Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 01/20/2016 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. 1
Overview Toronto Central CCAC is pleased to present our 2016-2017 Quality Improvement Plan (QIP). The QIP is one of the many ways our CCAC demonstrates how we are moving forward on the goals of our Strategic Plan for quality improvement. On our website, we have a range of public information on Toronto Central CCAC performance measures and quality improvement including our Strategic Plan, Annual Reports, Accountability Agreement with the Toronto Central LHIN, long-term care waitlists, and Strategic Plan measures. In addition, there is external information on our CCAC s performance on our own website, in the Ontario CCAC Sector Quality Reports, and on the home care reporting page of Health Quality Ontario. Four years ago, the Toronto Central CCAC launched a new strategic plan centered wholly on improving client and caregiver experience and the quality of care we deliver. Our 2012-2016 Strategic Plan called Opening our hearts, opening our minds was designed to help us see the endless possibilities for driving quality and client experience to the highest possible level, in keeping with our definition of quality. We launched our Strategic Plan with four goals: 1. We will relentlessly pursue every option to deliver what is most important to every client. 2. We will support our clients to live the fullest and healthiest lives possible. 3. We will unleash the potential of our people. 4. We will drive the highest possible care integration for our client populations who need it the most. Through every year of our strategic plan, we get closer to achieving these goals, and our QIP is one of the ways we can report our progress. We are proud of the difference that the Toronto Central CCAC has made locally, as well as nationally, and globally through improving care and experience for clients and their families/caregivers; Integrating care to create the One Client, One Team experience and approach; and influencing change at a local, provincial, national and global scale. QI Achievements From the Past Year Toronto Central CCAC s Strategic Plan is designed to drive improved client and caregiver experience and improved quality of care. Each year we establish specific goals and activities designed to improve our performance on quality. The following are examples of some of our most significant achievements from the past year: i) Client and caregiver engagement Most existing research on patient engagement has been focused on acute care and long-term care settings, with a particular emphasis on patient and family advisory councils. Given that many home care clients are home-bound, frail, or too ill to be engaged through traditional approaches, the Toronto Central CCAC initiated a joint research study with HNHB CCAC to understand how to more meaningfully engage clients in home care, and how to best measure the achievement of improved client experience. The results of this research with clients and caregivers was used to inform the 2
development of Toronto Central CCAC s client and caregiver engagement strategy, including the launch of Toronto Central CCAC s Palliative Care Advisory Group in fall 2015. ii) Client and caregiver experience Four years ago, Toronto Central CCAC and its 22 contracted service provider partners launched a more client-centered approach to care planning and delivery called Changing the Conversation. Changing the Conversation focuses on asking clients "what is most important" to them and then using that information as the basis for how care is delivered. Changing the Conversation has made a measurable difference to clients' experiences, as reported through our Client and Caregiver Experience Evaluation survey results, and has now expanded to other parts of the province and the country. In a 5 year period, Toronto Central CCAC s scores on the survey question Would you recommend the CCAC to your family or friends if they needed help? jumped from 88% to 98% and our scores for overall satisfaction have climbed to above 90% and stayed at that level. For the last few years, we have continued to focus our client experience efforts on sustaining what s most important to clients as the foundation of our approach to planning and delivery of care. In 2015, this was recognized as a Leading Practice by Accreditation Canada. Given our success in achieving a higher overall client experience score over the past 5 years, we are now committed to maintaining our results at this level. iii) iv) Safety and quality Caring for patients with acute or chronic wounds accounts for 50% of the nursing care provided by the CCAC. In 2014/15, an audit of our wound care services found that Toronto Central CCAC clients had longer than expected healing times and that the frequency of dressing changes was not aligned with best practice guidelines for nursing care. In fall 2015, the CCAC launched a comprehensive wound care improvement effort to improve quality of care, wound care outcomes and cost-effectiveness. The improvement approach includes three components: i) implementation of wound care bundles/pathways for each of the main wound types; the wound care bundles are based on evidence and input from the nursing providers, ii) a specialized wound care clinical team consisting of a nurse and nurse practitioner to monitor wound care practices, to support Care Coordinators and service provider nurses with wound care consultation and provide care to clients with complex wounds, and iii) performance management and monitoring of wound care practice to ensure greater accountability at the service provider level for ensuring quality wound care services. Our evaluation of results for the improvement of wound care with a sub-set of 760 clients showed a decrease in wound healing times from a mean of 44.8 weeks to 35.3 weeks (approximately 20% improvement) and an improvement of more than 50% in the number of clients who were changed from daily dressing changes to a frequency of dressing changes that aligns with wound care best practices. Integrated palliative care The Toronto Central CCAC s strategic plan includes driving the highest possible care integration for our client populations who need it the most. In 2014, Toronto Central CCAC and our partners, including the Temmy Latner Centre for Palliative Care, Dorothy Ley Hospice, and others were awarded the Ontario Minister s Medal for Quality and Safety. In 2015/16 we achieved our goal to increase the number of patients 3
supported by our integrated palliative program by 10%. In 2015/16 we also continued to advance our work in creating a more integrated palliative care model, including launching a client and family Palliative Advisory Council and planning for the launch of an integrated electronic health record in 2016/17 that will allow all members of the palliative team, from different organizations, to share communications and work more effectively as a team for clients. This will be the first fully integrated electronic health record for home care and primary care in Ontario. In addition, in 2016/17, the 14 CCACs will be developing a new measure for palliative care that evaluates whether clients are dying in their preferred place, for example at home, in a hospice, or in a hospital. This will enable the 14 CCACs to provide comparative information starting in 2017/18 that helps identify potential variations in availability and level of palliative care across the province. v) Addressing caregiver distress - Unpaid caregivers, primarily family and friends, provide an estimated 70-80% of care to home care clients. Over the last 5 years, Ontario has seen a dramatic rise in rates of reported caregiver distress in home care. Ontario s home care population has among the highest acuity of any jurisdiction in the world. For example, the Toronto Central CCAC has seen an exponential growth over the last 5 years in the proportion of clients with symptoms of depression, medical acuity, cognitive impairment and need for assistance with multiple activities of daily living. This reflects the shift in the role of CCACs to support greater numbers of clients at home with very complex and chronic health conditions, which contributes to the rising rates of caregiver burden and distress. Unpaid caregivers are essential members of a client s care team and last year, Toronto Central CCAC initiated a research study to understand how to better identify caregivers who are at risk of stress, and ultimately identify ways to better support them. Phase 1 of this research study was completed in 2015/16 with support of researchers at the University of Waterloo to use evidence to identify caregivers most at risk. Phase 2 of the research, which include engaging caregivers to help us develop and test supports for them, will be initiated in 2016/17. vi) Integration of home care and primary care We know that clients and caregivers interact with many different service providers and organizations, and that at times the health care system can seem complicated and fragmented. As health care providers, we must create an environment where our clients see and experience a single health care team, working together with them, communicating effectively with each other, and ensuring that every client receives the care they need, when they need it. For our most complex and vulnerable clients, the gap they experience between their primary care, hospital and community care teams can lead to higher safety risks and poorer health outcomes. For our system, it often means frequent emergency department visits and hospitalizations that are avoidable and 4
unsustainable. This is why Toronto Central CCAC has made one of our strategic plan goals to drive the highest possible care integration for our client populations who need it the most. Although we have made considerable progress in our integrated care work, as recognized through winning both the Minister s Medal (for our integrated palliative care work) and achieving the Honour Roll for the Minister s Medal (for our integrated care work for seniors care), one of the areas we continue to see significant opportunity for creating a better, safer and higher quality care experience for clients is through increased integration of care between home care and primary care. With over 1200 primary care practitioners in Toronto, our CCAC has been steadily making closer connections between our primary care practices and our own CCAC Care Coordinators. This means having designated Care Coordinators assigned to work with primary care practitioners to develop shared care plans for clients and to have regular communication about changes in clients health status. This both improves continuity of care and ensures that primary care practitioners are up-to-date on the home care services their patients are receiving. This has been a multi-year strategy that started with group primary care practices (clinics, family health teams, family health groups and other types of group practices) and is now spreading to solo-practices. In 2015/16 we set a target to increase the number of primary care practitioners we have connections with by 10% (from 60% to 70%). By the end of Q3 2015/16, we had already achieved our 2015/16 goal. In 2016/17, we have set a target of75% for our connection rate with primary care. The primary care practitioners we are now connecting with are almost all solo practitioners rather than group practices. Our 5% improvement goal for 2016/17 (from 70% to 75%) reflects the additional effort involved in building individual connections with solo-practicing primary care practitioners. vii) Ensuring patients are in the right place of care across the health system One of the Ministry of Health and Long-Term Care s priorities for the last several years has been to reduce the number of patients who are in hospital but who require an alternate level of care (ALC), meaning that they no longer require acute care services but are waiting in a hospital bed for rehabilitation, long-term care, home care or other types of care. Having a higher proportion of patients designated as ALC, means that hospitals have fewer resources available to support patients who need hospital-level care. Last year, Toronto Central CCAC, with the support of Toronto Central LHIN and partner hospitals, developed and tested a toolkit specifically designed to help hospitals reduce the number of ALC patients by ensuring a more proactive approach to working with patients, families, physicians, and hospital staff. In 2016/17, we will be evaluating the impact of our ALC toolkit with a plan to adopt its use across all Toronto Central LHIN hospitals. 5
Engagement of Leadership, Clinicians and Staff The 2012-2016 Strategic Plan focused on quality was developed with extensive consultation from the clients and communities we serve, service delivery partners as well as CCAC staff, leadership and the Board of Directors. The commitments and targets in this QIP are shared with staff, service providers, leadership and Board members. Ongoing progress towards our QIP commitments and targets is communicated to all key stakeholders. Each team in the organization has their own work plan and targets that align with the Strategic Plan, Operational Plan, and QIP and they are accountable for achieving the performance results. Although Toronto Central CCAC leadership is confident that we will be able to achieve the targets and goals in our QIP, we anticipate some risks and challenges this year, including: 1) Planned changes in the structure of CCACs and across the health system in December 2015, the Minister of Health and Long-Term care announced that the role of CCACs will be transferred to the Local Health Integration Networks. The CCAC Boards will cease to operate and staff of the CCACs will become employees of the LHINs. This will change how CCACs work in local communities. While our goal during the transition will be to remain focused on client experience and quality as our most important aim, the additional responsibilities for leading change will place pressures on our resources and our people. With this in mind, we have been cautious in setting a large number of targets for improvement that we may be unable to meet. Instead we have decided to focus our efforts on improving our performance in a small number of areas, namely wait times and local targets for integration of home care and primary care. We are also starting to collect information on our palliative care program related to the number of clients who are able to die in the place they choose (for example home, hospice, long-term care or hospital) because they receive sufficient palliative care support. These are the measure (wait times, integration of home care and primary care, and launching a new measure for palliative care) for which we have the greatest ability and opportunity to effect change in the coming year. At the same time, we will commit to monitoring our current performance in other areas such as falls, client experience, emergency department visits and hospital readmission rates to ensure that our performance in these areas remains at an appropriate level. 2) Fiscal pressures Over the last four years, Toronto Central CCAC has experienced significant growth in the number of our highest complexity/highest need client groups (we have experienced an 18% average annual growth rate over the last four years). Last year was the first year that we did not receive any additional funding from our Local Health Integration Network. The pressures of increasing client needs and growth in demand has meant that the CCAC has to find more innovative ways to improve our operations and care delivery in order to balance our budget. The organization is committed to a sustainable healthcare system. We have advanced, and continue to advance, a sustainability strategy that is a continuous effort to evolve and transform care delivery for better value. This strategy focusses on improving client care at a lower cost. We expect the broader health transformation agenda, the implementation of new funding models and the implementation of fiscal restraint will only add to the fiscal pressures 6
and challenges faced by the organization. We are forecasting a balance budget for 2015/16, due to the implementation of several successful financial management strategies. We will continue to plan for financial pressures into 2016/17 and will be planning for the impact of additional financial constraint measures with the Toronto Central LHIN. The Toronto Central CCAC has focused on building integrated relationships with our partners in the healthcare system to support a better client experience. We work with our 22 contracted service provider partners to make sure that their quality improvement priorities for 2016/17 align with ours. By working together on the same priorities for quality improvement, CCACs and our service providers are better able to improve our performance in these areas. Client Engagement Toronto Central CCAC s Strategic Plan includes engaging clients as partners as part of advancing our strategy. In particular, the first Strategic Direction We will relentlessly pursue every option to deliver what is most important to every client, focuses on recognizing the importance of engaging clients as partners in their care. Client and caregiver input was essential to designing our current strategic plan and areas of focus for quality improvement. Toronto Central CCAC has a client engagement framework to continually improve how we work with clients and caregivers to partner with us at different levels including for an individual care plan, at a program and service level, and at the system and policy level. Although there are many definitions of patient-centred care, the Toronto Central CCAC s goal is that every CCAC client will have the opportunity participate in decision-making that affects their care. In 2015/16, the CCAC initiated the following new activities related to client engagement: i) Dedicated Resources The Toronto Central CCAC acknowledges that engaging with clients and caregivers requires dedicated support. We have identified a staff resource to work with our different teams to support client and caregiver engagement activities, including developing consultations, advisory groups, staff training, and client and caregiver outreach and support. ii) Research on client and caregiver engagement in home care - As noted in our quality improvement achievements from the past year, most existing research on patient engagement has been focused on acute care and long-term care settings. Last year, the Toronto Central CCAC initiated a joint research study with HNHB CCAC to understand how to more meaningfully engage clients in home care, and how to best measure the achievement of improved client experience. The research was helpful in identifying additional opportunities for engaging clients and caregivers in our efforts to improve home care and for validating that traditional ways of engaging clients and caregivers through meetings and focus groups in other settings may not meet the needs of home care clients. 7
iii) New Client and Caregiver Palliative Advisory Group - In fall 2015, the Toronto Central CCAC launched a Client and Caregiver Palliative Care Advisory Group. This newly formed Advisory Committee is working closely with our Palliative Care Team to inform improvements in the delivery and design of palliative care in Toronto. In 2016/17, the Toronto Central CCAC will be expanding our client and caregiver engagement work to include improvements in design and delivery of our personal support services and other priority areas for improvement. Other - Accountability Each year, the Toronto Central CCAC Board of Directors establishes performance goals and a performance evaluation for the CEO. This performance plan includes goals and targets for quality improvement. The goals and targets in the QIP are included as part of the overall performance plan for the CEO. For overall performance, 6% of the CEO s salary is held back (called pay-at-risk ) if certain performance targets are not met, and an additional 6% of the CEO s pay is dependent on specific quality goals being achieved. In addition to the QIP, the Board of Directors produces an Annual Report to the community that highlights performance results and quality improvement activities of the CCAC. The Board s Quality Committee is responsible for oversight of client experience, client safety, and quality of care. It fulfills this role by setting annual improvement goals for quality, reviewing regular reports of CCAC performance metrics and targets, reviewing client experience survey results and action plans, and monitoring the rates of client safety and quality incidents. 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 Quality Committee Chair (signature) Chief Executive Officer (signature) CEO (signature) 8