Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 27/03/2019 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. Orillia Soldiers Memorial Hospital 1

Overview The Orillia Soldiers' Memorial Hospital (OSMH) 2018-19 Quality Improvement Plan (QIP) represents our formal set of quality commitments to our patients, staff, credentialed staff and wider community. The QIP is our pledge to continuously strive for excellence in the care and services we provide at OSMH. Our Mission is simple and straightforward, to be your trusted partner in health care, with values that encompass compassion, accountability, respect and engagement. To achieve our priorities we will work with patients, families and our system partners to deliver high quality care. Safety Our 2018-19 Quality Improvement Pledge We pledge to use antibiotics wisely, making sure patients get the right antibiotics, when they need them (and only when they need them) We will keep you safe by comparing your up to date and complete list of medications that you take at home versus medications ordered during your hospital stay. We will make workplace violence prevention a priority by proactively addressing harassment and bullying in the workplace in alignment with our values. Patient Experience Timely We will provide cultural competency training to improve the knowledge, attitudes and skills of OSMH staff to meet the needs of our diverse patient population. We will provide increased opportunities for you and your family to be involved in your care by conducting the transfer of your care at shift change at your bedside. We pledge to focus on hourly inpatient check-ins. We will ensure our Emergency Department patients get the care they need in a timely way. Efficient We will improve our discharge process to ensure that patients who are ready for discharge can be discharged regardless of weekday or weekend. Our 18-19 QIP was developed in alignment with these strategic priorities. The following key inputs were used in the preparation of this plan: Health Quality Ontario guidance documents and the Common Quality Agenda North Simcoe Muskoka LHIN (NSM LHIN) priorities Legislative requirements (Hospital Service Accountability Agreement (H-SAA)) Hospital Sector Funding Reform expectations (Quality Based Procedures) External environmental scans (Senior Management Team data walk & Clinical Services Plan) OSMH performance on 17/18 Quality Improvement Plan initiatives (QIP Dashboard) Performance trends Quality and Safety Scorecards and performance against peer benchmarks Critical incidents or serious safety events (Quality of Care Reviews) Patient and family experience feedback Consultation with the OSMH Patient and Family Advisory Council Input from hospital leadership and credentialed staff through a series of focused planning events Orillia Soldiers Memorial Hospital 2

Describe your organization's greatest QI achievements from the past year OSMH Accredited in 2017 In March 2017 OSMH hosted four Accreditation Canada Surveyors for an on-site assessment of the quality and safety of our care and service delivery. As part of the Accreditation Canada Qmentum Program, staff, volunteers, credentialed staff, patients and families were given an opportunity to participate in this assessment. Following the on-site survey the surveyors were unanimous in their praise of our organization, highlighting the positive and engaged culture throughout the hospital and our steadfast commitment to safe, quality care and continual improvement. In total, OSMH was compliant with 98.9% of more than 2,300 standards of care, and successfully completed 29 of the 31 ROPs (Required Organizational Practices). OSMH wins Positive Community Organization award at the Simcoe Pride Gala On August 12th 2017 Orillia Soldiers Memorial Hospital (OSMH) was awarded the Positive Community Organization award at the Simcoe Pride gala. In March 2014 OSMH created the Lesbian, Gay, Bisexual, and Transgender (LGBT) Committee for individuals interested in developing a welcoming, safe, nurturing and accepting organization for the LGBT community in North Simcoe Muskoka. Moving forward the OSMH LGBT Committee is working on more staff education for LGBT patient care and will also present at the Rainbow Health Ontario conference next year focusing on the health needs of transgender residents in the region. Reduced MRI Wait Times Orillia Soldiers Memorial Hospital has made a significant achievement in the past year of reducing the wait times for patients requiring MRIs. Patients are now waiting on average about 15 days for an MRI at OSMH, below the provincial average. The hospital s MRI operation has moved from 16 hours Monday through Friday and 8 hours on weekends to 24 hours a day Monday to Friday and 12 hours a day on the weekend thanks to additional funding received from the Local Health Integration Network. At one point, our wait time was around 140 days, far above the 28 day provincial target. The impact has been great for patients. Approximately 90 per cent of patients are now getting their MRI within the provincial standard, compared to about 20 percent not too long ago. Credentialed Staff Discharge Summary Turnaround Time It is a goal of Orillia Soldiers Memorial Hospital to ensure that discharge summaries for all patient discharges are available to their primary care providers within 48 hours of patient discharge. The content of the discharge summary must be of a consistently high quality that complies with OSMH guidelines. Timely, high quality discharge information may help prevent adverse events and gives the subsequent treating physician a full medical picture to optimize continuity of patient care Canadian Medical Protective Association (CMPA). In 2017-18 targeted education and increased communication with our physicians has led to measureable improvement. Through tracking the progress of this initiative we were able to identify 14 physicians who were consistently managing to achieve their dictation timeline targets. These physicians were recognized by name to our Board of Directors and each of them was congratulated for supporting the effective transition of patients to the community. Medication Reconciliation Medication reconciliation (Med. Rec.) is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. Ensuring that this process is embedded in our day to day practice has been a focus of our OSMH interdisciplinary Med Rec Sustainability Committee. The hard work and focus of the team has demonstrated great results. We have achieved our organization wide improvement targets. Through this multi-year process we have learned that sustaining this accomplishment will require leadership commitment at all levels. In 2018-19 our QIP improvement focus will be on improving Med. Rec data collection, monitoring and reporting. Orillia Soldiers Memorial Hospital 3

Resident, Patient, Client Engagement and relations Transforming the Patient Experience through a relentless focus on patient and family engagement, quality, safety and service is one of the pillars of our 2016 Strategic Plan. We believe that patients and families have an important role in guiding the work that we do within the hospital. Patient and Family Advisors are a resource to guide the hospital s priorities and planning. The OSMH Patient and Family Advisory Council (PFAC) was established in July 2016 and has been meeting regularly ever since. The PFAC meets every second month with opportunities for Council members to participate in ad hoc hospital committees or special projects throughout the year. For example, a PFAC representative was a member of the hiring committee for the new IMRS (Integrated Medicine and Rehab Services) manager. The PFAC consists of (up to) 12 Patient/Family members and 8 OSMH staff members. Through its first 6 months, the PFAC has provided feedback on a number of important items, including but not limited to: OSMH policy on Medical Assistance in Dying OSMH Strategic Plan graphic design Bedside Reporting Initiative Ethics Framework Staff ID badges Inpatient Entertainment System Patient Declaration of Values Accreditation OSMH Quality Improvement Plan (QIP) Diagnostic Imaging proposals to move to a 24/7 MRI service It should be noted that there are multiple PFACs available to OSMH patients and family members. In addition to the primary OSMH PFAC, there is also a PFAC supporting the OSMH Regional Women and Children s Program, a PFAC supporting the Regional Kidney Care Program Simcoe Muskoka, and a PFAC for the Simcoe Muskoka Regional Cancer Centre, with representatives from Orillia. Collaboration and Integration OSMH recognizes that hospital care is only a component of the patient care journey and that we must look for ways to partner with other organizations and service teams to ensure that the needs of patients in our community are met. One of the main pillars of our Strategic Plan is To Be Proactive in Shaping Health System Change. OSMH has a substantial role in a developing a high performing care delivery system for healthcare services in NSM LHIN and beyond. OSMH has a number of partners with whom we work to improve the care of our patients. Collaboration occurs daily with the Home and Community Care Services for the North Simcoe Muskoka LHIN in order to ensure that patients are discharged to the right place for their continued care, whether that is a long term care home or to the patient s own home. Collaboration for improving patient care is achieved through weekly alternate level of care (ALC) rounds and through the daily work of our Home and Community Care coordinators and our patient navigator team. Community Mental Health Partners OSMH has built a strong partnership with community mental health resources in order to provide the most seamless transitions for mental health patients from hospital to home. This partnership includes work with crisis intervention teams, community paramedics and the OPP. Working with the acute care partners within the LHIN allows for the transition of patients to the right level of care no matter where they live and provides for follow up with community mental health providers. Orillia Soldiers Memorial Hospital 4

Joint Birthing Program for OSMH and Georgian Bay General Hospital In 2017 OSMH and Georgian Bay General Hospital (GBGH) proudly announced the opening of a joint birthing program. OSMH and GBGH working with the NSM LHIN and the Ministry of Health and Long Term Care have developed a sustainable program with appropriate funding that will see low-risk birthing services continue at GBGH and higher risk scenarios transferred to OSMH. Mothers and families referred to GBGH by their family doctor will continue to receive quality birthing care in Midland and through an improved and standardized referral process high risk mothers will be identified early on so that they are better prepared to deliver at OSMH. OSMH strengthens Regional Women and Children s Program by joining Kids Health Alliance (KHA) As part of its ongoing commitment to Excellent, Compassionate Care Everyday, Orillia Soldiers Memorial Hospital (OSMH) is proud to announce it is strengthening its Regional Women and Children s Program by joining Kids Health Alliance (KHA), a partnership aimed at enhancing the paediatric health system with providers who share a common goal of improving the health of children and youth in Ontario. The partnership will initially focus on enhancing paediatric care in the OSMH Emergency Department. Then, through continued sharing of specialized paediatric expertise and implementation of best practices, the collaboration will extend to enhancing care in neonatal intensive care and paediatric inpatient units. The benefits of the partnership are not limited to OSMH, the hospitals we work closely with to provide paediatric services such as Collingwood General and Marine Hospital, Georgian Bay General Hospital, Muskoka Algonquin Healthcare and West Parry Sound Health Centre will also benefit from this coordinated approach to care. Cross Sectoral Collaborative QIP In 2017-18 OSMH collaborated with several of our NSM LHIN community partners to formalize our shared goal of preventing the re-hospitalization of patients with Chronic Obstructive Pulmonary Disease. Together with our partners, North Simcoe Muskoka LHIN Home and Community Care, the Couchiching Family Health Team (CFHT) and the Couchiching Health Link we created a collaborative QIP dashboard that identified individual change initiatives and allowed us to monitor our individual progress to our collective goal. We anticipate that in spite of a spike in readmissions of COPD patients in July-Sept 2017 we will experience a measureable improvement and will meet our shared target in reducing 30 day readmission rates to OSMH for patients with Chronic Obstructive Pulmonary Disease. In 17-18 our improvement focus has been on: Increasing the number of referrals to the Tele homecare program for both COPD and Congestive Heart Failure (CHF) patients Analyzing post hospital discharge surveys to identify gaps in patient experience during transition from hospital to home Ensuring that primary care providers at CFHT receive completed discharge summaries for all COPD patients discharged from OSMH within 48 hours. Providing education about community programs to both patients and health care providers Increasing the number of appropriate referrals to Health Links program Implementing a data monitoring system to track eligible Health Links patients admitted to OSMH Increasing staff access to Health Links Coordinated Care Plans Orillia Soldiers Memorial Hospital 5

Transitional Bed Program In collaboration with OSMH and the North Simcoe Muskoka Hospice Palliative Care Network, Helping Hands Orillia has opened Clint House, a six-bed transitional program. These beds will allow temporary care for patients whose home arrangements are not suitable and to monitor patients after surgery, those with infections, those who are palliative and those who require post-fall assistance. Helping Hands has worked directly with OSMH discharge staff and NSM Home and Community Care Services to fill these beds. This program will expand the versatility of transition beds, with the expectation of reducing strain on the hospital system and improving the healthcare experience for clients in the community. Due to the success of the program Clint House has just received approval to expand to 9 beds with funding provided through the NSM LHIN. Engagement of Clinicians, Leadership & Staff To strengthen the alignment of OSMH s annual corporate planning with the annual budget and Quality Improvement Plan (QIP) we integrated three separate annual planning streams with a goal of reducing duplication and increasing stakeholder engagement. 2017-18 marks the third year of the integrated corporate planning process. As we have learned over these years, bringing stakeholders together at the outset of the planning process allows for broad multidisciplinary perspectives. Hospital leadership and clinicians have been actively involved from start to finish in the selection of indicators and in the generation of change initiatives. OSMH s Senior Management Team, Clinical and Non-Clinical Leadership Teams, Medical Advisory Committee, Nursing Advisory Council and Inter-professional Practice Council representatives have played an active role in the development and oversight of this year s QIP. Population Health and Equity Considerations At OSMH we are committed to providing the best possible experience for our patients and families. To do this we must acknowledge and honor the unique personal values, beliefs and customs of patients when delivering care and service. In 2018-19 we will expand the current role of Pastoral Care and Cultural Affairs to include Patient Relations. In addition to overseeing and ensuring timely delivery of spiritual and cultural care to patients, this position serves in a leadership capacity to plan and implement spiritual and culturally sensitive programs and services at OSMH. Our commitment to provide cultural competency training will improve the knowledge, skills and attitudes of our OSMH staff to meet the needs of our diverse patient population. LGBTQ Committee Transitioning our LGBT Task Force to an acknowledged hospital committee marked a milestone for our hospital. It is a concrete demonstration of the importance of fostering this culture change in the organization and in the community. Recently, the committee included the addition of the letter Q to their mission statement and will begin using the full acronym LGBTQ. Adding the letter Q is more than adding a letter, it reflects our values. We recognize a growing number of people in our community identify as queer or questioning to best reflect their gender and/or sexuality. In 2017/18, OSMH secured a grant from the NSM LHIN to have the Gilbert Centre and Laurentian University examine the health needs of transgender people and families in the Simcoe Muskoka region. The report findings will be presented at the 2018 RHO (Rainbow Health Ontario) conference as well as a poster presentation highlighting OSMH s LGBTQ journey. OSMH is currently proposing collaboration with community partners to create a regional Trans Health Hub in Orillia. Orillia Soldiers Memorial Hospital 6

French Language Services Committee OSMH is proud to be a leader in the North Simcoe Muskoka LHIN in raising the profile of French language usage and services provided in our hospital. We have successfully recruited 15 staff to comprise our first ever French Language Services Committee. In 17/18 the committee focused on promoting the use of the French language in conversations, improved signage and a commitment to flying the francophone flag for Ontario on significant occasions such as Saint- Jean-Baptiste day. We have identified over 90 staff with French language skills that will be accessible to provide peer to peer teaching as well as connect with our patients whose first language is French. Work is currently underway to secure a patient / family representative to join the team. Signage is being developed for the Regional Women and Children Program (Paediatrics / NICU / OBS) and the Intensive Care Unit. We will continue our LHIN partnership with College Boreal with an opportunity to offer free French language education to staff on-site at OSMH. First Nation-Metis-Inuit The provision of support and services unique to First nation-metis-inuit clients has been a longstanding practice at OSMH. Traditional healing and medicine teaching is offered by our hospital elder. Spirituality classes are offered regularly to both inpatient and outpatients. We accommodate special religious ceremonies using smudging, healing medicine bags, and our healing circle, a sacred space for this community. In 2017/18, we are establishing a First Nation, Métis and Inuit (FNMI) Committee consisting of representation from Beausoleil First Nation, Chippewas of Rama First Nation, Georgian Bay General Hospital, Enaahtig Healing Centre and OSMH staff. The FNMI Committee in conjunction with the NSM LHIN and Rama First Nation will also be supporting the new Indigenous Patient Navigator in the OSMH Emergency department. Future Hospital Project -Planning for tomorrow s hospital now Future Hospital Vision The future hospital project is designed to identify the optimum configuration of services to best meet the health care needs of the patient populations served by OSMH. The Project recognizes that the current infrastructure is highly inefficient and increasingly unsustainable over the long term, and that substantive change is a need, not a want. The goal of this project is to ensure effective, efficient use of OSMH facilities and associated operating resources, and to get into the 10-year capital planning cycle of the Ministry of Health and Long-Term Care s approval process. Stakeholder engagement is an integral part of the process. We have already begun the process of internal engagement with our credentialed and non-credentialed staff, as well as our Patient and Family Advisory Council. This process will result in a Master Program, Master Plan and a capital submission to Government for the next phase of development. Orillia Soldiers Memorial Hospital 7

Supporting need for Residential Hospice OSMH has been working to support the development of a successful proposal for a Residential Hospice in the Orillia and area community. Operational funding for the Hospice has now been announced for 2018, and two community groups have joined in a memorandum of understanding to apply for the funding and operate the hospice under the name Mariposa House. Interim funding for 17/18 is not available. The aim is to have a standalone facility by April 1, 2018. The hospital will continue in an advocacy role. Access to the Right Level of Care - Addressing ALC Reducing the amount of time individuals who no longer require acute care services wait in hospital to access placement in a more appropriate setting such as home or residential care has been our improvement priority for several years. This patient population is referred to as Alternate Level of Care or ALC patients. One of the biggest health care frustrations over the past several years has been the length of time it takes to transition a hospital patient onto their next level of care, such as those requiring long term care, The frustration is shared by patients, families and those working in health care, with some patients waiting multiple months before a solution is found Here are some of the ways we continue to work to lower our ALC numbers: Weekly meetings of our ALC steering committee - Community partners meet weekly with hospital staff to review individual patient needs and collaborate to identify solutions that are in the patient s best interests and help transition the patient to an appropriate destination in the shortest amount of time. Joint Discharge Operations - senior leadership from OSMH in collaboration with Home & Community Care (HCC) discuss barriers to discharge including making patients ALC to long term care. Physician Champions - key liaisons for communication Culture Change senior leadership and medical directors focus and support of the Home First philosophy, supported by physicians, patient flow team, nursing and all staff. Opening of Integrated Medicine Rehab Services (IMRS) unit care wrapped around patient with fewer bed transitions. Focus is on readiness for community return. Focus on getting long stay patients into more appropriate sites of care or on the way to a final destination if necessary focus on not allowing patients to linger in hospital. Community, Community, Community established multiple partnerships including retirement homes, transition beds, and partners who provide in home supports such as Home and Community Care etc. Transition Beds - In January 2016, Helping Hands, in collaboration with OSMH and the North Simcoe Muskoka Hospice Palliative Care Network (NSMPCN), opened Clint House, a 6 bed transitional program offering beds to clients in the community. In 2017 three more beds were added for a total of nine transitional beds. Orillia Soldiers Memorial Hospital 8

Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder The North Simcoe Muskoka LHIN and Simcoe Muskoka Public Health Unit are jointly leading a multi-sector collaborative effort to create a regional comprehensive opioid strategy inclusive of prevention, harm reduction, treatment and enforcement. This pillared approach is underpinned by the development of a strong surveillance system. This work has included a high level gap analysis and the development of pillar action plans to improve collaboration and prioritization of efforts in the short and long term. The treatment pillar is working towards the development of a rapid access addiction medicine clinic, chronic pain clinic and distribution of naloxone kits into ER. As part of the treatment pillar action plan, the OSMH Medical Advisory Committee recommended that the hospital pursue a naloxone dispensing policy for any patients known to be at risk of opioid overdose who are being discharged from the hospital or emergency department. As well, Medical Chiefs and Program Medical Directors will share the following resources at their department meetings: Catalog of local resources for prescriber education Referral information for pain management and addiction services for patients Educational articles about: post-operative prescribing of opioid analgesics and Emergency protocols for alcohol withdrawal and opioid withdrawal OSMH has a comprehensive order set for acute pain in use for inpatients and post-operative analgesia. Workplace Violence Prevention Keeping Health Care Professionals Safe on the Job On May 15th 2017 the Ministry issued the recommendations from the Workplace Violence Prevention in Health Care Report. Ontario s Workplace Violence Prevention in Health Care Leadership Table endorsed 23 recommendations and outlined further practical steps needed to make hospitals safer, reduce incidents of workplace violence in hospitals and across the health sector and change attitudes around safety for health care workers. Workplace Violence prevention has been a strategic priority for OSMH since 2016-17, and as such some of the initiatives included a corporate wide risk assessment for Workplace Violence by Safe Management Group in September 2016 that resulted in a plan to address identified gaps over the next three years. Many of the recommendations of the plan have already been implemented or are in progress. These would include an alert code policy that introduced flagging in our electronic medical record for violent/aggressive patients as well as patients with restraining orders, a partnership with our union groups via the creation of a corporate Workplace Violence Committee, the removal of all staff lanyards as well as NO tolerance posters for Workplace Violence that are now visible in all departments and entrances. In addition, in the fall of 2016 we launched a mandatory Civility e-learning education that has a completion rate over 80%, and recognized a week in November 2016 as Civility week. Over 200 OSMH staff made a formal acknowledgement of a kind act that they have seen or witnessed. Finally, we have commenced work on an upgrade to our code white system and have committed to additional security guards, and Workplace Violence Prevention Training will continue in 2018/19. Orillia Soldiers Memorial Hospital 9

Current Performance Target for 18/19 Allocation of performance pay Performance Based Compensation 2018 to 2019 Performance-based Compensation Program Participants: The positions included in the performance-based compensation program are: President and Chief Executive Officer (CEO) Chief of Staff (COS) /VP Medical Affairs VP Regional Patient Programs Senior Program Director Local Patient Programs and Chief Nursing Executive (CNE) Executive VP Corporate Services/Chief Financial Officer (CFO) Senior Director/Chief Human Resources Officer Program Design The program period is in line with the fiscal year, running from April 1 to March 31. For the 2018/2019 fiscal year, the amount of performance pay is 5% of base pay for the CEO and 3% of base pay for each of the other identified participants. This money will be divided between 5 QIP objectives with performance improvement targets. The amount of performance pay allocated to each of these objectives ranges from 10% to 35% of the total amount as described in the table below. The calculation of performance pay will be pro-rated relative to success in meeting each performance goal. Calculations will be completed within 90 days of the end of the fiscal year. Pay Allocation Plan 2018-19 Quality Dimension Objective Measure/ Indicator Would you recommend this hospital In-patient Patient Centered Improve patient satisfaction Percentage of respondents who responded positively to the following question from the Canadian Patient Experiences Survey - Inpatient Care (CPES-IC): "Would you recommend this hospital to your friends and family?" 65.5% 68% 10% Would you recommend this hospital ED Patient Centered Improve patient satisfaction Percentage of respondents who responded positively to the following question from the Ontario Emergency Department Patient Experiences of Care Survey (EDPEC): "Would you recommend this emergency department to your friends and family?" 56.0% 58.0% 10% Safe Increase antibiotic free days (ICU) The number of antimicrobial-free days (both antibacterial and antifungal) in ICU for the reporting period (rate per 1000 patient days) 337.48 337.48 0 Orillia Soldiers Memorial Hospital 10