Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/27/2018 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein. Central Local Health Integration Network 1
Overview The 2018-2019 Annual Quality Improvement Plan (QIP) is an integral to fulfilling our ongoing commitment to patients, caregivers, the community and funders to provide the best quality care in a fiscally responsible manner. This year marks the first Home and Community Care QIP of the Central LHIN. As part of our commitment to the Patient s First Act, 2016, our focus continues to be centered on providing care that is coordinated, safe, timely, and evidence-informed, while engaging patients and caregivers so we can fully understand their needs and concerns. We utilize best practices in our approach to setting targets and incorporate feedback from our Patient & Family Advisory Committee (PFAC) on deciding the most appropriate areas for improvement for our QIP. This year s Central LHIN s initiatives focus on the following dimensions of quality: Effectiveness Care is provided based on best evidence and produces the desired outcome. Patient-Centeredness Decisions about the patient s care reflect the goals and preferences of the patient and family/caregivers. Safety The care the patient receives does not cause the patient to be harmed. Timeliness Care is received within an acceptable time after the need is identified. Like all quality improvement journeys, we anticipate challenges during the implementation of these initiatives. With a population of over 1.8 million, Central LHIN has the most residents, is among the most diverse and is one of the fastest growing of all LHINs. The population trends that will have significant impact on planning and delivery of health services in Central LHIN are growth, aging and diversity. A key challenge is to meet the increasing demand for care and services as our population continues to grow and age at a rate above the provincial average. The Central LHIN is experiencing greater-than-average population aging (2011-2021). Currently, 12.5 per cent of residents in the LHIN or 221,068 people are seniors aged 65 or higher. This puts the Central LHIN among the top three LHINs in terms of absolute numbers of seniors. By 2021, seniors will comprise 16.1 per cent of all residents or 342,538 people, resulting in more patients requiring home and community health services to ensure they can remain healthy, while continuing to maintain their independence in the community. Additionally, Central LHIN serves unique populations that include: children, patients with developmental delay, palliative, mental health, acquired brain injury and patients with chronic obstructive pulmonary disease and congestive heart failure. Describe your organization's greatest QI achievements from the past year Patient safety is paramount in the delivery of Central LHIN s home and community care services. Central LHIN s multi-faceted Falls Prevention Strategy is an organizational priority focused on promoting patient independence, risk reduction, increasing patient safety and well-being that includes a least restraint approach to care. Central LHIN has leveraged partnerships with Public Health and community organizations to develop local and regional strategies to support fall prevention in the home and community. As of September 30, 2017, Central LHIN had the second lowest rate of falls, at 34.70% compared to the provincial rate of 41.10%. Central LHIN s Fall Prevention Strategy includes the following components: Multi-factorial falls assessment, education and intervention Inclusion of a specific falls section on service providers reports goals/outcomes Regular falls prevention education for staff and service providers Central Local Health Integration Network 2
Utilization of Resident Assessment Instrument-Home Care (RAI-HC) data and specialized reports Medical equipment review to enhance patient safety Medication management and reconciliation practices Electronic referral to community-based Group Exercise Programs and Falls Prevention Programs Creation of a dedicated fall prevention page on the Centralhealthline.ca in partnership with the LHINwide Falls Prevention Committee Adherence of related policies and guidelines, including the Least Restraint Policy As part of the Falls Prevention Strategy, a concerted effort has been made to reduce the use of full bed rails in the community as per the LIHN s Least Restraint Policy. A significant reduction in use of full bed rails has been seen over the past two and a half years. In July 2015, 63 active patients had full bed rails in place compared to only 4 patients as of October 2017. This outcome has been driven by: Data informed practice Electronic alerts and specialized reports regarding equipment requests Case reviews Practice and policy updates for Care Coordinators and Service Provider Organizations Sharing best practices with service providers, hospitals, partner LHINs and community organizations The above strategies have assisted care coordinators and service providers in educating patients and families regarding risks associated with bed rail use and alternate options to support patient safety and reduce the severity of injuries. According to HQO s 2016-17 Insights into Quality Improvement Services Home Care large-scale change to reduce falls in long-stay home care clients will require a multi-dimensional approach linking a defined population to appropriate and available falls prevention programs through an efficient process. As the complexity of patients continues to increase, it is essential that a multi-faceted approach to falls prevention, strong partnerships and datainformed practice be sustained across Central LHIN to help reduce the impact of falls. Patient/ resident engagement and relations Central LHIN utilizes a range of tools to engage our patients and families. Some approaches include; patient and family panels, surveys (postal, telephone, online, etc.), ad hoc focus/working groups, patient stories, and trending reports from events/incident reporting system. Feedback is gathered and analyzed regularly to identify improvements, and is incorporated into our Central LHIN strategy and day-to-day work. Third party patient and caregiver experience surveys are conducted and analyzed to understand how our patients and caregivers experience health care and service delivery. The Central LHIN also conducts surveys in-house for patients receiving services in clinics or through our direct nursing programs including Rapid Response Nursing, Nurse Practitioners and Telehomecare. Patient/caregiver feedback from these surveys ultimately informs action plans and quality improvement initiatives. Central Local Health Integration Network 3
The Central LHIN s events/incident reporting system gathers information from our employees and contracted service providers to track and monitor risks and complaints. This data is reviewed recurrently to analyze trends and drive quality improvement in collaboration with individuals involved in the patient s care. Our events/incident management system also tracks compliments, providing us with a better understanding of how our patients and caregivers view high quality care. A key milestone for the Central LHIN this year was the creation of the Patient and Family Advisory Committee (PFAC) a committee comprised of patients and caregivers. The PFAC s main focus is to identify and advise on opportunities to incorporate the patient s perspective in organizational initiatives and to better integrate care across the region and across the health care system. One of the first areas of engagement for the group was to provide input on areas for quality improvement for the QIP. Over the coming year we will continue to proactively engage with patients and caregivers through focus groups, interviews, quality improvement events and surveys. We will also leverage our PFAC on a more regular basis to gain insights on patient and family perspectives. Collaboration and Integration Many of the quality initiatives driven by the Central LHIN require collaboration across the care continuum. An example of this collaboration is our work with our hospital and Service Provider Organization (SPO) partners. Throughout the year, the hospital care coordination team at the Humber River Hospital has collaborated with the hospital staff to design, develop and implement an alternate levels of care (ALC) dashboard that provides real time data on the status of a patient s discharge. This expedites the identification of gaps to a safe discharge and facilitates collaboration amongst the hospital and the Central LHIN to work towards a better transition. This pilot project has proven its value and as a result, we are looking to collaborate with other hospital partners to use the dashboard as part of the discharge planning process. A second initiative undertaken with our hospital partners to ensure safe transitions for our patients is the E- notification project with Markham Stouffville Hospital. This initiative alerts the Central LHIN when a patient receiving home and community care services presents to the emergency department (ED) at Markham Stouffville Hospital. Receiving this alert allows the Home and Community Care Coordinators to connect with the care team to revise the care plan in an effort to avoid a readmission or return to the ED. The Central LHIN is currently in discussions with our other hospital partners to spread this initiative. The Central LHIN and our SPOs are focused on improving Overall Satisfaction, a dimension of the Client and Caregiver Experience Evaluation Survey. SPO are sharing their own strategies, successes and challenges regarding the improvement of these results. Support will also be provided to the agencies regarding the interpretation and analysis of other indicators that support the indicators reflecting the Overall Satisfaction dimension. Engagement of Clinicians, Leadership & Staff At the Central LHIN we believe that the engagement of our frontline staff is instrumental in the ultimate success of the QIP. As a result, we have engaged staff in the development of change ideas, particularly for the 5-day wait time: Personal Support for complex patients and our custom measure, 90th percentile wait time from community to home care services. We will continue to work with staff to implement these change ideas throughout the year. Central Local Health Integration Network 4
Our leadership team has provided input around the setting of targets for our Quality Improvement Plan by applying HQO s guide on Approaches to Setting Targets for Quality Improvement. In addition, the leadership team has helped establish the foundations for accountability over the last several years by assigning leads to each change idea to ensure successful implementation. The staff Quality and Safety Committee has provided oversight of these quality improvement initiatives while addressing any barriers. This has been a successful process over the years and the Central LHIN will continue to use this framework to ensure the success of our QIP. Population Health and Equity Considerations Demographics, patient complexity and system issues in the Central LHIN are resulting in more patients requiring home and community health services to ensure they remain healthier and are able to live independently in their own home for as long as possible. Central LHIN s population include: Children, adults and seniors Patients with developmental delay Palliative patients Patients with a mental health diagnosis Patients living in a registered retirement home Patients with chronic obstructive pulmonary disease and congestive heart failure Patients with a stroke diagnosis Patients who have an acquired brain injury All patients have access to Central LHIN care coordination, have services approved and referrals/linking to other community resources and agencies. Indigenous population: Central LHIN Home and Community Care team members and health planners meet with the Georgina Island health care team (including the band council with the health portfolio) two to three times yearly to provide updates, discuss concerns and report on patient referral volumes. Francophone Population: The city of Markham has a French language designation. A Central LHIN planning working group meets regularly with the city of Markham and the Ministry of Francophone Affairs to ensure the Central LHIN will meet designation requirements by July 2018. Patients with Developmental Delay: In October 2015, the Central LHIN created a specialty team to assist patients with Intellectual Developmental Delay a patient population with complex care needs. Working with our neighbouring LHINs, the specialty team participates in cross-sector high-risk escalation planning activities and works to mitigate challenging patient situations, supporting an improved quality of life for these patients. As well, in partnership with REENA housing and March of Dimes services, the Central LHIN supports young adults with physical and cognitive limitations to live independently, in a supported environment, through the provision of professional services as required by the residents. In partnership with community partners and providers, small care model trials have been undertaken to pilot potential service models better suited to meet the needs of this population. Central LHIN participated in piloting an addendum to the RAI-HC assessment tool, which captures additional information for this population that is not captured in the current RAI-HC. The outcome of this pilot has provided valuable information for this population, and it is anticipated that an addendum will be added to the RAI Suite of instruments in the future. Central Local Health Integration Network 5
High Risk Escalation Table: Central LHIN participates on a high-risk escalation table with several community partners including the Emergency Medical System (EMS) and police departments. This group came together to problem-solve challenging situations for individuals, such as patients evicted from their residence, no financial means, or are in frequent contact with the EMS system. The group members work together with the individual and other community partners as needed, to assist them in resolving their issue. Alternate Level of Care (ALC) The Central LHIN is collaborating with our hospital partners to address the increase in ALC rates at each hospital. Hospital care coordinators attend daily rounds and Joint Discharge Operations meetings twice weekly to review the status of all patients. In the last two years, the Central LHIN has been collaborating with Humber River Hospital on ALC collaborative initiatives focused on the development and implementation of the discharge planning pathway and electronic dashboard Our goal is to spread this collaborative initiative to all Central LHIN hospitals this fiscal year. In addition, we are working closely with Markham Stouffville Hospital to develop and implement the Integrated Care Coordination pilot. The goal of this pilot is to eliminate the duplication of steps that high risk patients currently experience during discharge planning. Improvements will be focused on family meetings, whereby patients/families review care plans to ensure awareness and consensus of discharge plans. Another ALC improvement program that the Central LHIN continues to pilot is to proactively identify patients who would benefit from Home First and Transitional Care Home. This pilot supports patients with enhanced levels of services to return to the community. Recently, the Central LHIN has been working in partnership with hospitals transitioning patients to the Reactivation Care Centre to support reactivation and plan discharge to various destinations including Long Term Care, Convalescent Care and home and community. These initiatives continue to improve communication and engagement with patients and substitute decision makers, while supporting flow and reducing barriers to discharge that impact ALC pressures in the system. Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder In the fall of 2016, Central LHIN staff met with Addictions Services York Region (ASYR) to discuss an approach towards the development of a 3-Year Addictions Strategy. Supporting People Affected by Addictions: A Strategy for the Central LHIN in September 2017. Recommendations support a variety of programs and services that are closely aligned with the recent provincial priorities for managing opioid abuse, particularly in the areas of increased need for housing supports, withdrawal management services, expansion of Rapid Access to Addiction Medication (RAAM) Clinics, interventions for youth, and greater service coordination and integration. In October 2017, the Ministry Emergency Operations Centre (MEOC) was activated to provide health system support in managing the ongoing opioid crisis. The MEOC supports mechanisms to monitor and share information to better understand operational system pressures, and to help navigate, problem solve, and coordinate potential responses. Weekly teleconferences have been scheduled among various stakeholders impacted by this crisis, specifically public health units, EMS, provincial associations, regulatory colleges and LHINs. Central LHIN has been a participant on these calls, to date there have been no urgent or emergent local or regional issues identified. Central LHIN Health Service Providers (HSPs) continue to be engaged and kept informed of MEOC Situation Reports as necessary. The Central LHIN has received monthly ED data for opioid overdoses, between April and November, 2017. During this period, approximately 7% (402 of 5,639) of all opioid overdoses in the ED presented at a Central LHIN hospital. The average median age as of November 2017 is 35.5 years. Central Local Health Integration Network 6
Investments in case management, outreach workers, and peer support were made in December 2017. This funding will help support those with substance use by forming therapeutic relationships, providing linkages with appropriate services and community resources, connecting with vulnerable populations (including the homeless and marginalized individuals) who are unable to access traditional programs of treatment and providing information and education to help facilitate the recovery process. The Central LHIN works closely with our in house pharmacist in reviewing Nurse Practitioners prescribing practices for controlled substances. The detailed auditing process consists of utilizing data from our health information system to provide us with an overview of prescribing practices. Areas of the audit focus on patient demographics, patient population (palliative or chronic pain patients), type of controlled substance prescribed, concentration and frequency. Workplace Violence Prevention The Central LHIN is committed to the prevention of workplace violence and recognize their ultimate responsibility for worker health and safety. All reasonable steps are taken to protect workers from workplace violence from all sources. Central LHIN staff, contractors, and suppliers are expected to work together to prevent workplace violence and are accountable for upholding the organizational policies relating to workplace violence prevention. To support the safety of our staff, the Central LHIN has committed to: At minimum, on an annual basis, the Central LHIN conducts a formalized risk assessment to identify potential sources of workplace violence exposures. The results of the risk assessment are used to determine risk and mitigation strategies are developed to reduce the risks. Development and maintenance of a number of policies to support the safety of employees, including but not limited to: Workplace Violence Prevention, Incident/Accident Reporting and Investigation, Workplace Inspections, Workplace Harassment and Discrimination, Occupational Health & Safety, Risk Assessment and Emergency Response. These policies are reviewed by the Joint Health and Safety Committee (JHSC) and updated on and annual or bi-annual basis. Providing training and education to all new hires to promote an understanding of our roles and responsibilities relating to safety and violence prevention in the workplace. Course material and safety booklets/resources are found on a dedicated intranet page for staff. Specific to their roles, some staff have received training in Non-Violent Crisis Prevention. Maintaining security card access and panic alarm systems at office locations. At times of identified potential risk, on-site third party security services or police services have been engaged. Incidents of workplace violence are investigated in accordance with Incident/Accident Reporting and Investigation Policy. The JHSC review incidence summaries and identify recommendations for appropriate escalation and communication within the LHIN. Working collaboratively with the front line, leaders, unions, and the JHSC, the Central LHIN is committed to providing staff with a psychologically and physically safe and healthy environment, and the resources they need to provide quality care to our patients. Central Local Health Integration Network 7
Contact Information Mr. Joseph Figliomeni Director, Quality Central Local Health Integration Network Sign-off It is recommended that the following individuals review and sign-off on your organization s Quality Improvement Plan (where applicable): I have reviewed and approved our organization s Quality Improvement Plan: Board Chair Warren Jestin (name) (signature) Patient Services and Quality Committee Chair Charles Schade (name) (signature) Chief Executive Officer Kim Baker (name) (signature) Central Local Health Integration Network 8