Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario FINAL 29/03/2016 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. St. Mary s General Hospital 1
Overview 2015/16 was an exciting, challenging and rewarding year for St. Mary s General Hospital. There are many things for us to be proud of as an organization as we continue to work towards our vision to be the safest and most effective hospital in Canada characterized by innovation, compassion and respect. Staff, physicians and volunteers continue to work very hard and remain dedicated to providing our patients with the safest and highest quality care possible. How we plan to achieve our vision St. Mary s identified several goals in last year s Quality Improvement Plan (QIP) that will help us achieve our vision of being the safest and most effective hospital in Canada. The goals for 2015/2016 were: Reducing the length of stay for emergency department patients who are admitted and waiting for an inpatient bed Reducing the number of patient falls even further Reducing the number of staff injuries Operating a balanced budget Our goals for this year are: Reduce hospital acquired clostridium difficile infections o Infections spread in hospital were the second highest source of harm to patients after falls, which have now been reduced significantly. Continue to reduce the number of staff injuries from blood and body fluid exposure and musculoskeletal injuries o Keeping staff safe and injury free means that they are able to provide high quality care in a safe environment. Reduce the number of inpatient days with no increase in readmissions o Patients who stay longer than necessary in hospital run the risk of increased complications. As well, ensuring patients are in the right place means that patients flow efficiently through the emergency department and into our inpatient beds. QI Achievements From the Past Year There are two major achievements this year that both have a significant impact on patients: reduction in falls and the length of stay for admitted patients in the emergency departments. After two consecutive years of work on falls reduction, St. Mary s has reduced falls by approximately 50% or 132 falls per year. This has been achieved through a number of initiatives, including, but not limited to, regular checks with patients to ensure all their needs are being met, rigorous screening of all patients, ensuring clear pathways to the washroom in patient rooms, lighting changes, and vigilant and prompt investigation of all falls. St. Mary s General Hospital 2
The emergency department and inpatient areas have significantly reduced our length of stay for admitted patients. Substantial focus throughout the hospital on this objective has meant patients are no longer waiting 25+ hours for an inpatient bed. Most recently, wait times have been reduced to below 15 hours, bettering our 16 hour target. By fully examining all the factors related to wait time, we have been able to ensure a smooth transition for patients. Initiatives such as decreasing turnaround time for lab and diagnostic tests, inpatient bed realignment and the creation of an ambulatory treatment area have assisted in a multi-faceted approach to decreasing this wait time. Over the past three years, St. Mary s has seen a 15% rise in the number of visits to the emergency department. Despite this rise, the staff and physicians have reduced the time to Provider Initial Assessment (PIA) by 30% (from 5.4 to 3.6 hours). The wait time for an inpatient bed has been reduced by 17%. The reduced PIA wait time has been helped by the creation in 2014/15 of the Ambulatory Treatment Area, where patients see doctors and Nurse Practitioners directly from triage. Also, with the increased number of ED visits we have received additional funding to increase the number of physician shifts in this area. Additionally, the following achievements took place in 2015/16: As an organization, St. Mary s set a goal of 1,300 hospital-wide improvements between April 1, 2015 and March 31, 2016. Currently we are at about 1100 and on track to reach our goal. In June of 2015, SMGH achieved Accreditation with Commendation for 2015 to 2019. There were 1,877 criteria evaluated, 200 more than last survey in 2011. SMGH met 1,863 of the criteria. Surveyors called our score of 99.4 % exceptional. The Outpatient Falls Prevention Program was implemented in all out patient areas including the Emergency Department in November, satisfying the follow-up requirement of Accreditation Canada. A screening tool is now being used for patients who are at risk of falling. One example of the benefit is that approximately twelve outpatients are being identified in our diagnostic imaging department each day. In June of 2015, the Patient and Family Advisory Council recruited a diverse group of 15 patients and family members. Orientation was held in September and this group will provide important input on many hospital initiatives, including hiring of key positions, potential implementation of 24/7 visiting hours and a refresh of the patient relations policy and process. November of 2015 marked one year since visiting hours were expanded. St. Mary s is now investigating what needs to be put in place to potentially extend visiting to 24/7 in 2016. Integration & Continuity of Care St. Mary s recognizes that for patients, we are only one part of the care they receive and it is therefore critical that we partner with primary care providers, the Community Care Access Centre (CCAC), community support agencies and other health care organizations. We know that achieving our QIP goal of reduced length of stay for admitted patients requires partnerships and collaboration with the entire circle of care for each patient. St. Mary s General Hospital 3
Engagement of Leadership, Clinicians and Staff As part of our annual operational planning process extensive consultation and engagement is undertaken with clinical staff (nurses, therapists, pharmacists, physicians, etc.). The entire management team, Board of Trustees, and Board Quality Committee provide input into the annual goals and the subsequent process measures used to achieve these goals. The Board Quality Committee holds a special meeting each January outside of its regularly scheduled meetings to specifically develop the annual Quality Improvement Plan (QIP). Patient/Resident/Client Engagement St. Mary s places tremendous value on the voice of our patients in all decision making. Through the use of patient experience surveying, leadership rounds with patients and families, and involvement of patients in the quality of care review process, we ensure that as we develop our QIP we know what is important to patients and their families. Additionally, this year marked the introduction of our Patient & Family Advisory Council. Members of the Council participated with our Board Quality Committee in drafting and approving this year s QIP. Performance Based Compensation As required under the Excellent Care for All Act (ECFAA) St. Mary s Board of Trustees has ensured that achievement of targets outlined in the QIP is linked to the compensation of its executive staff. The President, Chief of Staff, and Vice Presidents will have a portion of their compensation held back according to the achievement of the quality improvement plan as outlined below. A portion of the Chief of Staff s existing bonus (five percent of existing salary) will be tied to achievement of the quality improvement plan as outlined in the chart below. For the President, five percent of existing salary will be held back and awarded according to achievement of quality performance indicators as outlined in the chart below. For the remainder of the executive team, three percent of existing salary will be held back and awarded according to achievement of quality performance. Note: St. Mary s does not provide additional salary bonuses to its Executives for achieving performance targets. St. Mary s General Hospital 4
The performance based compensation is linked to the following indicators: Quality & Safety Patient and Family Centred Care Our People Objective Reduce Hospital Acquired Clostridium difficile infections by at least 25% by March 31, 2017 Reduce the number of inpatient days by at least 5% by March 31, 2017 Reduce staff injuries (MSD and BBF) by at least 25% by March 31, 2017 Outcome Measure/Indicator Strategy A3* will be developed and deployed to at least 3 areas of hospital where HAI happens most frequently. Each area will develop their own A3 and deploy strategies to reduce HAI. Strategy A3* will be developed and deployed to 6 areas of hospital that have the greatest opportunity to reduce length of stay. Each area will develop their own A3 and deploy strategies to reduce length of stay. Strategy A3* will be developed and deployed to 6 areas of hospital where MSD and BBF injuries occur most frequently. Each area will develop their own A3 and deploy strategies to reduce MSD and BBF injuries. Weighting % of Available Incentive 1/3 Yes 1/3 Yes 1/3 Yes 100% 0% Not Not Not *Note: The impact of the implementation of the improvements from the A3s must be clearly demonstrated on the Senior Leader and Board of Trustees Huddle Board. St. Mary s General Hospital 5
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 Quality Committee Chair President Dieter Kays Scott Smith Don Shilton St. Mary s General Hospital 6
2016/17 Quality Improvement Plan "Improvement Targets and Initiatives" St. Mary's General Hospital 911 Queen's Boulevard AIM Measure Change Quality dimension Objective Measure/Indicator Unit / Population Source / Period Organization Id Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Process measures Effective Reduce number of Number of inpatient Number / All Hospital 699* 50708 48173.00 Internal target 1)A3 will be developed to Standard process for A3 development with Will be determined based on results of A3 inpatient days days acute patients collected data / 5% reduction determine root causes, stakeholders 2015-16 contributing factors and countermeasures. Goal for change ideas Comments Will be determined based on results of A3 Safe Reduce hospital CDI rate per 1,000 Rate per 1,000 Publicly 699* 0.34 0.26 Internal target of acquired infection patient days / All 25% reduction rates patients Decrease staff injuries patient days: Number of patients newly diagnosed with hospital-acquired CDI during the reporting period, divided by the number of patient days in the reporting period, multiplied by 1,000. Staff injuries at work related to musculoskeletal injuries and blood/body fluid exposure. Number / All staff Reported, MOH / January 2015 December 2015 Hospital 699* 92 69.00 Internal target collected data / 25% reduction 2015-16 Baseline 1)Improve hospital cleanliness 2)Improve Infection Control Practice in Front line staff 3)New IPAC processes/ initiatives 1)Broaden scope of departments that are focusing on staff injury reductions. Add additional departments. a) Chlorine based disinfectant for floor cleaning b) Weekly cleanliness auditing on 500,600,700; monthly auditing on other inpatient units (IPAC) c)establish and train an outbreak cleaning team (HSKPG & IPAC) d) Monitor/promote usage of clinell clean tagging system a) Minimum 1.5 Hrs dedicated IPAC presence daily on unit b) 100% overbed tables to contain ABHR c) Routine Practice Auditing d) Hand Hygiene Audit Audit e )IPAC education f) IPAC consultative role for PT Safety goals at key areas ULC g) Promotional event for wiping a) Increase HH monitoring and publicly post monthly HH compliance data in a competitive way b) Incentivize/ recognize commitment to practice (with a concurrent accountability/ consequences model) c)strengthen compliance with Preemptive Isolation Prioritize staff injury reduction as a driver metric if unit has the Lean Management System (LMS) in place. Prioritize as a goal for other relevant units that do not have LMS in place. 2)Build culture of Develop working group with key stakeholders to staff/manager engagement address roll out of standards and develop process. in incident investigation and countermeasures Audit reports Audit results Observation Documented sign off HAI stats Number of new ideas to address barriers Status exchange tracking Audit findings Attendance/completion of IPAC education HH audits- Number of observations HH metrics board Recognition event in grapevine/ suture line Pre emptive Isolation tracking Cost savings analysis for swabbing Implement admission screening in Emerg tracking metrics HAI data Statistical charts/ annual report/ Minimum of 6 units with staff injury reduction as driver metric/area of focus. Adherence to standard process Increased hospital cleanliness Increase knowledge and expertise of front line staff in IPAC Increase awareness, decrease costs, decrease HAI, increase HH rates Reduction of MSD or Blood Fluid Exposure injuries for units focusing on staff injury Adherence to standard process for 90% of incidents 3)Continue focus on injury reduction in CV Operating Rooms Initiatives specific to Blood/fluid exposure and MSD injuries (i.e.safety blades, PPE, neutral zone, patient transport, leg lift procedures) # of Blood Fluid Exposures; # of MSD injuries Reduced MSD and/or Blood/Fluid Exposures 4)Improve tools and knowledge for patient handling. Improved standard work/visual guidelines and training for repositioning and lifting patients. New lifting/repositioning tools where relevant/required. # Patient handling MSDs Reduce MSD injuries from patient handling.