Excellent Care for All Quality Improvement Plans (): Progress Report for The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and gain insight into how their change ideas might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality improvement activities. Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ideas, and inform robust curriculum for future educational sessions. ID Measure/Indicator from 1 "Would you recommend this emergency department to your friends and family?" ( %; Survey respondents; April - June 2016 (Q1 FY 2016/17); EDPEC) 699 63.30 85.00 70.80 Change eas from Last Years ( ) Management of surgical admitted patients waiting transfer to Grand River Hospital. Implementation of A-I-D-E-T method of communication to patients in the Emergency Department. Extended CCAC hours in the ED 7 days a week to improve transitions in care and discharge planning from the ED idea implemented as intended? (Y/N 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? Since the policy was created and implemented our patients are safely transferred to GRH. Our ED has been following the policy and there has been no quality reviews in respect to surgical transfer since the policy was implemented. AIDET is being practiced by the program manager within the team. At the Unit Leadership Council in March roll out of AIDET for the staff will be initiated. A card is being made for the staff lanyards. CCAC has been a valuable asset to our Emergency Department. Improved process and real time discharge planning which is supportive towards our ED length of stay metric for timely discharge. We have been able to roll out AUA with CCAC and GEM which has been sustainable.
ID Measure/Indicator from 2 "Would you recommend this hospital to your friends and family?" (Inpatient care) ( %; Survey respondents; April - June 2016 (Q1 FY 2016/17); CIHI CPES) 699 89.40 90.00 84.40 Change eas from Last Years ( ) New survey methodology is being implemented for inpatient bedside surveying. idea implemented as intended? (Y/N 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? This pamphlet created by staff will have information for patients of what to expect when admitted to hospital, and should they be waiting for their inpatient bed. The pamphlet will also have a survey on the back that patients can fill out for feedback.
ID Measure/Indicator from 3 Average length of stay ( Days; All patients; April 2017-March; April 2016-March 2017) 699 6.20 6.10 5.90 Change eas from Last Years ( ) Integrated Discharge Planning Model in Collaborative with the Integrated Care model established at St. Mary's and the WWCCAC Senior's Friendly Emergency Department idea implemented as intended? (Y/N 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? Additional change ideas were implemented that had more impact on ALOS for patients (interprofessional rounds at the bedside, ERAS for CV surgical patients, same day discharge for PCI). state and gap analysis for SFH domains completed. Next steps is development of a work plan that address all domains in the provincial framework.
ID Measure/Indicator from 4 Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? ( %; Survey respondents; April - June 2016 (Q1 FY 2016/17); CIHI CPES) 699 CB CB 57.30 Change eas from Last Years ( ) This indicator is not collected currently at St. Mary's. Our Patient Experience Survey through NRC and our own survey methodology. idea implemented as intended? (Y/N 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? Collecting baseline information was achieved.
ID Measure/Indicator from 5 Hospital Acquired Clostridium Difficile Infections ( Number; All acute patients; April 2016-March 2017; In house data collection ) 699 16.00 12.00 6.00 Change eas from Last Years ( ) Strategic A3 is developed for the corporate approach. Sub A3s are developed in focused areas related to hand hygiene, vectors for transmission and environmental cleaning. idea implemented as intended? (Y/N 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? A great deal of attention was placed on cleaning, standardization of chemicals and auditing of cleaning practices. Units are tackling hand hygiene through a self audit process that has produced a positive increase in hand hygiene rates.
ID Measure/Indicator from 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 3 month period; Hospital collected data) 699 0.00 0.00 NA Change eas from Last Years ( ) Medication Reconciliation Refresh Project idea implemented as intended? (Y/N 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? SMGH is undergoing a clinical transformation project with the implementation of a New HIS. Medication reconciliation will be a fundamental component of this implementation therefore resources were not dedicated to adjusting current practice in our current HIS environment.
ID Measure/Indicator from 7 Medication reconciliation at discharge: Total number of discharged patients for whom a Best Possible Medication Discharge Plan was created as a proportion the total number of patients discharged. ( Rate per total number of discharged patients; Discharged patients ; Most recent quarter available; Hospital collected data) 699 0.00 0.00 NA Change eas from Last Years ( ) see Medication Reconciliation on admission for plan idea implemented as intended? (Y/N 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? SMGH is undergoing a clinical transformation project with the implementation of a New HIS. Medication reconciliation will be a fundamental component of this implementation therefore resources were not dedicated to adjusting current practice in our current HIS environment.
ID Measure/Indicator from 8 Percent of palliative care patients discharged from hospital with the discharge status "Home with Support". ( %; Discharged patients ; April 2015 March 2016; CIHI DAD) 699 84.29 90.00 91.52 Change eas from Last Years ( ) WWLHIN Collaborative Project for Palliative Care Common approach and language across SubLHIN. Substitute Decision Maker(SDM) identified on palliative care patients. idea implemented as intended? (Y/N 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? This change idea is still in progress and we are currently working with partners to standardize the approach to SDM for patients.
ID Measure/Indicator from 9 Percentage of acute hospital inpatients discharged with selected HBAM Inpatient Grouper (HIG) that are readmitted to any acute inpatient hospital for non-elective patient care within 30 days of the discharge for index admission. ( %; Discharged patients with selected HIG conditions; July 2015 - June 2016; CIHI DAD) as 699 12.76 12.76 NA Change eas from Last Years ( ) Monitoring indicator idea implemented as intended? (Y/N 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?
ID Measure/Indicator from 10 Percentage of patients discharged from hospital for which discharge summaries are delivered to primary care provider within 48 hours of patient s discharge from hospital. ( %; Discharged patients ; Most recent 3 month period; Hospital collected data) 699 CB CB NA Change eas from Last Years ( ) Evaluation of Information System technology to monitor this indicator idea implemented as intended? (Y/N 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? Evaluation of system was completed. SMGH is currently undergoing a clinical transformation project with the implementation of a new HIS. The ability to monitor this indictor will be a component of the implementation.
ID Measure/Indicator from 11 Percentage of patients identified with multiple conditions and complex needs (Health Link criteria) who are offered access to Health Links approach ( %; Patients meeting Health Link criteria; Most recent 3 month period; Hospital collected data) 699 CB CB NA Change eas from Last Years ( ) Hospital Wide Discharge Planning Project idea implemented as intended? (Y/N 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? This change idea had very little impact on identification of potential Health link patients. The KW 4 sub-regional planning group is continuing to work on the base line data for our region. This will continue to be on the work plan for this group. For acute hospitals, we will need to determine who is responsible for identification of patients, who would benefit from a coordinated care plan and how to facilitate an implementation.
ID Measure/Indicator from 12 Percentage of patients receiving complex continuing care with a newly occurring Stage 2 or higher pressure ulcer in the last three months. ( %; Complex continuing care patients; July - September 2016 (Q2 FY 2016/17 report); CIHI CCRS) 699 0.00 NA Change eas from Last Years ( ) not applicable idea implemented as intended? (Y/N 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?
ID Measure/Indicator from 13 Rate of psychiatric (mental health 699 X 0.00 13.10 and addiction) discharges that are followed within 30 days by another mental health and addiction admission ( Rate per 100 discharges; Discharged patients with mental health & addiction; January 2015 - December 2015; CIHI DAD,CIHI OHMRS,MOHTLC RPDB) Change eas from Last Years ( ) Not applicable to St. Mary's idea implemented as intended? (Y/N 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? This measure is not applicable to SMGH. All psychiatric patients are transferred to Grand River Hospital.
ID Measure/Indicator from 14 Risk-adjusted 30-day allcause readmission rate for patients with CHF (QBP cohort) ( Rate; CHF QBP Cohort; January 2015 - December 2015; CIHI DAD) 699 14.62 14.62 14.90 Change eas from Last Years ( ) Monitoring Indicator idea implemented as intended? (Y/N 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?
ID Measure/Indicator from 15 Risk-adjusted 30-day allcause readmission rate for patients with COPD (QBP cohort) ( Rate; COPD QBP Cohort; January 2015 December 2015; CIHI DAD) 699 15.86 15.86 17.17 Change eas from Last Years ( ) Monitoring indicator idea implemented as intended? (Y/N 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?
ID Measure/Indicator from 16 Risk-adjusted 30-day allcause readmission rate for patients with stroke (QBP cohort) ( Rate; Stroke QBP Cohort; January 2015 - December 2015; CIHI DAD) 699 X 0.00 0.00 Change eas from Last Years ( ) St. Mary's is a collaborative partner with Grand River Hospital who is the Regional Stroke Hospital idea implemented as intended? (Y/N 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? All stroke patients are transferred to Grand River Hospital.
ID Measure/Indicator from 17 Staff Blood and body fluid exposures ( Number; Staff; April 2017- March ; April 2016- March 2017) 699 35.00 31.00 31.00 Change eas from Last Years ( ) Strategic A3 is developed to identify focus areas and contributing factors. Sub A3s are developed in focus areas related to practice. idea implemented as intended? (Y/N 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? SMGH has focused on reducing BBF exposures for three consecutive years. This corporate target requires both process and equipment changes which take time to trial and perfect and then rollout to the rest of the organization. Engaging staff by means of ULCs and huddles has been key. Selecting driver owners of the sub A3s, at the unit level, was critical in ensuring ownership of the approach and strategies to drive down staff injuries.
ID Measure/Indicator from 18 The number of hospital patients who were physically restrained at least once in the 3 days prior to a full admission assessment, divided by all patients with a full admission assessment in the reporting period. ( %; Mental health patients; October 2015 - September 2016; CIHI OMHRS) 699 0.00 NA Change eas from Last Years ( ) not applicable idea implemented as intended? (Y/N 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?
ID Measure/Indicator from 19 Total ED length of stay (defined as the time from triage or registration, whichever comes first, to the time the patient leaves the ED) where 9 out of 10 complex patients completed their visits ( Hours; Patients with complex conditions; January 2016 December 2016; CIHI NACRS) 699 8.12 8.00 8.10 Change eas from Last Years ( ) Utilizing lean methodology the Emergency Department will conduct a value stream map to identify areas of opportunities. Increased availability of ultrasound hours idea implemented as intended? (Y/N 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? Increasing demand on the ED has limited the impact of PDSA developed from VSM. PDSA analysis showed some impact in the adjustment of resources for time of day volumes. PDSA for surge space was successful to increase flow within the department Access to US has improved flow within the ED. PDSA s are being conducted on other diagnostics that will help improve flow.
ID Measure/Indicator from 20 Total number of alternate level of care (ALC) days contributed by ALC patients within the specific reporting month/quarter using near-real time acute and post-acute ALC information and monthly bed census data ( Rate per 100 inpatient days; All inpatients; July September 2016 (Q2 FY 2016/17 report); WTIS, CCO, BCS, MOHLTC) 699 9.26 9.26 14.70 Change eas from Last Years ( ) Revised approach to ALC management within the organization in collaboration with CCAC. Integrated Discharge Planning agreement has been signed with CCAC. idea implemented as intended? (Y/N 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? state review of ALC practices based on provincial tool kit. This work will continue into the next fiscal year. This change idea made very little impact. Instead we will focus on incorporating best practice from the tool kit.