Final (Approved by Board of Directors March 22, 2012)

Final (Approved by Board of Directors March 22, 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. Southlake Regional Health Centre 1

Part A: Overview of Our Hospital s Quality Improvement Plan Purpose of this section: Quality Improvement Plans (QIPs) are, as the name suggests, all about improvement. They are an opportunity for hospitals to focus on how and what to improve, in the name of better patient-focused care. As such, they will be unique documents, designed by, and for, each individual hospital. Overall, a QIP should be seen as a tool, providing a structured format and common language that focuses an organization on change. The QIP will drive change by formalizing a plan and facilitating shared dialogue to support continuous quality improvement processes. This introductory section should highlight the main points of your hospital s plan and describe how it aligns overall with other planning processes within your hospital and even more broadly with other initiatives underway in your hospital and across the province. In addition, this section provides you with an opportunity to describe your priorities and change plan for the next year. Please refer to the QIP Guidance Document for more information on completing this section. [In completing this overview section of your hospital s QIP, you may wish to consider including the following information: Provide a brief overview of your hospital s QIP. Describe the objectives of your hospital s QIP and how they will improve the quality of services and care in your hospital. Describe how your plan aligns with other planning processes in your organization. Describe how your plan takes into consideration integration and continuity of care. Describe any challenges and risks that your hospital has identified in the development of their plan.] 1. Overview of our quality improvement plan for 2012-13 At Southlake Regional Health Centre (Southlake), we are committed to continuously improving the quality and safety of the care we deliver to our patients and the work environment we provide to Our People (i.e., physicians, staff, volunteers, and students). As such, our Quality Improvement Plan (QIP) is designed to challenge us to fulfill our Mission of caring for people and making their lives better. In 2012/13 we will seek to further reduce hospital acquired adverse events with a focus on reducing pressure ulcers, Clostridium Difficile associated infections and inpatient falls. 2. What we will be focusing on and how these objectives will be achieved In the past five years, the Southlake team made significant gains in key patient safety and patient satisfaction measures. We have worked with our critical care teams to reduce the incidence of infections, such as Ventilator Associated Pneumonia (VAP) and Central Line infections (CLI), and to improve our identification and treatment of Sepsis. Notwithstanding our successes to date, we know that there is always room for improvement. In our 2012/13 QIP, we have included objectives to sustain the gains we have made in these areas. Information on past and current patient safety measures are posted under the Our Performance section of the Southlake s website. As healthcare leaders, we have a responsibility to ensure that we identify all areas where we have the potential to improve in a substantial way. Therefore, for the 2012/13 QIP, we will give the greatest priority to achieving the following objectives (for further details see Part B): 1. Reduce the rate of hospital acquired Clostridium Difficile Associated Infection (CDI) by 20% (from 0.37 to 0.27 per 1000 patient days). In addition to sustaining Southlake s greater than 90% hand hygiene compliance, new strategies to reduce CDI for 2012/13 will continue by introducing antimicrobial stewardship best practices and a goal for zero transmission based CDI. 2. Reduce the overall incidence of hospital acquired (stage 2 or higher) pressure ulcers by 12% (from 20% to 8% stage 2 or higher). Southlake will seek to eliminate heel ulcers and decrease all other ulcers by 50%. We recognize that these targets are aggressive, but as an acute care facility with a significant population of long-term patients at risk for pressure ulcers, we are committed to achieving these results in 2012/13. 3. Decrease the rate of inpatient falls that result in an injury by 10% (from 0.82 to 0.74 per 1000 patient days). Building on Southlake s existing Fall Risk Reduction Program, a task team has been assigned to lead a series of initiatives aimed at reducing harm to our patients as a result of a slip or fall during their hospital stay. Southlake Regional Health Centre 2

4. Improve medication reconciliation compliance in the Emergency Department (from 14% to 75% received medication reconciliation). Medication reconciliation is considered a best practice and can save lives. As such, Southlake is committed to improving compliance with this important practice to 75% for all patients admitted through our Emergency Department. * All objectives are stated with targets to be achieved by March 31, 2013 3. How the plan aligns with the other planning processes The 2012/13 quality improvement objectives reflect Southlake s goal to be recognized as a performance leader in the delivery of safe, quality healthcare services. As such, our QIP targets are aligned with our Hospital Services Accountability Agreement with the Central LHIN and our obligations under the Ministry s Pay-For-Results program. They are also aligned with Southlake s strategic quality/safety goals of Satisfied Customers, Safe Healthcare Environment, and Access to Service and Excellent Outcomes. Lastly, as Southlake transforms to a teaching and research centre, the emphasis on quality and safety will remain a high priority, as we train future healthcare professionals and discover new ways to deliver exceptional care. 4. Challenges, risks and mitigation strategies As an acute care hospital that offers regional tertiary services and is expanding its teaching and research efforts, Southlake will be challenged to accomplish our improvement goals in a fiscally responsible manner. In addition to the high population growth, we have a higher than provincial average of the 65+ segment of the population within our service area. The following objectives have additional specific risks that my limit our success in 2011/12: Clostridium Difficile Associated Infection (CDI) reduction: Risks: Patients currently developing CDI at Southlake tend to be complex, frail, elderly patients. Long standing use of antibiotics prescribed in the community increase the risk for these patients when hospitalized. Mitigation: Southlake s Antimicrobial Stewardship Program will examine opportunities to expand its work beyond the inpatient environment. Reduce inpatient Falls with outcomes: Risks: A patient s risk for falls increases with his/her age and is compounded by conditions associated with aging, such as delirium. Some strategies are dependent on the ability to invest fully in specialized injury reduction equipment. Mitigation: Southlake will prioritize the most critical investments required to support this initiative while balancing the need for other investments. Perform medication reconciliation in Emergency for all admitted patients: Risks: Activities identified to meet this ambitious objective are highly dependent on human resources and subject to unpredictable events associated with a very high volume emergency department. Mitigation: In an effort to keep pace with growing volumes in Southlake s Emergency Department, additional resources (i.e., staff) have recently been assigned to perform medication reconciliation. During high volume periods where demand exceeds available resources, the healthcare team will focus on those patients with the greatest need to receive the service. Southlake Regional Health Centre 3

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.] Southlake s Improvement Targets and Initiatives- Part B spreadsheet provides full details of our entire Quality Improvement Plan. The spreadsheet is included at the end of this document or can be viewed now by following this link. Southlake Regional Health Centre QIP- Part B Improvement Targets and Initiatives. Southlake Regional Health Centre 4

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.] The Performance Based Compensation will apply to all Executives and all Management Staff at Southlake Regional Health Centre in the following manner: 1. Total variable pay linked to performance based compensation strategy including all QIP initiatives will be 10% (based on the base salary). 2. Forty percent of the performance based compensation will be linked specifically to achievement of the QIP. 3. The forty percent allocation linked to the QIP will be calculated for all Executives and Management staff utilizing the following terms: All 9 QIP indicators will be linked to performance based compensation utilizing the following weighting: The Priority one QIP indicators will be weighted x 3 The Priority two QIP indicators will be weighted x 2 The Priority three QIP indicators will be weighted x 1. Achievement will be based on the percentage of the targeted change which was achieved. Under-achievement from current will result in a negative percentage achievement. Over-achievement from targeted goal will result in a score greater than 100%. The calculation of all QIP indicators with the weightings will provide for a final % achievement overall and will fall between the range of 0% and 100%. Southlake Regional Health Centre 5

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). original signed by original signed by original signed by Bruce Herridge Board Chair Jonathan Harris Quality Committee Chair Dr Dave Williams Chief Executive Officer Southlake Regional Health Centre 6

PART B: Improvement Targets and Initiatives 2012/13 [Insert Hospital Logo] Southlake Regional Health Centre, Lower is Better Please do not edit or modify provided text in Columns A, B & C Higher is Better AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Current performance Target for 12/13 Target justification Priority level Planned improvement initiatives (Change Ideas) 1) Establish Antimicrobial Stewardship "best practices" to optimize the use of the right drug, for the right purpose, and for the right duration: Methods and process measures Goal for change ideas (2012/13) Comments Safet ty Reduce clostridium difficile associated diseases (CDI) Improve provider hand hygiene compliance Reduce incidence of new pressure ulcers CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospital acquired CDI, divided by the number of patient days in that month, multiplied by 1,000 Current Performance = Average for Jan Dec. 2011, consistent with publicly reportable patient safety data (per health Quality Ontario [HQO] guideline) Hand hygiene % compliance before and after patient contact: The number of times that hand hygiene was performed before and after patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by 100. Current Performance = Jan Dec. 2011 Southlake all units. Moment 1 (before patient contact) = 88% Moment 4 (after patient contact) = 92% Blended percent compliance = 90% Percent of patients with new pressure ulcer (stage 2 or higher). Current Performance = Nov 2011 audit from Health Outcomes report (13/76 patients with Length of Stay (LOS) past 1 week acquiring a new ulcer) as baseline. Included adult acute care, complex care and rehab 0.37 0.27 90% Blended 100% 20% 8% Target to meet other high performing peers (i.e. large community hospitals) within Ontario Theoretical best is 100% and represents our stretch goal hospital wide Reduce the incidence of heel ulcers to 0% and the incidence of all other ulcer types by 50% 1 2 1 promote judicious use of the antimicrobial agents to prevent, control, and eliminate the transmission of CDI and other antimicrobial resistant organisms develop and promote use of an Antimicrobial Susceptibility pocket card for quick reference 2) Eliminate patient to patient transmission of CDI through PIDAC (Provincial Infectious Diseases Advisory Committee) input & "Hand Hygiene" best practices (see H.H. Objective) and Management of CDI best practices: focus on environmental cleaning practices with implementation of approved sporicidal products for twice daily disinfection of the entire rom for a single case of CDI 1) Continued Management and Leadership involvement with regular staff "rounding", unit specific data postings & internal accountability mechanisms will help to maintain our diligence and continued success seen this past fiscal year. 2) Environmental changes and support systems to include a visual flag for empty alcohol station dispensers 1) Corporate education proper equipment use assessments within 24 hours documentation of pressure ulcers 2) Re defining hospital acquired pressure ulcers as an adverse event. 3) Ensure replacement of beds, surfaces and mattresses is based on pressure ulcer evidenced based research to reduce pressure ulcers Measure inventory usage of antibiotic (specific anti microbial TBD). Percent compliance with best practice. Number of transmission based CDI, monitor Infection Prevention & Control database. All computer monitors are linked to display compliance weekly audit corporate & individual unit scores. Electronic and card info distributed to clinicians by April 30, 2012. Zero transmissionbased CDI. Weekly engagement with staff on inpatient units. Monitor for change in Purchase and install HH compliance % after ABHR to high volume installation to a areas/units. specific unit. Increasing uptake of electronic incident reporting (post initial assessment) for pressure ulcers and monthly audits. Equipment replacement purchases. 4) Implement heel boot strategy corporately Monitor corporate implementation and % heel ulcers. 100% compliance with reporting (reconcile audit with Incident reporting). Purchase new beds, surfaces and mattresses as per replacement development plan. Reduce to 0% heel ulcers Education Collaborative with 3M. Note: Southlake will re audit prevalence and incidence starting in June 2012 & quarterly thereafter.

AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Reduce Inpatient Falls with Outcomes Improve medication reconciliation compliance for Emergency Department admits Rate of Falls with Outcomes per 1000 inpatient days: Total number of falls with a severity rating of moderate, severe or critical divided by the number of inpatient days multiplied by 1000. Data Source: Internal Safepoint Incident Reporting System. Current Performance = Apr Oct 2011 Percent of Patients at admission receiving medication reconciliation all adult patients in the Emergency Department at time of admission. Current Performance = Mar 2011 audit n=147 all ages Current performance 0.82 14% 75% Target for 12/13 Target justification 0.74 Target represents significant improvement for a high priority population. Resources are required to support this strategy. Priority level 1 Planned improvement initiatives (Change Ideas) Staffing Pharmacy Technician in the Emergency Department. Team will address the patients at highest risk and distribute resources accordingly. Methods and process measures Strategy is 1) Pilot on Transitional Care Unit (TCU) with injury prevention TCU percent of falls dependant on new equipment with an outcome. capital resources which will need to be Percent of patients phased in therefore with appropriate a 10% targets equipment. 1 overall, but will have 2) Completion of falls risk assessment within 24 hours of % completion within more aggressive admission. 24 hrs of admission. targets for pilot unit. 3) High risk injury/falls patients have a specialized care plan % of patients with a specialized care plan executed. Technicians are completing the BPMH (best possible medication history). Goal for change ideas (2012/13) 50% reduction in outcomes. 100% compliance 100% compliance 100% compliance 75% of all adult patients to have a completed, reconciled BPMH. Comments Our focus on the ED is based on current assessment of gaps and benefit. Effectiveness Reduce unnecessary deaths in hospital HSMR: number of observed deaths/number of expected deaths x 100. Current Performance = FY 2010/11, as of December 2011, CIHI (per HQO guideline) 81 81 Sustain our exemplary performance. We are significantly below the Canadian national average. 3 For priority 3, strategies are not included as per HQO guidelines, however our focus on the Priority 1 Indicators listed here will contribute to our continued success with keeping our HSMR below Canadian norms and will sustain this strong level going forward. Acces ss ER Wait times: 90th Percentile ER length of stay for Admitted d patients. t Reduce wait times in the ED Current Performance = Q3 2011/12, NACRS, CIHI in hours (per HQO guideline) 29 26 10% reduction from current performance or as per CLHIN P4R (Central Local Health Integration Network Pay for Results) target. 2 1) Remote telemetry monitoring equipment in MACU (Medical Assessment Consultation Unit). 2) Provide increased support & improved efficiency of IPAC (Infection Prevention & Control) support on weekends in collaboration with the Clinical Support Manager(s). 3) Hospital related ALC's (Alternate Levels of Care) successfully reduced at Southlake. Work with the CLHIN, CCAC and Public Health to develop a parallel process collaboration model to decrease community related ALC s in acute care. Turnover rate of MACU patients after installation. Number of unnecessary days of patients on "precautions". Monitoring turnover of ALC (Alternative Level of Care) beds Improve turnover rate by 25%. Zero unnecessary days on "precautions" Improve efficiency of ALC discharge & placement in community. Collaborate with Cardiac program. Achievement will be dependant on access to our acute care beds

AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Patient t centred Percent positive score: "Overall, how would you rate the care you received in the Emergency Department?" (question from NRC Picker) Improve patient satisfaction Current Performance = Nov2010 Oct 2011. (12 months baseline per HQO guideline) Current performance 84% 87% Target for 12/13 Target justification Priority level Planned improvement initiatives (Change Ideas) Methods and process measures Scripting questions in initial nursing & doctor assessment for eliciting patient anxieties/fears. Target represents Southlake meeting Incorporating specific the 90th percentile questions about of 21 peer Ontario Focus on Emotional Support quality dimension; specifically with remaining concerns in hospitals classified those team members that have direct contact with the patient preparation for as "very high 2 through their care experience. Managing patient anxieties, fears discharge. calls. and concerns will have the greatest impact. volume". Hospitals in this classification see more than 50,000 annual visits. (based on Q1 FY11/12 data) Goal for change ideas (2012/13) Management concurrent audit regarding consistency of practice (Goal >80% consistent use). Tool/prompt developed or edited. Audit in postdischarge phone Education to the entire Tracking team including participating in Physicians & Nurses educational goal about current (TBD). Results to be performance and goals discussed at monthly of intervention. staff meetings. Comments Strategies and process goals to be assessed by local ED lead. Integrated Reduce unnecessary hospital readmission Readmission rate within 30 days for Chronic Obstructive Pulmonary Disease (COPD) to Southlake only: The number of patients with COPD re admitted to Southlake Regional Health Centre for non elective inpatient care within 30 days of discharge for a similar condition. Current Performance = Q1 + Q2 FY11/12. 8.6% 8.6% We have reduced our readmission rate from 11.2% (FY10/11) to 8.6%. Target is to sustain within normal variation. 3 We choose to monitor re admissions to Southlake. The ministry collects re admissions to all Ontario facilities but this data is typically not available to hospitals until 9 months beyond the reporting quarter, rendering the information of little value in terms of analysis and action. By monitoring re admissions to Southlake on a quarterly basis with data available approximately 2.5 months beyond the reported quarter, we can intervene and react with a higher probability of meaningful impact and improvement.