Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario April 1, 2019 Oakville, ON L6M 0L8 1
Overview is pleased to share our ninth Quality Improvement Plan (QIP) for 2019/20. This plan, a subset of our broader Integrated Quality and Patient Safety Plan, describes the hospital s priorities for and commitment to a series of quality issues, goals, measures and plans for change that is relevant to and informed by a broad stakeholder group, including our patients, families and communities. Although this year s Quality Improvement Plan builds on the successes of our 2018/19 plan with key areas of focus on transitions in care and the patient experience, there is a new area of focus related to access to care. As such three of our indicators on this year s QIP have a system level focus on ensuring care is delivered to the right patients, at the right time and in the right care environment. considers a number of alignments in drafting this plan. s Strategic Priorities of Innovate, Collaborate and Empower, captured in Pathway 2020, have informed the ways in which we approach improvement goals for quality and patient safety. Quality Dimensions, also embedded into our organizational fabric, connect our quality goals to the broader international, national and provincial quality improvement communities. As well, the organization has strategically aligned the quality issues contained within this plan, with the identified provincial imperatives articulated by the Ministry of Health and Long Term Care (MOHLTC), through the provincial health quality advisor, Health Quality Ontario. Eight indicators have been selected for the 2019/20 Quality Improvement Plan and include: 1. Average number of inpatients receiving care in unconventional spaces per day 2. Alternate Level of Care 3. Emergency department wait time for inpatient bed 4. Percentage of complaints acknowledged to the individual who made a complaint within five business days 5. Patient experience: Did you receive enough information when you left the hospital? 6. Med Rec at Discharge 7. Readmission within 30 days for mental health and addiction 8. Number of workplace violence incidents (overall) This past year marked an important milestone in our quality journey as we successfully achieved Exemplary Standing in our Accreditation Survey in May of 2018 which served to bolster a greater focus on driving forward the Strategic Priorities within Pathway 2020 and maintain a sharp focus on quality, safety and creating Exemplary Patient Experiences, Always. The development of this plan continues to increasingly engage the voice of the patient with key strategies, such as our Annual QIP World Café Event, anchoring early engagement in quality issues and change ideas. The voice of the patient is also being further embedded throughout the organization. Increasingly Patient and Family Advisors are actively engaged in operational and quality committees and quality improvement work alongside bedside care providers. Oakville, ON L6M 0L8 2
The following will provide highlights of our Quality Improvement work over the past year, describe the engagement of stakeholders and will highlight a few achievements in the areas of Alternate Level of Care and Workplace Violence Prevention. This document will also outline the accountability framework for our executive team. QI Achievements from the Past Year Although we have seen significant progress on a number of our quality goals we wish to highlight quality improvement initiatives in the areas of access to care and elevating the patient experience. Alternate Level of Care ALC The Alternate-Level-of-Care (ALC) and resultant Emergency Department overcrowding issues continue to be a critical challenge for Ontario hospitals. Patients identified with the ALC designation are individuals who no longer require acute care hospital services, but are unable to live independently. This is an issue faced by virtually all acute care hospitals in the province and has become even more critical in the winter months when the acute care sector faces additional capacity due to seasonal illnesses. ALC rates have been an important indicator on many of our internal operational scorecards as well as the hospital Quality Improvement Plan for many years. Efforts have been focused on optimizing the acute hospital stay while working collaboratively with community providers to streamline transitions to the most appropriate care setting. In spite of these focused efforts, the ability to make gains in this area have been very challenging and influenced in large part by broader system capacity challenges exacerbated by an aging population and heavy chronic disease burden which are beyond the ability of the hospital sector alone to influence. In spite of these enormous challenges, this past year a tri-hospital team in partnership with the Mississauga Halton LHIN was successful in making substantive improvements in the rate of ALC in our organization. The team assembled to implement a series of industry best practices with early work focused on the establishment of the ALC Response Team and the identification of a team lead. A current state analysis was completed with learnings from this embedded into a comprehensive toolkit for leaders across the organization. An ALC avoidance and management framework, standardized pathways that described the ideal discharge pathway including escalation points and escalation scenarios and options as well as pathways for patients with responsive behaviors were included. The team developed standardized scripts for teams to utilize to ensure consistent, compassionate and respectful communication along the care journey. Oakville, ON L6M 0L8 3
In addition to the tools above, a central component of the strategy also involved the introduction of a new physician directed order; Medically Stable Ready for Discharge (MSRD). Physicians can now order MSRD to identify to the care team, medically stable patients who can be discharged back into the community but require additional discharge planning support to secure a safe plan. This change in paradigm and process, in alignment with the MOHLTC s Home First Philosophy, has empowered teams to focus efforts on a discharge to home first, in partnership with the community, instead of moving to ALC and the waits for Long Term Care (LTC), which can be years. The Access and Flow/Social Work and Discharge Planning teams continue to monitor ALC related metrics on a monthly basis and were able to demonstrate dramatic improvement to the ALC rate at all three sites within a few months of implementation. This reduction in the ALC rate has been particularly dramatic at the Georgetown Hospital where the ALC rate dropped from a high of 30% in July of 2017 to 0% in September of 2018. Elevating the Patient Experience Elevating the patient experience and the patient centered dimension of quality continues to occupy a central position within the provincial quality agenda. Since the inception of Quality Improvement Plans, the province has directed organizations to focus efforts on improving performance on two big dot measures, namely Would you recommend this hospital to family and friends? and Would you recommend the Emergency Department?. All healthcare sectors have been encouraged not only to incorporate best/leading practices into their annual plan, but also ensure these are developed, implemented and evaluated with input and engagement from patients and families throughout the quality improvement process. In lock step with the provincial patient centered agenda, s strategic plan, Pathway 2020 and vision of Exemplary Patient Experiences, Always served to galvanize our commitment to delivering high quality patient care and more fully refocuses the organization on achieving that vision. Our successful Accreditation Canada survey furthered our quest to deliver high quality patient care and by extension elevating the overall patient experience. That our patient experience scores improved in line with our pre survey efforts is testament to the synergies between quality and the overall experience of care. Prior to the move to the new expanded space at the Milton District Hospital, Organizational Development created and delivered Experience Excellence Training, a unique and comprehensive program, in an effort to prepare staff to deliver care in their new space. This training was so well received a recommendation was made to incorporate this change idea into the 2018/19 Quality Improvement Plan. Since virtually all Milton staff members received this training prior to the opening of the expanded space, the decision was made to next spread this training to Oakville and Georgetown s medical inpatient units. Oakville, ON L6M 0L8 4
This new team was provided with a detailed overview of the content to familiarize the leaders with the key concepts embedded in the training. The team confirmed the goal was to leverage the focused curriculum to engage staff in a self-reflective process about their individual and collective ability to impact the patient experience. As well the team confirmed the inclusion of the AIDET communication framework, which provides a standardized approach and common language for interactions with patients, families and each other. As the original Patient Experience curriculum had received extensive consultation from staff, volunteers and patient and family advisors during the initial development process only minor changes were made to the content. To implement the education, a variety of different models were used to evaluate the most effective mode of delivery of the material with over 100 staff members receiving training in the early fall. This same content was also embedded into the monthly orientation program so that all new staff received these foundational messages. A survey was distributed to the participants electronically and feedback from all sessions was extremely positive. This has set the stage for the next evolution of our organizational Patient Experience Strategy. Patient Partnering The engagement of all stakeholders in the development of our Quality Improvement Plan (QIP) continues to be an essential element of our overall quality and patient safety strategy. Since the inception of the QIP in 2010, those stakeholders have included bedside care providers, physicians, administrators and patients and families. We have endeavored to ensure individuals can see themselves and their role in our annual plan. On December 18 th 2018 hosted its 3 rd Annual QIP World Café. The World Café concept refers to a structured conversational process intended to facilitate small group discussion, linking ideas within a larger group to access the collective wisdom of the participants. The goal was to have diverse stakeholders discuss provincial healthcare quality issues and provide input into opportunities for improvement on key indicators relevant to the hospital. This year there were nine quality tables and physician and administrator co-leads provided facilitation and expertise at each of these tables. The table leads were provided with a package of materials on their specific quality issue including our organizational performance metrics, best practices and a provincial summary of innovative change ideas. One hundred and thirty-eight Staff, Physicians Volunteers, Patient and Family Advisors and Community Partners participated in the two-hour event. After a brief introduction to the session format, participants were asked to proceed to the table topic of interest. Leads at each table proceeded to provide an overview and context and engaged in a facilitated discussion. Recorders at each table captured the emerging themes, opportunities and ideas for change. The participants rotated tables at scheduled intervals, four times in total, to capture diverse perspectives in the room. A brief wrap up summarized common themes across the quality issues discussed. Oakville, ON L6M 0L8 5
Workplace Violence Prevention Violence against workers in health-care settings like hospitals is a complex, pervasive, under-reported, and persistent problem. Although this issue is not new to the healthcare sector or more specifically hospital workers, it has historically been an issue that has not received much profile and therefore largely unaddressed until more recently. Understanding issues and trends in workplace violence (WPV) relies, in part, on the collection of reliable and valid indicators of the incidence of workplace violence gathered in a consistent way over time. In 2018, the MOHLTC introduced a new mandatory indicator for WPV to be incorporated on Quality Improvement Plans. The impetus was twofold, firstly to raise awareness and more accurately quantify the issue and secondly to support the sharing of best practices and interventions to reduce the overall incidents of WPV. Organizations were empowered to identify their target performance as either increased or decreased reporting based on their assessment of their current reporting culture and WPV prevention strategies. At, as this was a new indicator, we identified a goal of increased reporting for the 2018/19 QIP. Under the leadership of the Workplace Violence Steering Committee a number of initiatives were identified in the WPV Action Plan. Some of these initiatives included raising awareness of the issue through strategic communications and messaging, streamlining the WPV reporting process, establishing WPV risk assessments and supporting managers and leaders to respond to WPV incidents in a standardized way through the development of a toolkit. Perhaps the most complex initiative however was the implementation of a risk assessment tool focused on identifying individuals at risk for violence. This tool, not only serves to systematically identify patients at risk for violence but provides decision support to the care team to implement compassionate and clinically effective care management strategies. It is hoped that early identification and management of patients at risk for violence will reduce the overall number of harm events that our staff, physicians and volunteers are exposed to. Performance Based Compensation The Excellent Care for All Act (ECFAA) requires that the compensation of the CEO and Executives reporting to the CEO be linked to the achievement of performance improvement goals laid out in our Quality Improvement Plan (QIP). The purpose of a performance-based compensation model related to ECFAA is to drive accountability for the delivery of QIPs, enhance transparency and motivate executives. Below is described the ways in which the Executive Team compensation will be linked to our improvement plan. Oakville, ON L6M 0L8 6
Terms The original Board Executive Compensation Strategy was established in 2012 and continues forward for the 2017/18 QIP. Each of the planned improvement initiatives will be associated with 1% of an executive team member s compensation for a total of 4% of annual base salary. Achievement is measured against achievement of the Goals for Change Ideas identified as performance based in the QIP work plan and noted below. The indicators are equally weighted. All members of the executive team participate equally in the performance-based compensation set out in the QIP. The positions affected include: President and CEO Chief of Medical Staff Senior Vice President Clinical Programs & Chief Nursing Executive Senior Vice President, Corporate Services & Chief Financial Officer Senior Vice President, Redevelopment Vice President Strategy, Performance & Partnerships Vice President, Human Resources and Organizational Development Chief Information Officer Chief Operating Officer, OTMH Chief Operating Officer, MDH Chief Operating Officer, GH Summary QUALITY DIMENSION Efficient Patient Centered INDICATOR Total number of inpatients receiving care in unconventional spaces in each day (at 12am), summed for all days in the given reporting period, divided by total submission days within the given time period. Percentage of complaints acknowledged to the individual who made a complaint within five business days. CHANGE IDEA Completion of Corporate Capital Master Plan. Develop and Implement Annual Patient Relations Workshop Series-Difficult Conversations, target audience: front line clinical leaders. Oakville, ON L6M 0L8 7
QUALITY DIMENSION Access to right level of care Safe INDICATOR Total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter. Number of Workplace Violence incidents reported. CHANGE IDEA Development and Implementation of Substitute Decision Maker (SDM) Toolkit. Workplace Violence: Development and Implementation of Staff Debrief Protocol Contact Information Joan Jickling Director Quality and Patient Relations Oakville, ON L6M 0L8 905-845-2571 x4473 jjickling@haltonhealthcare.on.ca Sign-off I have reviewed and approved our organization s 2019/20 Quality Improvement Plan. John Nyholt Board Chair Sharon Barkley Quality Committee Chair Denise Hardenne Chief Executive Officer Oakville, ON L6M 0L8 8