Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/22/2017 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. Royal Ottawa Health Care Group 1
Overview The Royal Ottawa Health Care Group ( The Royal ) is made up of The Royal Ottawa Mental Health Centre, the Brockville Mental Health Centre, Royal Ottawa Place (long-term care), The University of Ottawa Institute of Mental Health Research and the Royal Ottawa Foundation for Mental Health. For the purposes of Quality Improvement Plan (QIP) submissions to Health Quality Ontario (HQO), two Quality Improvement Plans (QIPs) have historically been submitted on behalf of our organization: one represents The Royal s mental health services (referred to in this narrative as The Royal) and the other refers specifically to our long-term care facility, Royal Ottawa Place (referred to herein as ROP). These two entities are governed by a single Board of Trustees and as such, a single QIP submission will be made for 2017-2018. Indicators and quality improvement projects for The Royal and ROP will continue to be reported separately to ensure clear and appropriate oversight of both QIPs. Our Quality Improvement Plans are driven by our mission to deliver excellence in specialized mental health care, advocacy, research and education. Our 2015-2020 Strategic Plan includes five strategic domains: care, discovery, partnerships, engagement, and resources. Under each domain is a set of objectives and indicators that show how we are progressing in our mission. Everything we do is guided by the strategic plan and supportive of the objectives set out within. The Royal s 2017-2018 QIP indicators incorporate opportunities for improvement that were identified through review of our Service Accountability Agreements, the Client Experience Survey, the Family Satisfaction Survey, our Staff/Physician Engagement Survey, and aggregated (critical) incident data. The 2017-2018 QIP was developed by reviewing the indicators from last year s QIP and identifying progress towards the established targets. The Royal s peer hospital scorecard was used to ensure common comparable indicators and benchmarks where available. Our peer organizations include Waypoint Centre for Mental Health Care, Ontario Shores Centre for Mental Health Sciences and the Centre for Addiction and Mental Health (CAMH). Highlights for 2016/17 include: Performance at 1.9%, well below the target of less than 5% for the use of physical/mechanical restraint. This exceptional performance can be attributed to the sustained implementation of the interventions collaboratively designed by the peer hospitals for the Restraint and Seclusion Minimization Project. In addition, anticipating at-risk behaviour and early detection of escalating behavior are improved through the consistent application of safety huddles in all program areas as well as intentional rounding and face to face transfer of accountability in select inpatient programs. Implementation of the Ontario Perception of Care (OPOC) client satisfaction survey, a new survey tool introduced in May 2016. An excellent baseline score of 79.2% positive score for inpatient for we consider the services of high quality was achieved and 93.2% positive for outpatient and community services. Royal Ottawa Health Care Group 2
QI Achievements From the Past Year One of the brightest highlights of the 2016-2017 year was the opening of The Royal s Brain Imaging Centre, featuring a PET - fmri machine the first in Canada solely dedicated to mental health research. We take pride in the knowledge that research done at The Royal with this new technology will help us better understand the biological underpinnings and psychosocial factors involved in mental illness and lead to more effective treatments. In 2016, we evolved our existing Young Minds Partnership with the Children s Hospital of Eastern Ontario, and have already taken great strides in improving access to care. Wait times for a first appointment in our Youth Mental Health Program plummeted to 20 days from 450, largely due to the implementation of the Choice and Partnership Approach (CAPA). This drop is especially significant because it happened amidst a surge in referrals to youth mental health services. It speaks volumes about the calibre and commitment of our staff. We look forward to continued improvements in timely access to care for those in our community who need mental health services. We have also seen some important changes to our Substance Use and Concurrent Disorders Program that enable our clinical team to treat an increasing number of clients with complex mental illness and substance use problems. In addition to the revamped Concurrent Disorders Unit, The Royal opened the Alcohol Medical Intervention Clinic, treating people referred by the Ottawa Hospital s Emergency Department. This new service is reducing repeated visits to the ER and serves as an effective outpatient detox model for the Champlain region. The Royal was also honoured as one of the National Capital Region s Top Employers for the second time by the editors of Canada s Top 100 Employers being noted for progressive and forward-thinking programs in our organization. We were also recognized as the research hospital with the greatest increase in research spending 35.7 per cent of all top 40 Canadian research hospitals, according to the 2016 Canada s Innovation Leaders analysis. Population Health The Royal serves several unique populations that we serve and works creatively to offer services that are evidence-based and innovative. Several examples include: The Community Mental Health Program offered specialized services to support transition within the Assertive Community Treatment Team (ACTT) by implementing an ACTT Transition Readiness Scale (ATR) to facilitate patient flow and access to the program. Our Conversations at The Royal events continue to provide members of the public with valuable information, the latest findings in research, and hope in the community. At the end of 2016, more than 9000 high school students have come through our doors for Is It Just Me?, our mental health literacy and anti-stigma program. Equity The philosophy of health equity, that is, helping people get the resources they need, is a foundation of service delivery planning at The Royal. A part of equity involves acknowledging social, cultural and linguistic services, in addition to respecting and valuing the voice of the client. In 2017, The Royal introduced Diversity training for all staff, in partnership with the Canadian Centre for Diversity & Inclusion. Royal Ottawa Health Care Group 3
We have particularly made increasing Indigenous cultural awareness and safety a priority. As such, the Royal along with our local Indigenous partners hosted an Indigenous Cultural Safety education event on with the theme of Culture as Healing. Topics covered included: The History of the Indigenous people, where First Nations, Metis, and Inuit Elders each provided education on the distinct cultures within each of these groups and with their respective ceremonial practice Looking beyond the diagnosis with a view to a more holistic approach to providing care Clinician Lead development: working with over 50 internal identified clinicians to increase their knowledge and training related to the Indigenous culture and history and in turn share that knowledge with their colleagues on the units in the course of their work. In addition to this work, an equity workplan will be developed in 2017-18, including an environmental scan, action plan and anticipated collaboration with peers to share best practices and work to develop an equity indicator appropriate for those receiving mental health services. Integration and Continuity of Care The Royal is proud of the leadership it provides to improve integration and continuity of mental health services within the Champlain LHIN. Significant accomplishments have been achieved using Lean Quality Improvement methodologies and implementation science. Highlights include: Pathways to Better Care Supporting the implementation of the Champlain LHIN s integrated services, plan, The Royal has lead the coordination of: o Optimizing Care for Complex Schizophrenia patients: Clozapine Pathways: Establishing the Foundation and plan for a regional approach to schizophrenia and psychosis care in Champlain by implementing and evaluating small tests of change (clozapine pilots) for new models of care for individuals on Clozapine, developing a proposal / plan for the LHIN investment and continuing to build/ enhance relationships between hospital, community, and primary care agencies and their clinicians o Ottawa Community Housing (OCH) and Community Development: working with OHC to understand their role in the delivery of mental health and addiction services within up to 13 of their communities/properties (identified as having a higher proportion of vulnerable tenants). Having a baseline of information and increase understanding it is hoped that OCH and community mental health and addiction services have enabled a discussion on collaborative practices/activities to improve the wellbeing of individuals and communities. Health Links The Royal has a lead role on the steering committee of four of its closest Health Links and is working with all 10 Health Links in the region help manage referrals for consultation, assessment or admission to programs. Access to the Right Level of Care - Addressing ALC Issues The Royal works continuously with local partners to address Alternate Level of Care (ALC) issues. We monitor our own ALC status and compare our results with mental health facility peers and are currently reporting the lowest ALC numbers amongst the peer group. Royal Ottawa Health Care Group 4
Engagement of Clinicians, Leadership & Staff In order to increase employee/physician awareness of the Strategic Plan Objectives and the Quality Improvement Plan, in 2016-17 The Royal introduced the QI/Strategy Transformation Education Series. These monthly day-long, program-specific training sessions provide clinicians, leadership and staff with the tools to implement QI that drive forward organizational priorities. The sessions have provided a wonderful opportunity for staff to see the linkage between strategy, QI and their own work. The sessions are ongoing and will culminate in a QI Recognition day in Fall 2017. Resident, Patient, Client Engagement The Client Advisory Council, formerly the Client Empowerment Council, celebrated its 10th anniversary in 2016. The name change signalled a new clarity of purpose and the 10th anniversary demonstrates that The Royal has long valued importance the lived experience of clients, who provide the client voice in many significant ways. Examples include membership on quality improvement teams (such as the CAPA Choice and Partnership Approach implementation in the Mood and Youth programs), the Accessibility, Ethics, Workplace Violence and Safewards teams, and attendance at the Quality Committee of the Board and the meetings of the Board of Trustees. The Client and Family councils contribute annually to development of the QIP Narrative during a facilitated workshop and provide feedback on QIP priorities, in addition to participating on improvement teams. We must particularly acknowledge that both the client and family voices were paramount to the success of eliminating visiting hours in 2016 as our policy and approach was revised the first amongst mental health facilities in Ontario to welcome family and significant others at any time. Staff Safety & Workplace Violence The Royal endorses a philosophy of safe workplaces and has a policy to guide Workplace Violence Prevention. We prioritize education and training to ensure that staff recognizes and responds to escalating behaviours from anxiety through to physical aggression. We also pay particular attention to physical plant design, Code White response, and provide security services. The issue of staff safety is key topics of discussion at site specific collaborative Joint Occupational Health and Safety Committee meetings and at discussions of the organizational workplace violence prevention subcommittee. Patient Safety and Employee Safety key performance indicators are also reported quarterly to senior management team, the Board Quality Committee and the Board of Trustees, in addition to being posted on The Royal s intranet, available to all staff. We also have a Quality Care Review process that encourages patient incident reporting and investigates incidents of violence to surface recommendations to improve processes and systems to limit the likelihood or recurrence and/or the harm done should there be a recurrence. Performance Based Compensation The Royal has a performance-based compensation plan in place for the Senior Management Team which includes: the Chief Executive Officer; Chief of Staff and Psychiatrist-in-Chief; Executive Vice President and Chief Financial Officer; Vice President, Professional Practice and Chief Nursing Executive; Vice President, Communications; Vice President, Patient Care Services. Accountability for the execution of both the annual QIP and the Strategic plan are delegated to the Chief Executive Officer from the Board of Trustees. The plans are reviewed, approved and monitored by the Board of Trustees through performance evaluations of the Chief Executive Officer which is Royal Ottawa Health Care Group 5
cascaded to the parties listed above. It is the sum of all objectives in these plans that determine the performance pay component of The Royal s Executives. As per Regulation 304/6 of the Broader Public Sector Executive Compensation Act, 2014 (BPSECA), The Royal will also develop an Executive Compensation Framework by September 5, 2017. The Royal has allocated 25% of the performance-based pay to the Quality Improvement Plan, with allocation to all 10 initiatives developed under the quality dimensions of QIP for The Royal and Royal Ottawa Place. Specifically, 25% is allocated to each of the indicators as outlined below: Quality Dimension Indicator Allocation 1 Effective Self-Care Index -Client Outcomes 2 Patient Centred -Patient Experience Satisfaction with Services: OPOC I think the services provided here are 3 Safe -Lost time due to staff injury (severity) 4 Safe -Lost time due to staff injury (frequency) 5 Safe -Medication reconciliation (outpatient) 6 Safe -Restraint Usage 7 Timely -Wait Times 8 LTC: Effective - Worsening Bladder Continence 9 LTC: Patient Centred -Resident Experience 10 LTC: Safe -Restraint Usage of high quality Lost days related to workplace violence Number of lost time claims due to workplace violence Implementation of medication reconciliation in the outpatient setting Use of physical/mechanical restraints Wait times in Mood & Anxiety Outpatient Clinic Percentage of residents with worsening bladder control Overall satisfaction Use of physical/mechanical restraints Total 25% Contact Information Tracy Wrong, Director, Quality, Patient Safety & Risk Management tracy.wrong@theroyal.ca Royal Ottawa Health Care Group 6
2017/18 Quality Improvement Plan "Improvement Targets and Initiatives" Royal Ottawa Health Care Group 1145 Carling Avenue AIM Measure Change Quality dimension Issue Measure/Indicator Unit / Population Source / Period Organization Id Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Process measures Effective Client Outcomes % of inpatients with symptoms on % / All inpatients Hospital 651* 62 70.00 Target set consistent with The Royal's 1)Engage programs to set Quarterly reporting of SCI by % of inpatients improved from admission who had a positive change Strategic Plan benchmarks for their specific program. Individual targets set by admission to discharge, Selffrom admission to discharge, Self-Care Q3 2016-17 programs and to focus on program. Aggregate target on Care Index (SCI) Index (SCI) developing specific initiatives QIP. as appropriate Target for process measure TBD Comments Patient-centred Patient Experience Satisfaction with Services: Ontario Perception of Care survey response to Question #31: "I think the services provided here are of high quality". % / All inpatients Hospital May 2016 651* 79.2 83.40 Target of 83.4% represents a 5% increase over previous year's performance. As this is a new indicator, data will also be shared with peers to refine target setting in 2017/18. 1)Corporate initiative to improve: Q16: I know how to voice concerns Convene formal QI team to identify QI opportunities for improvement Compare 2017 results Collecting baseline (question 16) to previous year's results (2016: 61.6% inpatient; 63.3% outpatient) Follow up initiatives to be determined over the year Safe Medication Reconciliation in Outpatient Clinics Medication reconciliation implemented in 30% of outpatient programs % / selected outpatient clinics with med rec Hospital 2017-18 651* CB CB 30% of clinics were targeted for year 1 (2016-1)Medication Reconciliation 17); 30% more clinics to be targeted in year 2 for new patients of a 3 year plan Meetings with individual clinics to assess (a) # new patients and (b) # who meet definition requiring med rec as per the policy definition # new patients (meeting the definition) with documented med rec / #new patients admitted to the program 65% of patients that meet the definition for requiring medication reconcilation receive it Reduce lost time due Number of lost time claims related to Claims per 100 to staff injury -claims workplace violence events expressed as fte / Health workplace violence incidents per 100 providers in the ftes entire facility Hospital Q3 2017/18 651* CB CB The Royal is working with peer facilities to collect baseline and set comparable targets in the coming year. 1)Consider and introduce recommendations from external consultant report Corporate initiative to implement workplace violence risk assessments Results from Workplace Violence Perception Survey Collecting Baseline Follow up initiatives to be determined over the year Reduce lost time due to staff injury Reduce use of physical (mechanical) restraints WSIB Lost days related to workplace violence expressed as workplace violence days per 100 fte Physical/Mechanical Restraints: % of patients whose RAI-MH admission assessment reported use of acute control procedures (mechanical) in the first 3 days of admission. Rate / Health providers in the entire facility Hospital Q3 2016/17 % / All inpatients CIHI OMHRS / Oct 1 2015-Sept 30 2016 651* CB CB The Royal is working with peer facilities to collect baseline and set comparable targets in the coming year. 1)Consider and introduce recommendations from external consultant report 651* 1.9 1.90 Performance improved significantly in Q2 2016/17; goal will be to sustain excellent performance over the long term. This initiative is in alignment with the ROHCG strategic plan, moving the organization closer to the 4 peer MH facility best performance Q3 of 1.9% (Q3 2015-16 - Ont Shores) 1)Spread successful QI Initiative (of 4 MHA organizations) organizationwide Corporate intitiative to implement workplace violence risk assessments 1) Client assessment / potential for restraint and triggers documented on comfort care plan 2) Debrief post untoward event - was comfort care plan followed? Results from Workplace Violence Perception Survey 1) Client assessment / potential for restraint and triggers documented on comfort care plan 2) Debrief post untoward event - was comfort care plan followed? Collecting baseline 100% Follow up initiatives to be determined over the year Timely To reduce wait times in the Mood and Anxiety Outpatient Service The number of days from the date a completed referral is received to the date the patient was seen by a clinician Days / Referrals to Outpatient Mood & Anxiety program Hospital Q1 2016-17 651* CB CB While current performance (Q1 2016/17 is 1)Continued implementation 198.2 days), work is ongoing on refinement of Choice and Partnership of this indicator and more data is required. Approach (CAPA) Target will be developed in consultation with senior leadership once more quarters become available. Enhance Consultation Clinic Introduce a calculation that TBD; We are captures a volume to wait time working towards ratio mathematical models to determine expected volume per fte 1
2017/18 Quality Improvement Plan "Improvement Targets and Initiatives" Royal Ottawa Health Care Group 1145 Carling Avenue ROYAL OTTAWA PLACE - Long Term Care AIM Measure Change Quality dimension Issue Measure/Indicator Unit / Population Source / Period Organization Id Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Effective To Reduce Worsening Bladder Control Percentage of residents with worsening bladder control during a 90- day period. % / Residents CIHI CCRS / Q2 2016/17 54482* 19.5 18.00 Target of 18% was determined 3 years ago by clinical team as comparators are not available for ROP population. While results have varied over the years and are currently headed in the right direction, the team feels additional effort will be required to achieve the 8% relative decrease to achieve the target. 1)Continence Management practice review 2)Enhance training plan for all staff on use of Continence Management Increase understanding of current coding practices regarding worsening bladder control & provide timely feedback to the frontline staff. Develop new training tools in accordance with LTC standards, to address gaps as per coding review, and to meet LTC requirements for annual refresher training. Process measures # patients that are amenable to a having toileting plan that actually HAVE a plan/#worsening bladder control patients. "# staff trained during blitz month/# staff to be trained # staff trained by month/# staff to be trained" Target for process measure To ensure those that can benefit from a toileting plan or appliance have access to one To meet LTC training requirements Comments A good number of our patients, due to their illnesses, may experience worsening continence. Patient-centred Resident experience: "Overall satisfaction" 4H Client Experience Survey (LTC Satisfaction Survey): "Overall, how would you rate the care you are receiving?". % / Residents Hospital 2016-17 (November) 54482* 91.9 91.90 Excellent performance in 2016-17 - increase of 15% over 2015-16 results. ROP-LTC will look to sustain performance in 2017-18. 1)Explore options to allow residents more input into planning of activities Work with Resident Council to sollict ideas from residents by June 30, 2017 (Goal: one idea for 2017 for each resident at ROP) # of new ideas/resident by June 30 2017 64 new ideas Safe To Reduce the Use of Restraints Percentage of residents who were physically restrained (daily) % / Residents CIHI ereporting Tool / Q2 FY 2016/17 54482* 4.2 4.20 Previous year's target (4.3%) met in 2016/17; Goal is to sustain performance as 32% decrease over 2015/16 results was achieved. 1)Annual personal assistive safety device (PASD)review Increase understanding of current coding practices regarding use of PASDs # adjustments/#restraints coded/month To ensure proposer coding by frontline staff and to facilitate targeted training plans as required 2