Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/12/2017 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a 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 Ontario (if required) in the format described herein. Almonte General Hospital, Fairview Manor 1 75 Spring Street. Almonte, Ontario, K0A 1A0
Overview Almonte General Hospital (AGH) is a small, rural hospital located in Almonte, Ontario, 40 kilometers west of downtown Ottawa. It serves a catchment population of over 30,000 people. The Hospital offers a wide range of acute and continuing care services including an Emergency Department. There are 21 Medical/Surgical beds, five level-one Obstetrical beds, 26 Complex Continuing Care beds and two Operating Rooms. In addition, the Hospital operates the Fairview Manor (FVM), a 112 bed Long Term Care Home located on the hospital campus, as well as the Lanark County Paramedic Service. The Hospital campus also includes the Ottawa Valley Family Health Team; the Leeds, Grenville & District Health Unit and Lanark County Mental Health. Together, these facilities provide our patients and residents with integrated, coordinated healthcare to support their seamless movement from one care setting to another. This year s Improvement Plan (QIP) will build on the success of the recently developed Mississippi River Health Alliance (MRHA) between our organization and Carleton Place & District Memorial Hospital (CPDMH). A number of initiatives are aligned with both organizations to improve the quality of the patient experience, through communication, ensuring a seamless transition from hospital to home and by ensuring internal procedures and processes are based on best practice and evidence. This year we will be implementing a Patient and Family Advisory Committee (PFAC) at AGH to allow us to enhance the delivery of health care services around the needs of our patients and their families. They will be asked to provide input on initiatives to enhance the patient experience (e.g. communication and transitions to home). The plan will work with our palliative network partners to ensure patients are connected to appropriate services in the community with a common understanding of the patient s goals of care in both FVM and the hospital. Our plan, while improving quality of care, will also include ensuring safe medication practices to meet legislative and Accreditation Canada standards from admission to discharge. FVM will be working towards reducing the number of falls with injuries, developing guidelines for when to transfer a patient to the emergency room, resident satisfaction and building on the impressive steps taken in this past year s QIP on reducing antipsychotics and restraint use. QI Achievements From the Past Year We are very pleased with all the efforts the teams at AGH and FVM have placed towards moving quality forward in all the initiatives this past year. FVM has performed exceptionally well in driving quality forward in a number of indicators. The team has reduced the rate of residents experiencing worsened pain, antipsychotic and restraint use. AGH is also extremely proud to have participated in the second year of an Assess and Restore pilot project, which originated in our partner hospital, CPDMH in partnership with the Regional Geriatric Program of Eastern Ontario. It involves a number of local and regional partners, working together to improve the lives of seniors by keeping them in their home longer through connecting them with specialized geriatric services, reducing emergency department visits and avoiding admissions to hospital. We worked with a GEM nurse to identify the frail elderly in our community, to improve their quality of life with supportive and specialized geriatric services keeping them in their home longer. The GEM nurse, Almonte General Hospital, Fairview Manor 2 75 Spring Street. Almonte, Ontario, K0A 1A0
who was shared between AGH and our partner hospital CPDMH worked together to identify seniors with restorative potential and connected them to a targeted program at the Almonte General Day Hospital. While the two year pilot project has met the objectives it had set out to achieve the program is currently on hold as we work collaboratively with our partners to ensure a financially sustainable program. We want to continue to deliver a high quality Assess and Restore program to our seniors and it is imperative time is spent planning appropriately. Health This year s plan focuses on improving the health of those patients with heart failure in our community. We will work collaboratively with the University of Ottawa Heart Institute (UOHI) to ensure the care those patients receive is aligned with the best practices included in the heart failure quality based procedure (QBP) order set. It is important to ensure there is a seamless transition from hospital to home, as well as, ensuring proper follow up with their family physician is in place. We want to leverage opportunities for patients to benefit from the best practices at the UOHI, while they are in their own community. Equity Part of our plan will focus on a communication framework in the ER and Inpatient units (Med/Surg, OBS, Complex Continuing Care). It is important to tailor this approach in order to meet the needs of patients from different cultures (eg. Indigenous), or for those who may speak different languages (eg. French or Spanish). We will work collaboratively with the PFAC and partner organizations to ensure we are ready to serve all of our patients with culturally competent staff and physicians. Integration and Continuity of Care FVM will be working collaboratively with the hospital to develop a Goals of Care Framework with common language that is clear to all healthcare personnel, residents and their families. This initiative is a continuation of last year s QIP work from the North Lanark Palliative Care Network. FVM will also be focusing on the process of when residents are transferred to the emergency room to ensure it is appropriate, timely and likely to result in an admission to the hospital. The work will focus on developing early recognition decision guidelines to assist and support the team, which will build on their critical thinking skills. One of the goals of the newly integrated relationship between AGH and CPDMH is to identify opportunities to align quality improvement initiatives and leverage the work involved. This year s QIP has met this goal in several priority indicators. The hospitals will work together to improve transitions from hospital to home for palliative patients and for those who have heart failure. Building on patient engagement, as legislated by the Excellent Care for All Act (2010), aligning initiatives focusing on receiving adequate information at discharge and/or the patient experience in the ER and Inpatient units will be developed. We will improve communication to our patients across both organizations through staff Almonte General Hospital, Fairview Manor 3 75 Spring Street. Almonte, Ontario, K0A 1A0
training on a framework, addressing common elements used for all patient interactions. Both hospitals will be reporting on the outcome from the patient experience survey questions Would you recommend this hospital (ER/Inpatient) to your friends and family? In addition, we will leverage education opportunities to ensure safe medication practices are aligned with Accreditation Canada standards. We will do this by working together on the medication reconciliation processes and ensuring they are in place for all transitions of care from admission to discharge. Access to the Right Level of Care - Addressing ALC Issues The Alternate Level of Care (ALC) rate in the hospital has not been an issue. And while reducing the ALC rate is not a focus for this year s QIP, the team continually works towards ensuring internal designation processes are aligned with the definitions from Cancer Care Ontario and ensuring appropriate destinations are achieved. Engagement of Clinicians, Leadership & Staff The development of the QIP incorporates the needs of the population based on data from provincial and regional reports, as well as, from our (AGH & FVM) internal quality indicators. The plan is reviewed and revised based on feedback from the Improvement and Risk Management Committee, the senior leadership team and the quality committee of the board. Quarterly progress reports and review of the plan are presented to the broader leadership group in order to engage key stakeholders in the processes. Staff is engaged as key people are identified to lead projects. There will be education opportunities for all staff in areas specific to certain priority indicators (e.g. inpt, ER, FVM). FVM engages staff during staff meetings and home area meetings on a monthly basis related to goals and objectives of the QIP as well as progress reports. Resident, Patient, Client Engagement FVM has a well-established and engaged resident Council. The Council meets monthly to discuss any issues that the residents bring forward as well as to share information from the organization. Details of our QIP are presented at resident council through a facilitator and any questions are then addressed in a timely fashion. The council focuses on issues that directly impact the quality of life and safety of the residents. As mentioned earlier, AGH is implementing a Patient and Family Advisory Committee (PFAC) to allow the hospital to enhance the delivery of health care services around the needs of our patients and their families. They will be involved in providing input on this year s QIP initiatives, which specifically work towards enhancing the patient experience (e.g. communication, transitions to home, post discharge phone calls for palliative patients, goals of care framework). Almonte General Hospital, Fairview Manor 4 75 Spring Street. Almonte, Ontario, K0A 1A0
Staff Safety & Workplace Violence AGH and FVM are committed to ensuring the staff is working in an environment, which focuses on their safety and supports education to prevent workplace violence. There are regular workplace safety inspections, which are reviewed at Occupational Health and Safety Committee. There are safety and security audits completed at AGH. There is a Patient Risk Incident Management System (PRIMS) in place, which captures all incidents (safety, clinical, workplace violence, etc). Quarterly reports are reviewed and discussed at the department and committee level to identify learning opportunities and process improvement requirements. The staff is encouraged to communicate safety issues to their manager, which are then discussed at staff meetings. On-going emergency drills take place to ensure the staff feel ready in the event of a real situation. There are personal safety pendants, which staff who work mostly alone wears as a safety device. Performance Based Compensation In Accordance with legislative requirements, the following positions (Senior Team) are subject to -based compensation: President and Chief Executive Officer Chief of Staff Vice President, Patient Services and Chief Nursing Executive Vice President and Chief Financial Officer Vice President, Corporate Support Services The -based compensation plan reflects our corporate values and has been created to contain congruent, not conflicting, goals for each member of the Team, and which rewards the Team for working together towards achievement of the goals. Achievement of the goals is d on a 5 point scale, with 3 being acceptable. If the Team achieves an average score of 3 or greater across the goals, each member will be paid 100% of the at-risk compensation. If the Team achieves an average score of 2 or lower, the at risk compensation will be reduced. Almonte General Hospital, Fairview Manor 5 75 Spring Street. Almonte, Ontario, K0A 1A0
2017/18 Senior Management Team Performance Goals and Structure Domain Indicator and % of Salary Linked to Achievement of QIP Scale AGH Patient Centered Percentage of staff trained on the communication framework, implemented in the ER, will successfully pass an evaluation test. 80% 5 90% 4 81-89% 3 80% 2 70-79% 1 69% 5 greater than 1.5% surplus Effectiveness Achieve balanced financial position on consolidated operating income. QIP target for 2017/18 is 0 4 0.6 % to 1.5% surplus 3 is 0.5% deficit to 0.5% surplus 2 0.6% to 1.5% deficit 1 deficit of 1.5% or greater Domain Indicator and Scale FVM Safety Reduce the percentage of residents (FVM) who were physically restrained every day during the 7 days preceding their resident assessment 11.27% 10.70% 5 10.4% 4 10.4-10.6-% 3 10.7% 2 10.8-11.2% 1 11.2 Almonte General Hospital, Fairview Manor 6 75 Spring Street. Almonte, Ontario, K0A 1A0
Contact Information Rachel de Kemp VP Patient Care Services & Chief Nursing Executive rdekemp@agh-fvm.com 613-256-2514 ext. 2235 Sign-off It is recommended that the following individuals review and sign-off on your organization s Improvement Plan (where applicable): I have reviewed and approved our organization s Improvement Plan Cindy Hobbs, Board Chair Dr. Michael Leonard, Committee Chair Mary Wilson Trider, Chief Executive Officer Almonte General Hospital, Fairview Manor 7 75 Spring Street. Almonte, Ontario, K0A 1A0
2017/18 Improvement Plan "Improvement s and Initiatives" Almonte General Hospital 75 Spring Street AGH FVM March 16 2017 RdK AIM Measure Change Effective Effective transitions 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 CIHI CPES / April June 2016 (Q1 FY 2016/17) (Change Ideas) Methods Process s 10% 1)Improve and update OBS patient improvement information book in order to align above with Public Health and best baseline practices. Working group to compare current OBS patient book with Public Health's information and identify areas of improvement. Prepare DRAFT copy for OBS interdisciplinary review. Seek feedback from OBS patients on updated DRAFT information book. for process Patient information book CPES: Responses to the to be updated and following dimensions will implemented by Dec improve by 10% by Q4 of 31st, 2017. 100% OBS 2017 18 1) information, patient records admitted education and after Dec 31st, 2017 to be communication regarding reviewed to ensure baby 2) information, patient received education and information book (audit communication regarding period Jan 2107 March mother 31st 2017). Effective Effective transitions Risk adjusted 30 day allcause readmission rate for patients with CHF (QBP cohort) Rate / CHF QBP Cohort CIHI DAD / January 2015 December 2015 34.30% Provincial Average = 21% Meet Provincial Average 1)Evaluation and use of current CHF pre printed order set to ensure alignment with Provincial QBP. Ensure follow up with patients Family physician within 7 days of discharge. Audit charts of patients admitted with a diagnosis of CHF to evaluate pre printed order set use. Develop evaluation tool to review CHF order set and QBP. Identify areas for improvement and alignment with QBP. Revise order sets as required. Education on changes for clinicians Develop a process to ensure patient has an appointment with the family physician within 7 days of discharge. # CHF order sets used/#charts audited # QBP standards omitted # clinicians who received education # Patients requiring physician follow up appointments within 7 days of discharge. The CHF order set will be aligned with the Provincial CHF QBP by Dec 31st, 2017. 90% of clinicians who use the CHF order set will receive education on any changes by Feb 28th, 2018. 90% of patients discharged btw Oct Mar 31st, 2018 with CHF will have a follow up appointment with their family physician within 7 days. Page 1 of 10
(Change Ideas) Methods Process s for process Effective Effective transitions Number of ED visits for modified list of ambulatory care sensitive conditions* per 100 long term care residents. Rate per 100 CIHI CCRS, residents / LTC CIHI NACRS home / October residents 2015 September 2016 15.28% 13.00% meet provincial average 1)Maximise the skills of RNs and RPNs to recognize resident changes of condition and treat before the need to sent to the ED. Develop early recognition guideline/decision tree. The Team Lead will notify resident's attending physician for a course of action that will be managed in the Home without the need for transfer. # of staff educated on the guidelines/decision tree. # of residents assessed by Team Lead and attending physician and successfully treated in the Home. # of residents transferred to ED 90% of residents transferred to the ED will require admission (March 31st, 2018) Curent transfers usually related to injury from a fall Effectivene ss Improve organizational financial health Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total corporate %/n/a (consolidated) expenses, excluding the impact of facility amortization in a given year. OHRS, MOH/Q3 FY 2016 17 1.90% Greater than or equal to 0% Hospital Service Accountabilit y Agreement (HSAA) requirement. Continue to identify opportunities for revenue generation. Page 2 of 10
Patientcentred Palliative care Percent of palliative % / Palliative patients CIHI DAD / April 2015 March 2016 77.78% 80.00% Improve on previous year's care patients discharged from hospital with the discharge status "Home with Support". (Change Ideas) Methods Process s 1)Palliative patients with Palliative Performance Scale (PPS) score of 60% or less will receive referrals for appropriate community supports 1) Referral to CCAC initiated in hospital for personal care and symptom management, as appropriate 2) Information provided to patient/family re: community services eg. Hub Hospice, friendly visitors 3) Clear documentation of referrals and community services provided through Physician Notification form (LACE tool) and Discharge Planning documentation in patient chart 4) Develop and Implement post discharge phone calls for palliative patients for process 1) # patient with PPS By March 31st, 2018, 80% score of 60% or less 2) # of palliative patients CCAC referrals for discharged home will Patients discharged from receive appropriate a hospital with DC status post discharge phone call "Home with Support" 3) # and a CCAC referral for completed post discharge appropriate community phone calls supports. 2)Complete the development and implementation of The Goals for Care Framework with North Lanark Palliative Care Network (NLPCN) Advance Care Planning Work Group. (carried over from 2016 17 QIP) Align hospital and Fairview Manor Goals of Care document. Seek feedback from Patient and Family Advisory Committee. Develop education plan for staff (including physicians. Implement Goals of Care framework. Evaluate effectiveness. # staff and physicians who received education # staff and physicians who have completed evaluation tool. 80% of staff will receive education by Feb 28th, 2018 90% of physicians (active staff) will receive education by Feb 28th, 2018 Hospital Goals of Care Framework will be implemented by March 31st, 2018. 80% of staff and physicians (active staff) will have completed an evaluation tool by May 31st, 2018. Page 3 of 10
(Change Ideas) Methods Process s for process Patientcentred Person experience Percentage of residents responding positively to: "What number would you use to rate how well the staff listen to you?" % / LTC home residents In house data, NHCAHPS survey / April 2016 March 2017 90.00% 95.00% Theoretical best 1)Improvement on person centred approach. Resident will be provided # residents who respond opportunity to voice care delivery to the question "When I concerns on an ongoing basis. voice concerns staff Concerns and potential solutions respond respectfully and discussed with the follow up." (will remain multidisciplinary team and the on the resident resident. satisfaction survey) 95% of completed satisfaction surveys will have responded with positive feedback (March 31st, 2018) Patientcentred Person experience Percentage of residents who responded positively to the statement: "I can express my opinion without fear of consequences". % / LTC home residents In house data, interrai survey / April 2016 March 2017 na na na Person Experience focus will be on ensuring residents concerns are responded positively (see above) Patientcentred Person experience "Would you recommend this emergency department to your friends and family?" % / Survey respondents EDPEC / April June 2016 (Q1 FY 2016/17) 78.60% 80.00% Theoretical Best 1)Support patient engagement and a culture of patient and family centered care by developing a Patient and Family Advisory Committee (PFAC). Recommend the development of PFAC to hospital board, develop terms of reference, application, interview process and advertising. Terms of reference to include the review of patient experience reports. # of applications received for PFAC. Patient satisfaction results for the question "Would you recommend this hospital for ED services" will be maintained above average for fiscal 2017 18. Page 4 of 10
(Change Ideas) Methods Process s for process 2)Implement the AIDET communication framework in all patient care areas. A=Acknowledge I=Introduce D=Duration E=Explanation T=Thank You Educate leadership group on AIDET communication framework, develop education plan for staff, implement tool, evaluate effectiveness of education and implementation. 1) # of staff (including leadership) who have received AIDET education by Dec 31st, 2017 2) # of staff (including leadership) who have completed evaluation tool post education and implementation by Feb 28, 2018. 1) Patient satisfaction results for the question "Would you recommend this hospital for ED services" will be maintained above average for fiscal 2017 18. 2) 80% of staff were satisfied with the method of education and implementation of the AIDET communication framework. Patientcentred Person experience "Would you recommend this hospital to your friends and family?" (Inpatient care) % / Survey respondents CIHI CPES / April June 2016 (Q1 FY 2016/17) 87.50% 90.00% Theoretical Best 1)Implement the AIDET communication framework in all patient care areas. A=Acknowledge I=Introduce D=Duration E=Explanation T=Thank You Educate leadership group on AIDET communication framework, develop education plan for staff, implement tool, evaluate effectiveness of education and implementation. 1) # of staff (including leadership) who have received AIDET education by Dec 31st, 2017 2) # of staff (including leadership) who have completed evaluation tool post education and implementation by Feb 28, 2018. 1) Patient satisfaction. results for the question "Would you recommend this hospital for Inpt services" will be maintained above average for fiscal 2017 18. 2) 80% of staff were satisfied with the method of education and implementation of the AIDET communication framework. Page 5 of 10
Patientcentred Resident experience: "Overall satisfaction" Percentage of residents % / LTC home who responded residents positively to the question: "Would you recommend this nursing home to others?" or "I would recommend this site or organization to others". In house data, InterRAI survey, NHCAHPS survey / April 2016 March 2017 100.00% 100.00% maintain current (Change Ideas) Methods Process s for process 1) No planned change initiative. Will maintain current Safe Medication safety Percentage of residents % / LTC home who were given residents antipsychotic medication without psychosis in the 7 days preceding their resident assessment CIHI CCRS / July September 2016 19.35% 19.00% theoretical best 1)Develop a process to identify residents who can safely begin to discontinue antipsychotic medication. Review antipsychotic usage with pharmacy monthly report. Consult with pharmacist, psychogeriatrician, Lanark County Mental Health, physician and family. Develop a plan for relevant residents to begin to discontinue antipsychotic medication. # chart audits completed of residents with a related diagnosis or supportive documentation. # residents who have safely discontinued antipsychotic medication. Monthly review of 100% of residents receiving antipsychotic medication. (completed by March 31st, 2018) Page 6 of 10
(Change Ideas) Methods Process s for process Safe Medication safety Medication Rate per total reconciliation at number of admission: The total admitted number of patients with patients / medications reconciled Hospital as a proportion of the admitted total number of patients patients admitted to the hospital Hospital collected data / Most recent 3 month period theoretical best 1)A) Investigate options for alignment and collaboration with other partners related to Medication Reconciliation on Admission (June 30, 2017). B) Review and revise Medication Reconciliation P&P, incorporating changes required related to CERNER immplementation and Accreditation Canada Standards (Sept 30, 2017). C) Roll out revised P&P and process (Education and training for all Nursing, Pharmacy and Medical Staff) accross all units (Oct 31, 2017) Review of current P&P and Percentage of Accreditaiton Canada Standards. staff/physcians Revise P&P based on standards educated/trained. and opportunities for change. Distribute to stakeholders for review. Modify P&P based on stakeholder input. Review at P&T/MAC approval. Develop and roll out education for all clinicians involved in the process. 80% of staff/physicians (active staff) educated/trained prior to implementation Page 7 of 10
(Change Ideas) Methods Process s for process Safe Medication safety Medication Rate per total reconciliation at number of discharge: Total number discharged of discharged patients patients / for whom a Best Discharged Possible Medication patients Discharge Plan was created as a proportion the total number of patients discharged. Hospital collected data / Most recent quarter available Theoretical Best 1)A) Investigate options for alignment and collaboration with other partners, particularly the OVFHT, related to Medication Reconciliation on discharge (June 30, 2017). B) Review and revise Medication Reconciliation P&P, incorporating changes required related to CERNER immplementation and Accreditation Canada Standards (Sept 30, 2017). C) Roll out revised P&P and process (Education and training for all Nursing, Pharmacy and Medical Staff) accross all units (Oct 31, 2017) Review of current P&P and Accreditation Canada Standards. Revise P&P based on standards and opportunities for change. Distribute to stakeholders for review. Modify P&P based on stakeholder input. Review at P&T/MAC approval. Develop and roll out education of all clinicians involved in the process. Percentage of staff/physicians educated/trained. 80% of staff/physicians (active staff) educated/trained prior to implementation Page 8 of 10
Safe Safe Care Percentage of residents % / LTC home CIHI CCRS / 9.39% 9.39% Maintain and 1)Strengthen the focus of the Falls residents who fell during the 30 days preceding their resident assessment July September 2016 focus on reducing degree of injury (Change Ideas) Methods Process s Prevention Team on clinical reviews post fall and implement modifiable factors. Identify current rate of falls # of falls resulting in resulting in injury from April 1st injury 2015 to March 31st 2016. Falls Prevention Team to monitor and ensure an individualized care plan is in place. Ensure the plan has been reviewed post fall including a root cause analysis and implement strategies to reduce further risk of falls. Review effectiveness of current strategies (Falls tracking tool, Falls Risk Assessment,High Risk Sheet, Monthly Fall team meeting (interdisciplinary), monthly Falls prevention education) for process Reduce the # falls resulting in injury by 5% by March 31st, 2018 Safe Safe Care Percentage of residents % / LTC home CIHI CCRS / 11.27% 10.70% theoretical 1)Provide education to resident residents families and staff on minimal restraint philosophy who were physically restrained every day during the 7 days preceding their resident assessment July September 2016 best (reduce # of restraints without an increase in the # of falls) Review RAI MDS coding for accuracy. Provide families with our resident safety brochure and include in strategies to prevent the use of restraint. Provide appropriate education to staff on minimal restraint. Ensure that sufficient bed/chair alarms are available. # of successful strategies to reduce the use of a restraint. # of staff who have completed minimal restraint education. No new restraints will be added to current numbers for this fiscal year 2017 18 Page 9 of 10
(Change Ideas) Methods Process s for process Evaluate compliance of % / All Delirium Screening inpatients Tool(CAM)completion and implementation of associated interventions (for CAM positive) for patients age 70 years and older on the med/surg and complex continuing care unit. CAM (Confusion Assessment Method) Health records / 2017 18 Theoretical best 1)Ensure completion of CAM tool and associated interventions for patients age 70 years and older on the med/surg and complex continuing care unit. (Supports Senior Friendly Hospital Plan to reduce delirium incidence) Develop a chart audit tool aligning with the EMR documentation screens in Cerner Complete chart audits Review results, identify gaps and identify areas of improvement Develop and action plan for any opportunities to ensure successful CAM completion. # chart audits completed 100% of charts of # improvement initiatives patients age 70 years and identified older on the med/surg and complex continuing care unit will be audited for completion of the CAM tool and associated interventions by Feb 28th, 2018. Senior Friendly Hospital Plan Implementation rate for Functional Decline Education Brochure % / All inpatients EMR/Chart Review / 2017 18 Theoretical best 1)Evaluation of whether all patients on the med/surg unit who are 65 years of age or older are receiving a copy of the "Keep your Mind and Body Active" brochure. (Supports Senior Friendly Hospital Plan to improve functional decline) Develop a chart audit tool aligning with the CERNER documentation screens, Implement and complete audit. Identify opportunities for improvement # patients who received the brochure/# charts audited 100% of patients aged 65 yrs or older will have received a copy of the "Keep your mind and body active" brochure by Jan 31st, 2018. Page 10 of 10