Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/16/2016 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 In 2017, Belmont House will be celebrating its 165th anniversary marking a significant milestone of providing care and services to seniors. Belmont House is a fully accredited charitable, Christian, not-for-profit home with 140 long term care beds and 81 retirement apartments, located in downtown Toronto. Belmont House principally serves the communities of downtown Toronto, Yorkville, Rosedale, and Forest Hill. Belmont House is classified as an A Long Term Care Home by the Ministry of Health and Long Term Care (MOHLTC). All aspects of life at Belmont House including care, support and the environment are designed and managed not only to meet but surpass the needs and expectations of our residents. There are a total of 5 units of care which includes a secure unit of 26 beds for people with Alzheimer s and severe dementia. At Belmont House, long-term care residents are offered programs in general geriatric care, including people with Alzheimer s disease, Cognitive Impairment, and Palliative Care. Residents also receive care for, depression, circulatory diseases, osteoarthritis, stroke, Parkinson s disease and dementia. In 2015 Belmont House revisited its Strategic Plan. With input from stakeholders including residents and families, the new Strategic Plan 2015-2018 was crafted and aligned with the home s Accountability Framework. Five (5) strategic directions were identified including: 1. Excellence in the Care and Overall Experience of our residents, tenants and their families 2. Excellent People: positioning for the future 3. Infrastructure renewal to support the evolving needs of residents, tenants and families 4. Foster Innovation 5. Leadership to improve the broader health system through advocacy and partnerships The Quality Improvement Plan (QIP) for Belmont House is directly aligned with two of the five the strategic directions: Excellence in the Care and Overall Experience of our residents, tenants and their families and Foster Innovation. In addition to the Strategic Plan, the QIP aligns with the following provincial priorities and planning processes: Belmont House Operating Plan; Toronto Central Local Health Integration Networks (TCLHIN) directions; Long Term Care Home Accountability Service Plan (L-SAA); Ministry of Health and Long-Term Care legislation, regulations and directives; Health Quality Ontario initiatives; Accreditation Canada Standards; Surge which is an on-line training program focusing on learning needs for long term care staff; Areas arising from the Quality, Risk and Safety Management Program; Areas arising from the annual Resident and Family Experience surveys. Our organizational goals and objectives are derived from the Strategic Plan. Key indicators are tracked quarterly utilizing a Balanced Scorecard approach and reported to the Quality, Risk and Safety Committee of the Board. A multidisciplinary Best Practice committee monitors indicators monthly, identifies trends and improvement initiatives. 2
QI Achievements From the Past Year Belmont House is proud to report on the success of its quality improvement plan. During 2015/16, Belmont was successful in meeting 3 of the 4 performance targets as outlined in the table below. Indicator Performance as of Q2 FY 2014/2015 Target Performance Achieved in Q2 2015/2016 Percentage of residents who had a recent fall (in the last 30 days) 15.40% 13.90% 12.90% Percentage of residents who had a pressure ulcer that recently got worse 4.00% 3.60% 3.40% Percentage of residents taking antipsychotics without a diagnosis of psychosis 27.20% 26.20% 19.00% Percentage of residents with worsening bladder control during a 90 day period 22.90% 19.10% 24.7% The quality initiative that most significantly impacted the falls improvement was the development and implementation of the post falls assessment. The assessment was set up in documentation software and all staff received education on the tool. By having access to the tool electronically, the nursing management could ensure the tool was completed and follow up to ensure appropriate interventions were in place. We learned that in spite of a comprehensive fall management program, residents continue to make choices that may have a negative outcome. Also cognitive status plays a significant role in resident falls as the resident may not understand instructions or may think they are still able to ambulate when they are not. Belmont has managed to maintain a low restraint utilization rate while decreasing fall rates. Senior leadership, Board committees (families and residents sit on the Quality, Risk and Safety Committee of the Board) and the multidisciplinary team (Best Practice committee) reviewed metrics (outcome and process measures) on a regular basis (monthly/quarterly) to ensure our strategies were resulting in improvement. Worsening pressure ulcers improvement was most significantly impacted by the introduction of high risk rounds and the purchase and implementation of a digital tool called the Zoom tool. Weekly rounds with staff involvement increased awareness and fostered just in time discussions about wound prevention and interventions. The Zoom tool digital measurements took away the human error in wound measurement and was trialed on one unit as a predictive tool to determine if the current treatment regime was working. Inappropriate antipsychotic reduction improvements can be attributed to increased physician awareness both in the media and at the Pharmacy and Therapeutic committee meetings. Utilization by physician and peer comparison as well as consultations with the consultant pharmacist assisted in physicians trying to reduce/eliminate inappropriate antipsychotics. Belmont did not meet target with worsening bladder control. The team felt that coding issue contributed in part. The numerous definitions (from occasionally to totally incontinent) was confusing for the Health Care Aides. In spite of education in this area, quality of coding has continued to be a challenge. In addition, resident length of stays have been decreasing and residents are being admitted with higher acuity levels and comorbidities and are already experiencing some level of incontinence. 3
Integration and Continuity of Care Belmont House, in keeping with its strategic direction of Leadership to improve the broader health system through advocacy and partnerships, has developed and implemented various initiatives to share best practices, improve continuity of care and integration. Some examples include: 1) Belmont is the lead in an Alliance group of non-profit organizations representing approximately 5000 beds in the Greater Toronto Area. This group focuses on sharing information, implementing best practices and benchmarking with each other to identify best performers. 2) We work closely with academic partners including the University of Toronto, Ryerson University, Centennial College and George Brown College. Student placements include nursing, dietary, environmental, recreation, medical administration and Masters of Health Information and Masters of Occupational Therapy. 3) Belmont is partnering with the University of Toronto on the Age Well- Research Project. The goal of the project is to generate technological and social innovation to enhance the health and quality of life for older adults and caregivers. AGE WELL is a national research organization funded by the Government of Canada and the Province of Ontario. It is a collaborative endeavor with universities and research institutes across the country. Belmont is very proud to be the first long term care facility to be invited to hold a position on its Advisory Council. Current projects include the Wheelchair Collision Avoidance project and a robotics project. 4) Belmont is associated with a number of partners to better manage responsive behaviours including the Behaviour Support Outreach Team, the Geriatric Mental Health Outreach Team and the Psychogeriatric Resource Consultant. 5) Senior Management participate in a number of projects and initiatives focusing on improving long term care including: a. Long Term Care Service Accountability Service Agreement Working Group; b. LTC Resident Care and Safety Task Force -OANHSS Representative; c. OANHSS Benchmarking Indicators and Target Group committee. 6) Our partnership with the Nursing Lead Outreach Team (NLOT) has assisted in preventing transfers to ED through enhanced monitoring and skills application in the home. Belmont is currently well below provincial average in this area. 7) Belmont House provides both long term care and retirement living and works closely with the Community Care Access Centre (CCAC) to ensure that residents are able to stay in their own community when their care needs increase. Engagement of Clinicians, Leadership & Staff The Senior Management team drives many of the quality initiatives to ensure they align with the strategic goals of the organization and that they are adequately resourced. Each manager/director is assigned indicators to track and part of this responsibility includes interfacing with front line staff to determine why the numbers are the way they are, and to elicit suggestions/change ideas to improve when targets are not met. The multidisciplinary team meets monthly to review real time key clinical and non-clinical data including indicators that form the Quality Improvement Plan (QIP) and the Balanced Scorecard. Quarterly the Quality, Risk and Safety (QRS) Committee of the Board reviews performance of key quality initiatives through internal reports and the Balanced Scorecard. The chair of the QRS committee provides the full Board with a report on a quarterly basis as well as status reports on the performance of the QIP. Various committees including the Medical Advisory Committee, Pharmacy and Therapeutics Committee, Infection Prevention and Control and the Joint Occupational Health and Safety Committee are used as a forum to review information including indicator data and the Quality Improvement Plan, identify areas for improvement and initiate improvement strategies. In addition 4
input to the Quality Improvement plan is sought from residents, families, staff, physicians and the Board through Councils and meetings. Resident, Patient, Client Engagement Belmont House engages with residents and their caregivers in a number of ways which has assisted in the development of the Quality Improvement Plan. Family and Resident Council meetings are held on a regular basis and quality improvement is a standing item on the agenda. The draft QIP was discussed and feedback on change ideas was obtained at meetings held in winter 2016. Resident and Family Experience Surveys are conducted annually and results are compared with a group of homes called the Alliance Group. Results of the survey are discussed at Council meetings, at the Board and in a town hall session led by the Chief Executive Officer. Areas for improvement are identified and change ideas are brought forward for input and discussion. Three to four initiatives are chosen and they become part of the organization s goals and objectives for the upcoming year. The goals and objectives for the upcoming year and highlights from the previous year are incorporated into the operating plan which is available to all staff and is also posted on the Belmont House web-site. A key focus this year is resident/family centred care and engagement. Representatives from Family, Resident and Tenant Council sit on the Quality, Risk and Safety Committee of the Board. Families and Residents are involved in the development of a new initiative called Better Together. Our Better Together strategy is an initiative that promotes transparency, encourages collaborative decision making and supports actively involving residents, tenants and families to achieve better outcomes. Families and residents will be involved in revising the admission process and evaluating our core programs (skin and wound management, falls management, continence management and pain management including palliative and end of life care program). Other Health Quality Ontario has identified key priority indicators in order to affect system change. Belmont also believes that the plan should address those areas in need of improvement at the home level and that the home must choose indicators for improvement with consideration to the resources that are available. Choosing too many key priority indicators given the current resources may dilute efforts and not result in improvement in any area. With that in mind, Belmont has chosen the following indicators on which to focus during 2016-2017: Reducing Falls Falls are the leading cause of death due to injury among the elderly. Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Due to the negative outcomes associated with falls, Belmont is focusing on reducing the incidence of falls within the home. Belmont House will endeavour to reduce the incidence of residents who have fallen in the last 30 days from 13.3% to 12.9% by Q2 2016/2017. Performance is currently below the provincial average of 13.9% but the intent is to move closer to the benchmark of 9%. Reduce worsening pressure ulcers The skin and wound program focuses on prevention. However once a pressure ulcer has developed, interventions must focus on preventing the pressure ulcer from worsening. Belmont House will endeavor to reduce worsening ulcers from 3.4% to 3.2% by Q2 2016/2017. Belmont s performance is below the provincial average of 3.6% but further improvement is a goal. Receiving and utilizing feedback regarding resident experience and quality of life 5
Belmont House has been conducting resident and family experience surveys since 2000 and incorporating the feedback in the development of its annual goals and objectives and comparing results with a group of other non-profit homes called the Alliance Group. The definitely yes responses to the question would you recommend Belmont House were 87% in 2015. Our target is 82% so our goal is to maintain the current satisfaction rate. Two questions were added to the survey: 1) Staff listen to me (87% usually/always response) 2) I can express my opinion without fear of reprisal (78% usually/always response rate) The Resident Experience domain is a key area of focus for Belmont House in the upcoming year. In collaboration with the residents and families were are working on a Better Together strategy to improve resident s quality of life through collaborative decision making. The initial areas of improvement efforts are focusing on early connections with residents and families, in particular new residents. The initiative includes connecting with new residents and families approximately 2 weeks post admission using a set of questions that were collaboratively developed. The goal is to get input on what is working well and what can we do to improve resident and families early experiences at Belmont House. Based on the results of the annual Resident Experience survey, pleasurable dining was identified as an area for improvement. Noise level and service have been identified as the key themes to work on. Service training, reducing noise from equipment and conversation are key areas of focus. Belmont is currently performing better than provincial average in the other key priority indicators suggested by Health Quality (restraints, inappropriate utilization of anti-psychotics, potentially avoidable Emergency Department Visits for Long Term Care Residents so these are not a focus for the upcoming year. 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 / Licensee or delegate Administrator /Executive Director Quality Committee Chair or delegate CEO/Executive Director/Admin. Lead (signature) Other leadership as appropriate (signature) 6
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