care by: 1. Early detection and treatment for patients with sepsis. Building on the success of implementation of the Institute for Healthcare Improvement sepsis bundle in our Critical Care Unit, the evidence-based program is being expanded to the adult medicine and surgical areas. Staff and physician education, evidence-based order sets (CPOE) and ongoing feedback will be enablers to the program. Improve access to care by: 1. Ensuring that our patients receive the right care at the time in the right location. Access to care continues to be a strategic priority for NYGH. As our work on patient flow and access evolve and matures, further opportunities to improve on the length of time a patient waits to be admitted have emerged and are being tackled. We recognize that improvements are multifactorial and have both internal and external factors. Different considerations are needed for the patient who is waiting for a bed, the patient being discharged home and the patient who is going to an alternate level of care environment. Our multi-year Access to Care strategy identifies structures, initiatives and resources required to continue to improve patient access to care. 2. In June 2011, NYGH opened 11 short stay beds (SSU) with a 72 hours length of stay. Through appropriate admission criteria and early development of a plan of care which includes a discharge plan we have exceeded our target of 80% of patients being discharged within 72 hours and have established a new goal for 2012/13. Successes from the SSU will look to be replicated in other units. Success in our work to improve access and flow is contributed to an organizational focus and the resources allocated for improvement. Though NYGH has seen improvements in wait times there is still work to be accomplished. Improve the patient experience by: 1. Patient and family-centered care is strategic priority at NYGH. Our Emergency Department (ED) is committed to ensuring that patients have an exceptional experience and that the overall quality of care they receive is excellent. In 2011/12, pain assessment and management in the ED were priorities; strategies for improvement were implemented and will continue to be monitored. At NYGH, we measure the patient experience through the NRC Picker external patient satisfaction survey. It provides details on where we are performing well and where opportunities exist. In the ED the results tell us we need to better address patient anxieties, fears and concerns. These communication gaps will be developed through staff and physician skill enhancement, scripting and role modeling. In addition, patient and family education of the plan of care at discharge will be enhanced through written information and confirmation of understanding. North York General Hospital 4
Improve the integration of care by: 1. Partnering with our external stakeholders on a shared vision and accountability is essential to improving transitions of care. We will strive for excellence in integrated patient-centred care, building on our current strengths and partnerships. 2. Implementation of an evidence-based Stroke Unit, a cross LHIN initiative, will ensure that patients receive the right care at the time in the right location. Shared outcomes will be evidenced amongst all stakeholders. 3. Strengthened CCAC partnership as they are critical to the transition of care for our patients. Through increased communication and shared planning, the patient stay in our acute care facility will be reduced. The initiatives identified in this integration of care dimension also impact our accessibility dimension and objectives and patient flow. 3. How our plan aligns with our other planning processes In February 2012, NYGH completed a strategic planning process with the unveiling of a new Mission, Vision, Values and Strategic Directions. In charting our future, the hospital embarked on an elaborate process of engagement with our community, key health system partners, physicians, staff and volunteers. Led by our Strategic Planning Committee and Strategic Advisory Group, this process enhanced our understanding of the current Ontario health system sector as well as our individual areas of differentiated strength. The two overarching strategic directions in the plan are Excellence in Integrated Patient-Centered Care and Building on Our Academic Foundation. Every year, NYGH undertakes a Planning Our Future: Operating Planning process that details our activities for the coming year. In addition to our Strategic Plan and strategic directions, the drivers for this planning include: People Plan Quality and Safety Plan Capital Plan which includes equipment, construction and building infrastructure, information technology and ehealth Hospital Services Accountability Agreements Public Reporting of Hospital Performance Operating Plan Master Clinical Plan Monitoring of activities is through our Leadership Evaluation Manager (LEM) tool and process. Monthly standard work and metrics and 90-day plans are developed in concert with President and CEO annual objectives. These cascade to all levels of management and set our roadmap for the year. Our Quality Improvement Plan aligns with our organizational strategy and is complementary to our existing Patient Safety Plan. The QIP has been informed by improvement activities and planning processes, such as: Accreditation Canada Qmentum survey, Central CCAC, Regional Planning (Emergency Department Pay for Results, Cancer Care Ontario, Alternate Level of Care) and Central LHIN priorities. Each indicator has an executive lead accountable for ensuring that there is an action North York General Hospital 5
plan with tactics, targets and timelines. Indicators are included in our Corporate Balanced Scorecard, and will be reviewed at operational and governance levels on a monthly basis. 4. How our plan takes into consideration integration and continuity of care beyond our walls In August 2011, the Central LHIN released their Patients First: An Action Plan to Improved Quality In Transitions of Care document. This action plan was a LHIN-wide collaboration and aligns with the Central LHIN Strategic Plan and provincial quality directions. The action plan identifies 3 system-wide strategies on which integration and continuity of care will flourish. These are: strengthening relationships standardizing hospital discharge processes identification of indicators in transitions of care The NYGH QIP plan aligns with these strategies and includes change plans that incorporate enhanced collaboration, planning and communication with acute care, the CCAC and other community agencies. Partnerships and shared objectives are essential to ensure that integration and continuity of care are 5. Challenges, risks and mitigation strategies At NYGH quality and safety planning is an iterative process. Monitoring, evaluating and learning are key components of our processes. Internal processes include review of aggregate data from critical incidents, other incident reviews, patient feedback and staff and physician involvement, discussions at all levels of the organization. External reporting requirements also help to inform the process. Informed decision making includes the expertise of external agencies that are provincial, national and International. Furthermore, the feedback received through the 2011 self assessment and on-site survey processes for accreditation provide opportunities to improve quality. Reporting on quality and safety is incorporated into both the Quality of Care and the Board Quality Committees. To mitigate the challenges we face and to ensure success in delivering on our Quality Improvement Plan, our Corporate Balanced Scorecard includes a Quality and Safety Dashboard that is integrated into our Business Intelligence (BI) tool. Classification of target achievement is done through a visual management approach. Green indicators identify metrics that are on/above target, yellow indicators are metrics within the performance corridor and red indicators are underperforming or below the performance corridor. When an indicator is yellow or red an analysis is performed and opportunities for improvement are documented in the BI tool. Indicators that are consistently underperforming are reported to the Board Quality Committee. NYGH supports many growing communities. Faced with an aging provincial and local population, one that is ethnically diverse and spans both ends of the socio-economic spectrum, the hospital will increasingly be faced with challenges in providing appropriate and equitable access to services for patients and families that is sensitive to a wide range of linguistic, cultural and socio-economic factors. These factors will impact the demands of our Emergency Department, inpatient units and ambulatory services, along with the pressures of responding to seasonal variations, unpredictable surges and unanticipated health crisis s. North York General Hospital 6
Access to Alternate Level of Care (ALC) is an ongoing challenge and one that does not appear to be abating. Throughout the health care system there is a lack of aligned policies, procedures and services. The patient and family decision-making process extends the length of time a patient remains in an acute care facility and reduces access to patients waiting in the Emergency Department. At NYGH, we are challenged to significantly reduce ALC days as improvements must be addressed both internally and externally. Partnerships and shared objectives are necessary to ensure that the system can meet its increasing needs in addition to those of the patient and family. An ongoing challenge for every hospital is a fiscal uncertainty. Both the provincial budget and the Drummond Report have called for greater integration and further fiscal restraints. NYGH has a strong history of fiscal responsibility. We have shown great leadership in protecting and improving patient care while operating within a balanced budget. We are well-positioned to identify and respond to fiscal challenges as they arise. North York General Hospital 7
Part B: Our Improvement Targets and Initiatives Purpose of this section: Please complete the Part B - Improvement Targets and Initiatives spreadsheet (Excel file). Please remember to include the spreadsheet (Excel file) as part of the QIP Short Form package for submission to HQO (QIP@HQOntario.ca), and to include a link to this material on your hospital s website. [Please see the QIP Guidance Document for more information on completing this section.] [Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Use the Text Box Tools tab to change the formatting of the pull quote text box.] Please see the accompanying document. North York General Hospital 8
Part C: The Link to Performance-based Compensation of Our Executives The purpose of performance-based compensation related to ECFAA is to drive accountability for the delivery of quality improvement plans (QIPs). By linking achievement of targets to compensation, organizations can increase the motivation to achieve both long and short term goals. Performance-based compensation will enable organizations to ensure consistency in the application of performance incentives and drive transparency in the performance incentive process. Please refer to Appendix E in the QIP Guidance Document for more information on completing this section of the QIP Short Form. The guidance provided for executive compensation is also available on the ministry website. Manner in and extent to which compensation of our executives is tied to achievement of targets [Compensation should be linked to targets for the CEO and those members of the senior management group who report directly to the CEO, including the chief of staff (where there is one) and the chief nursing executive. Members of the senior management team who do not fall under the definition of executive as listed in the regulations (i.e. those not reporting directly to the CEO) may also be included in performance-based compensation, at the discretion of the organization. Please refer to the regulation (Ontario Regulation 444/10) and the guidance on executive compensation available from the ministry s website.] Quality Dimension Patient Centered Care Objective Improve Patient Satisfaction From NRC Picker: Overall, how would you rate the care and services you received at the hospital? Access Reduce wait times in the ED ER wait times: 90 th Percentile ER length of stay for Admitted patients. The following roles in our Senior Leadership Team are included in this process: President and Chief Executive Officer (10%) Chair, Medical Advisory Committee (5%) Vice President, Medical and Academic Affairs (5%) Vice President and Chief Nursing & Health Professions Executive (5%) Vice President, Corporate Services, CFO & CIO (5%) Vice President, People Services & Organizational Development (5%) Vice President, Clinical Support Services & Stakeholder Relations (5%) Vice President, Planning, Facilities & Support Services (5%) North York General Hospital 9
Part D: Accountability Sign-off [Please see the QIP Guidance Document for more information on completing this section.] I have reviewed and approved our hospital's Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan: 1. Was developed with consideration of data from the patient relations process, patient and employee/service provider surveys, and aggregated critical incident data 2. Contains annual performance improvement targets, and justification for these targets; 3. Describes the manner in and extent to which, executive compensation is tied to achievement of QIP targets; and 4. Was reviewed as part of the planning submission process and is aligned with the organization's operational planning processes and considers other organizational and provincial priorities (refer to the guidance document for more information). North York General Hospital 10