Health Sciences North Horizon Santé-Nord 2015 2016 (QIP) Quality Improvement Plan March 31, 2015
Overview HSN 2015-2016 Quality Improvement Plan
Introduction Health Sciences North/Horizon Santé-Nord (HSN) is the leading academic health sciences centre in Northeastern Ontario devoted to HEALTH, not sickness. We are a network of integrated facilities and programs working together for the benefit of our patients, communities, physicians, researchers, staff, and learners in the areas of prevention, diagnosis, treatment and care. Our mission, vision and values guide our care delivery each day. Mission: o Improve the health of northerners by working with our partners to advance quality care, health education, research and health promotion Vision: o Globally recognized for patient-centred innovation Values: o Excellence o Respect o Accountability o Engagement Foundational Drivers: o Quality and safe patient-centred care; o Advanced research and education; o Enduring improvement; and o Accountability for all
HSN has been on the road of cultural transformation since the launch of the Strategic Plan in December of 2012. HSN s 2013-2018 Strategic Plan identifies 3 Strategic Priorities, which are detailed below: 1. Leaders in Care Transition We will be leaders in redesigning systems to enhance the delivery of patient-centered care across the continuum of care with the creation a hospital without walls where patients receive the care they need, where and when they need it. 2. Innovators We will advance our commitment to new or altered innovative health care solutions to improve health care quality. 3. Excellence in Evidence-Based Care We will lead in the provision of high-value, cost effective and efficient patient-centered care. Patient and Family Advisors
Defining True North at HSN (Long-term Perspective) Following the development of the 2013 2018 Strategic Plan, HSN began its strategy deployment process. At HSN strategy deployment includes four steps: 1. Develop the Plan 2. Deploy the Plan 3. Execute (Monitor and Check/Adjust) 4. Improve the System For 2013-2018 four key focus areas were identified that if breakthrough improvements can be achieved; will enable HSN to achieve its strategic goals including: Our People Provide safe care and a safe environment for our staff and our patients with Zero Harm Quality Improve access to care for all patients at the right time and place Our Patients and Families Improve the quality of care at transition within our walls and beyond with enhanced communication Financial Health To sustain a positive Operating Margin The 5 year targets for these focus areas are as follows:
Annual Perspective (2015-2016) For each True North focus area annual targets, with an associated action plan has been developed. These annual action plans or Strategy A3 s are developed by Senior Leadership and link to each of the True North focus areas and defined metrics. The improvement work detailed in the annual Quality Improvement Plan (QIP) is derived from the breakthrough improvement proposed in the annual strategy A3s and key local program priorities. A strategy A3 is a one-page storyboard on 11-inch by 17-inch paper that helps us tell our strategy "story." The A3 expresses the critical few improvement activities needed to achieve a vital business goal. 1 The Strategy A3 s set targets and initiatives for the current year. 1 Dennis, Pascal. (2006). Getting the Right Things Done: A Leader s Guide to Planning and Execution. Cambridge, MA: Lean Enterprise Institute.
Alignment HSN s process for development of this quality improvement plan is aligned with the Ontario Action Plan for Health Care and the North East Local Health Integration Network s Strategic Plan. In addition the Board and Management have built in a system to continue to monitor the execution of this plan in conjunction with other work with key partner organizations and the Hospital Service Accountability Agreement (HSAA), Multi-Sector Service Accountability Agreement (M-SAA), Ministry/LHIN Performance Agreement (MLPA) and the other requirements related to the Excellent Care for All Act (2010) and the Public Hospital Act. HSN will also continue to be an active participant and leader in the North, working with system partners in developing and/or executing joint, collaborative and complimentary quality improvement initiatives to improve integration and continuity of care for the population that we serve. Our vision is that our patient s will have seamless care provision and transition across the care continuum. Provincial and NE LHIN Priorities (Source: NE LHIN)
Integration & Continuity of Care HSN continues on the path of attaining the goal of becoming a hospital without walls providing truly patient-centred care across the continuum of care where patients receive the care they need, where and when they need it. One example of this is the expansion of HSN s Virtual Critical Care (VCC) unit. HSN has added seven new sites which now bring the total to 16 participating hospitals in northeastern Ontario. The Virtual Critical Care unit uses the latest in videoconferencing technology and electronic medical records sharing to connect HSN with Critical Care units and Emergency Departments at smaller hospitals within northeastern Ontario. The VCC enhances diagnosis and treatment of critically ill patients and potentially avoids the transfer of patients out of their local hospitals, away from their families and support systems. HSN will continue to work with Community Primary Care Providers with the Physician Office Integration Program. This allows the Primary Care Providers who do not currently have access to HSN`s electronic Health Information Systems to receive a patient`s personal health information as it relates to the results of diagnostics tests more quickly making them more readily available. To try and reduce hospital readmissions rates of patients after being discharged, HSN has teamed up with local pharmacists to assist with evaluating all medications a patient is prescribed in hospital and at discharge and comparing it to existing medications to minimize the risk of medication errors potentially leading to an adverse event. With this partnership, we can ensure the transition from hospital to home is as seamless as possible and make the care for our patients better and safer. HSN will continue to be an active participant and leader in the North, working with system partners in developing and/or executing joint, collaborative and complimentary quality improvement initiatives to improve integration and continuity of care for the population that we serve. Our vision is to have the seamless care provision and transition for the North. Patient Health Record in electronic format (Electronic Medical Record (EMR))
Challenges, Risks & Mitigation Strategies HSN continues to grapple with some of the same challenges and risks identified in the previous QIP as they are multi-level longer term system issues. These key risks and/or challenges, along with the corresponding mitigation strategies, are detailed in Figure 1 below. Figure 1 Summary of Key Challenges/Risks and Mitigation Strategies HSN provides care to Seniors and Frail elderly
Information Management Systems HSN continues to create software solutions to support HSN and NEON 2 in the delivery of quality healthcare to the patients of northeastern Ontario. The goal is to engineer software that is both easy to use and adds value to our colleagues and patients through the delivery of healthcare. HSN and the NEON group of hospitals continue to focus on an integrated patient record through the use of a shared software system in order to provide seamless delivery of healthcare throughout northeastern Ontario. The hospitals continue to work together to maximize on opportunities to share resources and to take advantage of cost saving measures. In order to facilitate immediate access to the entire patient record and enhance the care provided to our patients, HSN continues to work on implementing the electronic medical record. This is currently being phased in the outpatient clinics. HSN continues to work with the NEON group to implement the electronic medical record within the inpatient population. 2 NEON is a consortium of 22 hospital partners and 3 Independent Health Facilities serving residents of North Eastern Ontario.
Engagement of Clinical Staff and Broader Leadership As HSN continues its journey towards organization excellence with the ultimate goal to Improve Work, Improve Care, clinical staff, physicians and broader leadership engagement, expertise and experience are key to the success and will help us achieve excellence. The transformation that has begun at HSN challenges us to change the way we work and how we accomplish the work. The Organizational Excellence Framework will: Ensure strategic alignment from the bedside to the boardroom Create a shared understanding of how improvements are led, applied and supported across HSN Empower frontline staff and physicians to use their expertise and experience Support managers working in a new way to enable our cultural transformation through teach, coaching, facilitating and mentoring. This will enable us to improve our processes, patient experience and the environment in which we work together. HSN believes that the voice of the patient/family is of utmost importance and is part of a critical component in the development of a better and safer healthcare system for our patients. HSN currently has patient/family advisors serving on the CEO Patient and Family Advisory Council, NECC Patient/Family Advisory Council and a diverse group of advisors making up a Resource Pool. These Advisors are engaged with process improvement teams, Program Councils and other key committees and special projects at various levels of the organization. For example; Patient/Family Advisors serve on the Quality Committee of the Board and the Medical Advisory Committee. Each year, HSN aims to enhance its efforts to include as many stakeholders as possible in the development of its annual QIP. Presentations were made at the Medical Quarterly Staff meeting, the CEO Patient and Family Advisory Council, Senior Leadership, Performance Leadership (i.e. Administrative and Medical Directors), Clinical Management, Management Forum and others. HSN Patient andfamily CEO Advisory Council
Accountability Management The Excellent Care for All Act, 2010 requires that the compensation of the Chief Executive Officer, Chief of Staff, Chief Nursing Executive and any senior executive who reports directly to the CEO be linked to the achievement of performance improvement targets laid out in the organization s QIP. HSN QIP PRIORITY AREA Aligned with True North: Quality/Safety Improve Access Executive Sponsor: VP Clinical Programs Aligned with True North: Our Patients & Families Communication - Patient Experience Executive Sponsor: SVP & COO Aligned with True North: People Zero Harm Executive Sponsor: VP Human Resources Aligned with True North: Financial Health Positive Margin Executive Sponsor: VP & CFO KEY PERFORMANCE MEASURES ER Wait Times: 90 th Percentile ER Length of Stay for Admitted Patients Patient Satisfaction: Acute Care Experience Continuity & Transition Lost Time Days Percent (%) Total Hospital Margin The above table details the key performance measures related to each priority focus area of the QIP which will be integrated into the HSN Senior Leadership Performance Management program. The HSN Senior Leadership Performance Management Program integrates the evaluation of the executive s job related performance with the achievement of the hospital s mission, vision and goals that forms the justification for determining the executive s compensation. The HSN program integrates and aligns four key components into one program; (1) Performance Evaluation Program; (2) Professional Development Program; (3) Performance Goals (team and individual) and (4) Compensation Program. The PMP has been deployed at all management levels of the organization to foster the creation of shared accountability and focus on the strategic priorities.
Health System Funding Reform (HSFR) HSN has outlined a set of key tactics to ensure that it is aligned with the guidelines and conditions for practice that will be realized as a result of the system funding reform underway, including: Continuous capability building to improve the interpretation of HSN s performance in the HSFR environment. The integration of Organization Excellence, tools accompanied by a change of thinking will support the ability to improve QBP margins and maximize funding. Continued education/awareness for management, staff and physicians of the potential impact of funding reform. Participate on provincial committee and networking groups. Design and build an HSFR system model to assist with decision making when new or services changes are contemplated. HSN Senior Leadership Building Improvement Capability
Improvement Targets and Initiatives
2015-2016 QIP Improvement Indicators Measure/Indicator Current Performance Target for 2015/2016 Target Justification Aligned with HSN True North: Quality/Safety 1. Safety: Clostridium Difficile Infection (CDI) per 1,000 patient days 0.42 (Jan. - Dec. 2014) Source: MOHLTC 0.33 Provincial Median 0.40 (Jan. - Nov. 2014) 2. Safety: Medication Reconciliation at Admission (Medicine Program) 0.0% (Q3 2014/15) Source: Internal 85% Internal Target 3. Access: 90th percentile Emergency Department (ED) Length of Stay for Admitted Patients 30.72 hrs. (Q4 2013/14-Q3 2014/15 Source: NACRS, CIHI 25hrs FY 14/15 NE-LHIN Target is 25 hrs Provincial Target is 25 hrs (Q2 2014/15) 4. Integrated: % Alternate Level of Care (ALC) days 19.51 % (Q3 2013/14 Q2 2014/15) Source: DAD, CIHI 17.7% FY 14/15 NE-LHIN Target is 22% Provincial Target is 9.46% (Q2 2014/15) 5. Integrated: Readmission within 30 days for Selected Case Mix Groups 18.63% (Q2 2013/14 Q1 2014/15) Source: DAD, CIHI) 17.5% FY 14/15 NE-LHIN Target is 15% Provincial Target is TBD (Q2 2014/15) Current Expected 17.55% 6. Patient-Centred: Patient Satisfaction Acute Care Continuity and Transition 97.5 % (Q2 2014-15) Source: NRC Picker 96.4% Overall Satisfaction Internal focus on Continuity and Transition 87% - Home Meds 67% - Side Effects FY 14/15 Ontario Academic Hosp Avg. with Benchmark Hospital 95.2% (Q2, 2014) Aligned with HSN True North: People 7. Lost Time Days 170 (Jan. to Dec. 2014) Source: Internal 85 Internal target to reduce by 85 days (50%) Aligned with HSN True North: Financial Health 8. Hospital Total Margin 0% (Q3 FY 2014/15) Source: OHRS, MOH 0.4% Provincial Average is 2.4% (Benchmark range) 0-2%)
Other Quality Indicators Oversight of Ontario Patient Safety Indicators Health Quality Ontario (HQO) currently reports on nine patient safety quality indicators for the province of Ontario focused on: Hospital-associated infections, Surgical site infection prevention, Hand hygiene compliance Surgical Safety Checklist compliance. These indicators will be reviewed at the Quality Committee of the Board, along with other key leadership forums at least quarterly o o o o o o o o o Clostridium Difficile Infection (CDI) Methicillin Resistant Staphylococcus Aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Central-Line Primary Blood Stream Infection (CLI) Ventilator-Associated Pneumonia (VAP) Surgical Site Infection (SSI) Prevention Hand Hygiene Compliance (HHC) Surgical Safety Checklist Compliance (SSCC) Hospital Standardized Mortality Ratio (HSMR)
Sign-off I have reviewed and approved our organization's Quality Improvement Plan.
Appendix 1: Workplan Improvement Targets & Initiatives 2015/16 Quality Improvement Plan for Ontario Hospitals "Improvement Targets and Initiatives" Section of HSN 2015-2016 QIP Workplan