Quality, Risk and Patient Safety Report Fiscal Year 20, Fourth Quarter Submitted to: Board of Directors June 20, 2014 Contributed by Staff of the North East CCAC Date of Report: June 4, 2014
TABLE OF CONTENTS 1. INTRODUCTION... 3 2. DEFINITIONS... 4 3. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE... 5 a. Quality Framework and Enterprise Risk Management Framework... 5 b. Quality, Risk and Patient Safety Committee (Operational)... 5 c. Patient Services and Quality Committee of the Board of Directors... 5 d. Patient Safety Plan... 5 e. Quality Improvement Plan (QIP)... 5 f. Insurance... 6 g. NE LHIN Risk Registry... 6 h. Disaster/Emergency Response Planning... 6 i. Pandemic Influenza Planning... 6 j. Document Control (Policies, Procedures and Forms)... 7 k. Risk Events and Feedback... 7 l. Quality, Risk and Patient Safety Newsletter (all staff)... 7 m. Quality, Risk and Patient Safety Newsletter for Management... 7 n. Accreditation... 8 o. Internal Audit/Tracer Strategy... 9 p. Client and Caregiver Experience Evaluation (CCEE)... 9 q. Employee Engagement Evaluation... 11 4. INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT... 12 5. ACCESSIBLE: Wait time for CCAC services... 13 6. ACCESSIBLE: Access to long-term care home... 17 7. EFFECTIVE: Keeping people healthy in home care... 19 8. SAFE: Avoiding harm in home care and the community... 24 9. PATIENT-CENTERED: Meeting patients needs and preferences... 28 10. INTEGRATED: Primary Care Services... 33 11. APPROPRIATELY RESOURCED: Healthy work environment... 35 12. DATA SOURCES... 39 APPENDIX A: Patient Safety Plan Quarterly Report... 40 Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 2 of 44
INTRODUCTION 1. INTRODUCTION Home care is an important foundation for supporting an integrated health care system. Home care has a unique function as a key linkage point between various settings of care, such as acute hospitals, emergency departments, long-term care homes and various clinical services. Home care services are intended to meet patients needs in an individualized and comprehensive manner, and go beyond physical and mental health care to engage social supports as well. 1 The North East Community Care Access Centre (NE CCAC) Quality, Risk and Patient Safety Report aligns with the format of Health Quality Ontario s (HQO) Quality Monitor Report on Ontario s Health System. Where appropriate, indicators will align with those being collected by HQO so that we are doing our part to ensure quality healthcare for Ontarians. The nine attributes of quality that reflect a high performing health system include: accessible, effective, safe, patient-centered, equitable, efficient, appropriately resourced, integrated and focused on population health. To ensure that the NE CCAC is monitoring indicators across the quality spectrum, the report has been organized to link indicators to the applicable attribute of quality. The report also incorporates results from the Quality Improvement Plan and the Patient Safety Plan. As we continuously improve upon the report, the goal is to have indicators for each attribute of quality. The report includes data to March 31, 2014, the end of fourth quarter for fiscal year 20. Status reports and quality improvement strategy updates are current as of the date of the report. 1. Keep me safe 2. Heal me 3. Be nice to me in this order 2006 Healthcare Performance improvement, LLC. ALL RIGHTS RESERVED. 1 Ontario Local Health Integration Networks M-SAA Performance Technical Specifications Version: December 18, 2008 Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 3 of 44
2. DEFINITIONS Healthcare Quality Improvement: A broad range of activities of varying degrees of complexity and methodological and statistical rigour through which healthcare providers develop, implement and assess small-scale interventions, identify those that work well and implement them more broadly in order to improve clinical practice. 2 MAPLe Score: The MAPLe score was developed to prioritize patients for access to CCAC services. Patients who have been assessed and have MAPLe scores of high and very high represent the CCAC patients most in need of long term care placement. Performance Indicator: A measurement that is linked to a strategic direction. It demonstrates progress towards a stated goal and identifies areas for improvement. Performance Standard: A corridor or range around a performance target. It is established for variance reporting purposes. It takes into account expected variations such as statistical and seasonal fluctuations in performance. The Performance Standard is indicated by dashed red lines on the graphs. Performance Target: Sets a goal to achieve. It is measurable and used to demonstrate progress towards a stated goal. The Performance Target is indicated by a solid red line on the graphs. Quality in Healthcare: The nine attributes of a high-quality health system, as defined by Health Quality Ontario (HQO), are: ATTRIBUTES OF QUALITY ACCESSIBLE EFFECTIVE SAFE PATIENT-CENTERED EQUITABLE EFFICIENT APPROPRIATELY RESOURCED INTEGRATED FOCUSED ON POPULATION HEALTH OUTCOMES People should be able to get timely and appropriate healthcare services to achieve the best possible health outcomes. People should receive care that works and is based on the best available scientific information. People should not be harmed by an accident or mistake when they receive care. Healthcare providers should offer services in a way that is sensitive to an individual s needs and preferences. People should get the same quality of care regardless of who they are and where they live. The health system should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information. The health system should have enough qualified providers, funding, information, equipment, supplies and facilities to look after people s health needs. All parts of the health system should be organized, connected and work with one another to provide high-quality care. The health system should work to prevent sickness and improve the health of the people of Ontario. Risk: Anything of variable uncertainty and significance that interferes with the achievement of business strategies and objectives. Something goes wrong detracting from the organization s purpose and the quality of its programs and services. Risk Management: Risk Management is a systematic approach to identify, analyze and respond to risks. Most risks can be managed so that impact to the organization is minimized, mitigated or prevented entirely. Root Cause: The underlying or original cause of an incident or problem. 2 The Ethics of Improving Health Care Quality & Safety: A Hastings Center/AHRQ Project, Mary Ann Baily, PHD, Associate for Ethics & Health Policy, The Hastings Center, Garrison, New York, October 2004. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 4 of 44
3. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE a. Quality Framework and Enterprise Risk Management Framework The Quality Framework outlines the NE CCAC s commitment to quality improvement in the provision of patient services and a safe, productive workplace. The Framework is aligned with the NE CCAC s vision, mission, strategic plan and operational plan as well as Accreditation Canada standards. It provides a strategic overview of the key principles and practices necessary for the effective planning, management, delivery and improvement of NE CCAC services. The NE CCAC Enterprise Risk Management Framework supports the identification, assessment, and mitigation of risks through a standardized and documented method. The Top Risk Profile Report is provided to the Board of Directors and senior management on a quarterly basis. b. Quality, Risk and Patient Safety Committee (Operational) The Quality, Risk and Patient Safety Committee provides a mechanism to align enterprise-wide quality improvement, risk management and patient safety efforts occurring at an operational level with the organization s strategic priorities. The Committee includes representation from a broad range of backgrounds and geographic regions to obtain regional views and perspectives, is chaired by the Director, Quality and Risk, and is accountable to the CEO. The purpose of the Quality, Risk and Patient Safety Committee (operational) is to: Support a culture of quality, risk management, and patient safety at an operational level. Identify and remove barriers to patient safety and quality of care. Analyze organizational performance data and translate this data into meaningful opportunities for improvement. Support quality improvement initiatives. Identify strategies to mitigate enterprise-wide risks. The Committee met monthly to review and provide advice on a number of quality, risk and patient safety areas including readiness for the Qmentum accreditation survey scheduled for May 2014, risk assessment, escalation and communication of high severity risk events and adverse events to senior management, development of the Quality Improvement Plan (QIP) and the Patient Safety Plan for 2014-2015 including education initiatives, Patient Safety Month activities (held in February) and the development of patient risk event case studies for use at team meetings. Committee members also provided valuable input through their review of the Reprocessing education module. c. Patient Services and Quality Committee of the Board of Directors This Committee provides governance oversight related to risk management in the areas of patient services, patient safety, human resources, ethics and health system partnerships. The Committee provides input into the development of the annual Quality Improvement Plan. d. Patient Safety Plan The Patient Safety Plan outlines the North East CCAC s commitment to Patient Safety and supports the mission and vision through the practice of developing and implementing a culture of safety. The Patient Safety Plan details specific objectives, activities, indicators, responsibilities, and target dates to facilitate meeting the organization s goals and objectives related to patient safety. Refer to Appendix A for the 2013-2014 Patient Safety Plan Quarterly Report. The 2014-15 plan was approved by the CEO and effective April 1, 2014. e. Quality Improvement Plan (QIP) The Quality Improvement Plan (QIP) is an annual plan required under the Excellent Care for All Act. This legislation currently applies to hospitals and to the primary health care sector. A Ministry of Health and Long-term Care directive requires that every CCAC shall develop, make publicly available, and submit to Health Quality Ontario their first annual QIP by April 1, Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 5 of 44
2014 for the fiscal year 2014-2015 using standardized templates and guidance material. As recommended by the CCAC CEOs, the CCAC-specific QIP priority indicators are: 1. Patient Experience Percentage of Good, Very Good and Excellent Client Experience Survey responses on a 5 point scale (poor to excellent) to the three patient experience KP 1 survey questions: a. Overall rating of CCAC Services; b. Overall rating of management /handling of care by Care Coordinator; c. Overall rating of service provide by service provider. (Key Performance Indicator 1 CM Services) 2. 5 Day Wait Times for Nursing Services and PSW Services for Complex Patients 3. Falls Percentage of adult long-stay home care patients who record a fall on follow-up RAI-HC assessment. 4. Hospital Readmissions Percentage of home care patients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital. 5. Unplanned Emergency Department (ED) Visits Percentage of home care patients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital. To prepare the NE CCAC QIP, a review was conducted of the Ministry of Health and Long-Term Care Guidance Document for Ontario s Health Care Organizations, Indicator Technical Specifications and related narrative and workplan templates. Two webcasts were also held to guide development of the QIP: one by the Ministry of Health and Long-Term Care on January 15, 2014 and one hosted by OACCAC on February 11, 2014. Consultation meetings were held with Directors and Managers to identify improvement initiatives for each of the core indicators, as well as consultation with the Quality, Risk and Client Safety Committee (operational committee) on February 18, 2014 and with the Client Services and Quality Committee of the Board on February 20, 2014. The Quality Improvement Plan was presented for review and approval by the Board of Directors on March 7, 2014 with provision for setting and/or adjusting performance targets that align with targets in the 2014-2015 Balanced Scorecard and/or the M-SAA, once approved. The QIP was submitted to Health Quality Ontario on March 28, 2014. Quarterly reporting will be incorporated within the 2014-2015 Quality, Risk and Patient Safety Report. The 2013-2014 NE CCAC Quality Improvement Plan status update is incorporated into the quality dimension sections of this report (Accessible, Safe, Patient-Centered, Integrated, and Efficient), and is flagged by a highlighted star. f. Insurance The NE CCAC carries insurance protection through the Healthcare Insurance Reciprocal of Canada (HIROC). Annual information updates were submitted to HIROC for liability and property insurance. g. NE LHIN Risk Registry This report alerts the NE LHIN of risks or opportunities that may influence achievement of objectives. The 4 th quarter Risk Registry Report was submitted to the NE LHIN on March 18, 2014. h. Disaster/Emergency Response Planning The NE CCAC Emergency Management Plan provides a systemic response to any emergency. It was recently updated to reflect changes to the organization and simplify some response procedures. The internal James Bay Contingency plan continues to be in development and is intended to provide a standardized approach to annual James Bay flooding. Contingency plans provide a documented method to consistently respond to identified situations, particularly those that can be predicted with a certain degree of frequency. i. Pandemic Influenza Planning The NE CCAC Pandemic Plan provides a systemic response in the case of a pandemic. The NE CCAC participates on a provincial emergency response group that has reviewed the provincial template for CCAC pandemic response plans to ensure it is aligned with the Ministry of Health and Long-Term Care pandemic plan. The template is now finalized and the NE CCAC pandemic response plan will be updated in 2014-15. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 6 of 44
j. Document Control (Policies, Procedures and Forms) The Policy and Procedure Manager software is used to manage policies, procedures and related documents developed to standardize processes within the NE CCAC. Each Senior Director of the Executive Team is accountable for the Table of Contents of their respective portfolio manual and is responsible for delegating, writing and/or editing policies, procedures and related documents to their Managers. Forms are managed and housed on a SharePoint site. Using SharePoint allows for using electronic forms to their fullest capabilities, including fillable Word forms and InfoPath forms. The Forms Management Committee completed a major review of Client Services forms and is now reviewing forms from other portfolios as well as any new forms. As resources permit, documents in the Policy and Procedure Manager and the Forms site are gradually being reassigned to new document owners based on the new organizational structure. k. Risk Events and Feedback The Risk Event and Feedback System (REFS) is a database that captures patient risk events and feedback (compliments and complaints), risk events affecting employees, service providers and other third parties, general feedback, health and safety hazards, non-conformances, as well as enterprise-wide risks. A REFS e-learning intranet site ensures that training materials are available to staff throughout the NE CCAC 24/7. The Business Intelligence team produces Risk Event and Feedback reports and ad hoc data extracts for in-depth analysis and utilization of REFS data for quality improvement initiatives. Risk event and complaint reporting is a challenge for many health care organizations with documented reports reflecting only the tip of the iceberg. Maximizing the overall value of the reporting system as a source of actionable data could improve patient safety and patient experience. To streamline the system for users, certain fields in the submission form were eliminated and other maintenance was carried out to align with organizational structure. Other strategies to streamline the system are being reviewed for feasibility. The process for managing patient complaints referred from MPP offices was reviewed to ensure documentation and tracking in the event management system. A work group of directors and senior leaders within the organization is reviewing processes for communicating and escalating high severity risk events and adverse events to internal stakeholders. l. Quality, Risk and Patient Safety Newsletter (all staff) The Quality and Risk Newsletter is a communication tool to inform all NE CCAC staff about quality and risk issues affecting the organization. The newsletter provides updates on issues related to current systems such as Policy and Procedure Manager, the Risk Event and Feedback System, Patient Safety topics and Accreditation. The following topics were featured: January: Medication Management Program February: Client/Patient Safety Month March: On-Site Qmentum Survey Process, Advance Documentation, Priority Processes, Tracers, Record Reviews April: Accreditation Members Portal, Survey Schedule, Surveyors, Role of Leads and Coordinator m. Quality, Risk and Patient Safety Newsletter for Management The first issue of the Quality, Risk and Patient Safety Newsletter was released in October 2013. This newsletter specifically focuses on what managers need to know and communicate to ensure a successful Qmentum Accreditation Survey and support a culture focused on delivering quality and safe care to patients. The intent is that managers will review applicable information with their staff at team meetings. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 7 of 44
The following topics were featured: January: Risk Event Case Study Customized Managing Medication Standard: Narcotics and Controlled Substances, Abbreviations, Heparin February: Client/Patient Safety Month, Accreditation Jeopardy, Client Safety Education, Client Safety Framework and Plan March: Prospective Analysis, Quality Improvement Toolbox April: NE CCAC Accreditation Members Portal Site, REFS Case Studies, Abbreviations, Accreditation Jeopardy, Home Safety Risk Assessment and Education Modules n. Accreditation The NE CCAC participated in the Accreditation Qmentum Survey from May 4-8, 2014. A summary of the results is included in the tables below. Overview by Quality Dimensions Quality Dimension Met Unmet N/A Total Population Focus - Working with communities to anticipate and meet needs 32 0 0 32 Accessibility - Providing timely and equitable services 15 0 0 15 Safety Keeping people safe 101 4 4 109 Worklife Supporting wellness in the work environment 60 0 0 60 Client-centred Services Putting patients and families first 39 1 1 41 Continuity of Services Experiencing coordinated and seamless services 14 0 0 14 Effectiveness Doing the right thing to achieve the best possible results 203 1 0 204 Efficiency Making the best use of resources 28 0 1 29 Total 492 6 6 504 Overview by Standards Total Criteria High Priority Criteria Other Criteria (High Priority + Others) Standards Set Met Unmet N/A Met Unmet N/A Met Unmet N/A # (%) # (%) # # (%) # (%) # # (%) # (%) # Governance 44 0 0 34 0 0 78 0 0 Leadership 46 0 0 84 1 0 130 1 0 Customized Infection Prevention and Control 33 0 0 11 0 0 44 0 0 Customized Managing Medications 21 0 2 9 1 1 30 1 3 Case Management Services 24 1 0 73 0 1 97 1 1 Home Care Services 38 2 0 52 0 0 90 2 0 Total 206 (98.6%) 3 (1.4%) 2 263 (99.2%) 2 (0.8%) 2 469 (98.9%) 5 (1.1%) On May 22, 2014, Accreditation Canada notified the organization of its decision: North East Community Care Access Centre / Centre d'accès aux soins communautaires is Accredited with Commendation under the Qmentum accreditation program This is a milestone to be celebrated, and we congratulate you and your team for your commitment to providing safe, high quality health services. Very good news indeed! The final Accreditation Report will be reviewed and the results shared with the board of directors, staff and other stakeholders. Areas for improvement will be addressed. 4 Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 8 of 44
o. Internal Audit/Tracer Strategy An audit is a systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled. ASQ Auditing Handbook The internal audits were being used to evaluate compliance to Accreditation standards and to prepare staff for participation in the Qmentum survey. In 2013, the Quality and Risk Team completed internal audits at all six branch offices, resulting in 38 findings, 22 of which have been corrected and closed. In January 2014, meetings were held with audit finding leads to review the findings, as well as expectations for short-term and long-term corrective actions and documentation of followups in the Risk Event and Feedback System. To sustain the current gains and identify further opportunities for improvement, additional internal audits may be identified by the Executive Team to address specific operational areas. The focus for the coming year will be the completion of the HIROC risk assessment. Internal audits are performed by Quality and Risk Specialists who are American Society for Quality (ASQ) Certified Quality Auditors. p. Client and Caregiver Experience Evaluation (CCEE) The provincial Client and Caregiver Experience Evaluation (CCEE) Provincial Committee oversees a coordinated approach of ongoing patient surveys to gather comparable information across and within individual CCACs about the satisfaction and experience of their patients, for the purpose of improving service and reporting to funders and the public. The surveys are currently completed by National Research Corporation Canada (NRCC) using a continuous sampling approach spread over four waves during a one year period. The survey tool has been revised and streamlined to reduce the number of questions and amount of time required for patients or caregivers to respond to the telephone survey. Results: The report Client and Caregiver Experience Evaluation North East CCAC Final Aggregate Results April 2013 to September 2013 was received from NRCC in April 2014. Comparisons are made only in relation to the provincial aggregate results and Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 9 of 44
not to other specific CCACs, following the guiding principles set out in the CCEE Communications Approach & Provincial Positioning. Note that these results must be interpreted with caution as they represent only half the sample size (2 survey waves over a six-month period). The following results demonstrate that the North East CCAC is within the provincial overall for all Key Performance Indicators (KPIs). Compared to NE CCAC 20 scores, results for KPI 5 (Building Relationships & Trust) and KPI 8 (Expectations of Quality) are significantly lower, and significantly higher for KPI 6 (Linking to Other Services). The following graph depicts the NE CCAC score for each KPI. For comparison purposes, the NE CCAC 2012-2013 result is located to the left of the graph and the provincial overall result is located to the right of the graph. Arrow represents statistically significant differences at the 95% confidence level, from NE CCAC current score. NE CCAC score current score is higher or lower. Key Performance Indicator 1 Overall Experience, is the indicator that will be used for public reporting through Health Quality Ontario. The NE CCAC s percent positive score was 92.1%. Though not statistically significant, this result is lower than our 20 result and lower than the provincial overall result for KPI 1, 92.4%. This KPI is comprised of the results to the following three questions: NE CCAC Apr 12-Mar 13 NE CCAC Apr-Sep 13 Provincial Overall Apr-Sep 13 1. Overall, how would you rate the services received from the CCAC? 93.8% 90.8% 92.3% 2. Overall, how would you rate the management and handling of your care 92.8% 91.6% 90.6% by the care coordinator? 3. Overall, how would you rate the service provided by the service provider agency? 94.7% 94.1% 93.8% The percent positive score reflects responses of Good, Very Good and Excellent. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 10 of 44
Action Plan Reports were disseminated to Care Coordination and Clinical Services senior management as a source of information for improvement initiatives involving CCAC staff and Service Providers. Relevant results were presented to a group of external contracted therapy providers and internal therapy managers with plans to meet other groups and flag potential areas for improvement. Priority areas for improvement at the NE CCAC include: Helping to link patients to other community services Home health providers explaining things understandably Service worker being up-to-date re: care/treatment at home Ease of contacting Care Coordinator Focusing on strategies to improve results in these areas will be most effective in improving our overall results. q. Employee Engagement Evaluation A work plan has been established based on the results. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 11 of 44
# of Days 4. INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT The nine attributes that reflect a high performing health system are: 1. Accessible 2. Effective 3. Safe 4. Patient-centered 5. Equitable 6. Efficient 7. Appropriately resourced 8. Integrated 9. Focused on population health To ensure that the NE CCAC is monitoring indicators across the spectrum of the definition of quality, the following section of the report has been organized to link indicators to the applicable attribute of quality. At this time the CCAC sector does not have indicators for every attribute of quality; however, the intent is to continuously improve upon the report and to add information as it becomes available and/or is required. For each attribute, from a NE CCAC perspective, there is a definition of What we want, Consequences if we don t get it and To whom does this matter?. For each indicator there is a mini-graph to indicate progress or lack of improvement over time. The actual indicator, performance corridor (range) and target are displayed on the graphs as shown in the example below: Wait Time for Patients Referred from Community Settings 25 Actual 20 15 10 Performance Standard (range) 5 Target 0 08-09 08-09 08-09 08-09 09-10 Fiscal Year, Quarter 09-10 09-10 09-10 BETTER As applicable, to the right of each graph there is an arrow indicating which direction is better for that particular indicator. As well, there is a brief summary of the current status of the indicator along with a brief analysis and ideas for improvement. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 12 of 44
# of Days ACCESSIBLE 5. ACCESSIBLE: Wait time for CCAC services What we want Consequences if we don t get it To whom does this matter? Short wait times and efficient care processes for CCAC services. Long wait lists represent a barrier to accessibility for patients. In some cases a delay in providing care could result in a crisis and the need for more intensive forms of care. Patients seeking accessibility to CCAC services in north eastern Ontario. 100 90 80 70 60 50 40 30 20 10 0 11-12 Indicators and Trends for Wait Time for CCAC Services Wait Time for Clients Referred from Community Settings to Community Home Care Quarter, Fiscal Year BETTER Value: 94 days 20 Target: 48 days 20 Performance Standard: <60 days Analysis: The metric s value is 94 days, considerably higher than the target of 48 days. A number of factors influence this metric: The strike by Red Cross Care Partners at the end of the quarter caused some patients to be put on waitlists for personal support. Other low need patients were also being put onto a waitlist. These patients negatively affected this metric in as they are pulled off the waitlist. Clinical services were addressing many of the patients that had been on the waitlist for a very long time. Specifically, this included initiating therapy services for lower priority patients at the bottom of the waiting lists, rather than exclusively removing patients from the top of the waiting lists. As well expanded use of rehabilitation assistants and mobility clinics has continued. While these patients are being pulled off the waitlist and provided their first visit, this metric will be negatively affected. Of the 324 patients who received their first visit in and were over 48 days from the start of the referral: o 18 were for personal support (those removed from the waitlist) o 6 for nursing (monthly visits that were not required to start for 30 days) o 171 for OT o 96 for PT o 33 for other therapy services Waitlist for both OT and PT have been dramatically reduced during this quarter (which negatively affects this metric). The PT in-home waitlist was reduced Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 13 of 44
# of days ACCESSIBLE Indicators and Trends for Wait Time for CCAC Services from 545 patients at the start of January to 339 patients at the end of March. Median wait time went from 71 days to 36 days. During this same time period, 1620 new patients were authorized for PT The OT in-home waitlist was reduced from 817 patients to 528 patients for the same time period while 1527 new patients were authorized for OT. The median wait time went from 91 days to 52 days. The Sudbury and North Bay branches were the most successful in reducing their waitlists for PT and OT, while Timmins and SSM saw a smaller reduction. Ideas for Improvement: Introducing new roles to facilitate improvements in referral processing Continued focus on reducing patient wait times for therapy services, implementing guidelines, and building capacity Data Source: Business Intelligence Business Intelligence > NE Reports > Indicators > Category: MSAA 2011-14 > MSAA - Metric 90th Percentile Wait Time from Community Setting to Community Home Care 160 140 Wait Time for SRC 92 Patients Referred from Community Settings to Community Home Care Quality Improvement Plan Objective: Wait time for a community home care service for Rehab patients (SRC 92) will be reduced. 120 100 80 60 40 20 0 Actual SRC 92 Quarter/Year QIP Target BETTER result: 147.8 days 20 QIP Performance Goal: 67 days As of March 31, 2014, the number of patients waiting for therapy services decreased from 1572 to 998 with over 82% of those remaining waiting for Occupational Therapy and Physiotherapy services. Strategies focused on the rehabilitation service population can have greatest impact on overall wait time. Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 14 of 44
# of Clients ACCESSIBLE 1800 1600 1400 1200 1000 800 600 400 200 0 Indicators and Trends for Wait Time for CCAC Services APR MAY JUNE Therapy (SRC 92) Waitlist JUL AUG SEP OCT Month, Year NOV OT PT SW SLP Nutrition DEC JAN FEB MAR Measure Target for Fiscal Year 20, End YTD # of clinics held for adult rehab services # of patients served in adult rehab clinics # patients on adult rehab wait list 13 28 (10% over 2012-13 results) 207 221 (10% over 2012-13 results) 1147 (10% over 2012-13 results) 998 In, 8 therapy clinics were held in Sudbury and North Bay reaching 52 patients. Results for the fiscal year have met and surpassed targets with 28 clinics held serving 221 patients. This has resulted in fewer patients on the adult rehab wait list, again meeting and surpassing the target. Efforts were concentrated on providing services to patients who had been on the waitlist for the longest time. As previously noted, while the number of patients on the wait list decreased significantly, this negatively affected the wait time metric as patients are being pulled off the waitlist and provided their first visit. Over the last fiscal year, challenges and/or barriers encountered to implement this change initiative and meet targets include: Patient accessibility to clinics Reduced clinician availability to cover clinics. New staff hired in the summer and fall were focused on orientation and training to increase their proficiency with their caseloads. Care Coordinator education about the clinics to increase the number of referrals and optimize the number of patients served in each clinic. Data Source: Business Intelligence Business Intelligence > NE Reports > Indicators > 90th Percentile Wait Time from Community Setting to Community Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 15 of 44
# of Days ACCESSIBLE Indicators and Trends for Wait Time for CCAC Services Home Care Business Intelligence > NE Reports > Patient Services > Category: Management > Service Waitlist Analysis 12 10 8 6 Wait Time (Days) from Hospital Discharge to Service Initiation BETTER 20 Value: 7 days (last available report) 20 Target: 6 days 20: Performance Standard: 6.6 days This M-SAA indicator defined by the LHIN measures the number of days from the hospital discharge date to the first non-case management service for patients whose referral source was the hospital. 4 Analysis: 2 0 11-12 11-12 Quarter, Fiscal Year As this result is from, 20, it meets the 20 target (7) and is within performance standard. Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. CCAC is not able to replicate baseline numbers and identifies a large variance in referral to counts. Six month delay in data availability will impact reporting abilities. Data Source: Ministry of Health and Long- Term Care, MSAA Indicators, MSAA 1.1.access_wt1 Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 16 of 44
Number of Clients ACCESSIBLE 6. ACCESSIBLE: Access to long-term care home What we want Consequences if we don t get it To whom does this matter? Short wait times to get into a long-term care home. If the person is waiting at home, a heavy burden could be placed on loved ones who are caring for the individual. If the person is waiting in hospital, then the hospital bed is used unnecessarily, which can lead to emergency department overcrowding and wasted resources. Patients in north eastern Ontario who are currently on the wait list for placement into a long-term care home, along with their families and caregivers. To do our best to allow people to get their first choice of long-term care home. Being placed in a second or third choice home may mean being placed further away from loved ones or in a home that does not specialize in meeting one s ethnic, cultural or medical needs. Residents can move to a higher-ranked choice later, but that can be inconvenient and disruptive to the residents continuity of care. Indicators and Trends for Access to Long-Term Care Home As of March 31, 2014: Patients on wait list including transfers: 1890 2200 2100 2000 1900 Total Long Stay Wait List, with Transfers BETTER The number of individuals waiting for initial placement has remained relatively stable over the last 12 months but still significantly exceeds the number of available beds in Long-Term Care Homes (LTCH). There are minor fluctuations based on the number of applications pending for placement and the number of available LTCH beds at any point in time. 1800 1700 1600 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Month, Year Data Source: Business Intelligence > NE Reports > Patient Services > Category: Placement > Placement Waitlist Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 17 of 44
% of Clients Placed ACCESSIBLE 80% 70% 60% 50% 40% 30% 20% 10% Indicators and Trends for Access to Long-Term Care Home % Placed to 1st, 2nd and 3rd Choice of LTC Home April 2013 to March 2014 Average: 1 st Choice: 55.3% 2 nd Choice:23.4% 3 rd Choice: 10.8% The percentage of patients placed into their 1st choice of LTC home remained consistent and within normal variation in the 12-month period from April 2013 to March 2014. 0% Apr May Jun Jul Aug Sep Month, Year Oct Nov Dec Jan Feb Mar Data Source: Business Intelligence > SSRS Report List > Indicators > Other Misc. Indicators > LT Placements by Ranking 1st Choice 2nd Choice 3rd Choice Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 18 of 44
% of complex clients EFFECTIVE 7. EFFECTIVE: Keeping people healthy in home care What we want How to get it Consequences if we don t get it To whom does this matter? Patients receive effective home care to improve their health, maintain it or prevent deterioration to avoid hospitalization and/or admission to long-term care homes. Promote activities to maintain health and independence (e.g. preserving bladder function and mobility, controlling pain, preserving communication ability, memory and thinking abilities and avoiding depression and weight loss). Patients experience loss of independence, reduced quality of life through admissions and/or readmissions to hospital and/or admission to long-term care home. All CCAC patients 80% 75% 70% 65% 60% 55% 50% 45% Indicators and Trends for Keeping People Healthy in Home Care Complex Patients Remaining in the Community for 60 Days or More Post Hospital Discharge BETTER Value (as of March 31, 2014): 62% Target: 60% Performance Standard: <60% and 54% The percentage of complex patients who are maintained in their home met and exceeded the target in March 2014. Through the Integrated Discharge Program coupled with the Home First philosophy, local health service partners are creating a cultural shift in practice to reduce the number of ALC-LTC patients. Note: this is a new M-SAA indicator in 20. 40% APR May JUN JUL AUG SEP OCT Month, Year NOV DEC JAN FEB MAR Data Source: Business Intelligence > Indicators - Other Misc. Indicators > Percentage of Complex Patients remaining in Community for 60 plus days post hospital discharge Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 19 of 44
# of Patients % of patients EFFECTIVE Indicators and Trends for Keeping People Healthy in Home Care 100% Patients placed in LTC Home with MAPLe SCORES High or Very High (i.e. appropriately) Quality Improvement Plan Value = 83% * M-SAA 20 Target: 79% M-SAA 20 Performance Standard: > 75% QIP Performance Goal: 84% 90% 80% 70% BETTER The result for this indicator exceeds the M- SAA target and performance standard. The QIP Performance Target is greater than the M-SAA target and has not been met in this quarter. The chart will continue to reflect the M-SAA target and performance standard. 60% 50% 40% Quarter, Fiscal Year Most people placed into a LTC home have very heavy needs that require them to be in that type of setting; however, one in four people placed in LTC have relatively lighter needs. Alternatives, such as Assisted Living, might be possible if they were available. An ongoing review of our placement crisis patients is being done to ensure that these patients are high or very high. *Note: Changes were made to the calculation methodology of this indicator to align with the provincial methodology effective 20. 600 500 400 300 200 100 0 Number of Patients Eligible and Waiting For Assisted Living 97 MAR 175 89 APR 145 233 May 273 321 179 191 Jun Jul 359 217 228 Aug 394 Sep 438 246 Month, Year Oct 478 503 539 535 531 259 268 263 246 246 246 Nov Dec # of Eligible Patients # Patients Waiting Jan Feb Mar BETTER QIP Improvement Initiative #1: Increase the number of patients on the Assisted Living Program roster. Target: Steady increase each quarter in the number of eligible patients referred to Assisted Living who are on the roster for the Assisted Living Program. As the program is just being implemented, this target will help to build the baseline of patients waiting for and accessing the program. With more patients accessing Assisted Living resources, more CCAC resources are available to maintain other patients in the community who may otherwise require LTCH placement. Result = 531 eligible patients as of March 31, 2014. Analysis: The number of patients waiting Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 20 of 44
EFFECTIVE Indicators and Trends for Keeping People Healthy in Home Care for assisted living and found eligible for Assisted Living has leveled off in and the number waiting also stabilized. These numbers indicate that more patients are being referred and waiting for assisted living prior to completing LTCH applications. The current challenge is lack of availability in the Assisted Living program. If increased funding does not occur then we will continue to see the list of eligible patients grow with little to no movement. A community crisis escalation process was implemented in December and fully rolled out to all branches in January. This process will assist with ensuring that the most appropriate patients are placed into LTC. Ongoing monitoring of MAPLe scores continues. QIP Improvement Initiative #2: All Care Coordinators are required to complete the e-referral to Adult Day Program and Assisted Living Program education module. Target: 90% of Care Coordinators have completed the education module. This training is mandatory for Care Coordinators. Final Result: 80% of Care Coordinators have completed the education module, representing the result of the focused training effort in. As this training is not in the Learning Management System, it is not practical to document further progress toward meeting the target. The training has been rolled into the orientation program for new Care Coordinators. Data Sources: Business Intelligence > NE Reports > Indicators > MSAA 2011-2014 > MSAA - Patients Placed in LTC with MAPLe High or Very High as Portion of Total Patients Placed Assisted Living Report Business Intelligence special report Talent Development Report Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 21 of 44
% of all patients # of Patients EFFECTIVE 3400 3300 3200 3100 3000 2900 2800 2700 2600 2500 2400 Indicators and Trends for Keeping People Healthy in Home Care Number of patients with MAPLe scores high and very high living in the community supported by CCAC Quarter, Fiscal Year Value: 3333 patients 20 Target: 3,000 patients 20 Performance Standard: > 2,850 patients The number of patients with high and very high MAPLe scores living at home with CCAC support exceeds the established target. Data Source: M-SAA Quarterly Progress Report to the NE LHIN: (2011-2014) 23% 22% 22% 21% 21% 20% 20% 19% 19% Percentage of patients with MAPLe scores high and very high living in the community supported by CCAC Quarter, Year BETTER Value: 21% 20 Target: 22% 20 Performance Standard: <22% and 19.8% The percentage of all patients with high and very high MAPLe scores living at home with CCAC support increased in and is within the performance standard. This M- SAA indicator and target are new in 2013-14. Data Source: Business Intelligence > Indicators > Patients in Community with MAPLe High or Very High Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 22 of 44
Average ALC Acute Rate EFFECTIVE 30% 25% 20% 15% 10% 5% 0% Indicators and Trends for Keeping People Healthy in Home Care NE LHIN ALC Acute Rate 4 Hub Hospitals Quarter, Year BETTER average: 20.7% Target: 17% Performance Standard: >17% and 18.7% Analysis: The average ALC-Acute days is over the performance standard for 20. Ideas for Improvement: NE CCAC Directors, Care Coordination, continue to work closely with all four HUB hospitals in the district (North Bay Regional Health Centre (NBRHC), Timmins and District Hospital (TDH), Health Sciences North (HSN) and Sault Area Hospital (SAH)). Regular meetings of stakeholders (NE LHIN, hospitals and NE CCAC) have supported greater problem-solving at a system level. Strategies implemented or in process include Weekly ALC Rounds, executive escalation process and Discharge Bullet rounds. Technological strategies are also being implemented such as HPG (Client Viewer) and ED-Notification ALC Long Stay/Hard to Serve Committees implemented in Sudbury, North Bay and Sault Ste. Marie. Hardto-Serve Committee being reconsidered for TDH. Home First refresh educational sessions were held with hospital/community staff and physicians at NBRHC, SAH and TDH. Unfortunately some of the new Timmins LTC beds remain idle. The provider is working with system partners to consider alternate bed preference to support crisis designation transitions from TDH and community. IDP-QI Proposal approved by ET is going out to partners for support Note: For consistency with the M-SAA, quarterly results will be reported rather than monthly results. Data Source: M-SAA Quarterly Progress Report to the NE LHIN (2011-2014) Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 23 of 44
# of Events / # Clients (1000s) SAFE 8. SAFE: Avoiding harm in home care and the community What we want How to get it Consequences if we don t get it To whom does this matter? No risk events and complete patient records to identify high risk patients Implement preventative measures to minimize risk events to the extent possible. Monitor completeness of patient records. Risk of temporary or permanent disability and death; more emergency department visits and hospitalizations. High risk patients may not get the help they need in an emergency/disaster situation All patients, caregivers and family members. Those identified as long-stay home care patients are at particular risk. Indicators and Trends for Avoiding Harm in Home Care and the Community 3.5 3.0 Total Number of Client Risk Events per 1000 Clients R12, Apr-13 to Mar-14 Result: 1.7 risk events per 1000 patients (average). Analysis: The number of risk events reported per 1000 patients is within expected normal parameters based on past history with minor fluctuations above and below the trend. 2.5 2.0 1.5 1.0 0.5 0.0 APR MAY JUN JUL AUG SEP OCT Month, Year NOV DEC JAN FEB MAR Ideas for Improvement: The Quality & Risk Team continues to work with staff members who submit reports as well as those who are responsible for the investigation and resolution. A group of directors and senior leaders is developing a more effective method of communicating and escalating high risk and adverse events to internal stakeholders. Initial work is underway to improve the process for investigating risk events and identifying root causes. Data Source: Risk Event and Feedback System (Report 10-005) Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 24 of 44
Number of Risk Events Number of Client Risk Events SAFE Indicators and Trends for Avoiding Harm in Home Care and the Community Number Client Risk Events by Specific Event Type (Top 5) R12, Apr-13 to Mar-14 Analysis: The top 5 patient risk events by specific type remain consistent with previous reporting periods. 80 70 60 50 40 30 20 10 76 59 40 38 27 Ideas for Improvement: Service Delivery Missed Visits: CCAC and service providers strive to reduce missed visits. Service Delivery Other: Wound Therapy Project is impacting service delivery quality through improving wound management. Fall: Introduction to Falls Prevention e-learning module launched on LMS. Medication/Fluid Error: All events involving fluid or medication errors are reported to the Medical Supplies and Medication Management Improvement Team. 0 Service Delivery -Missed Visit Service Delivery- Other Fall Specific Event Type Medication/ fluid error Other Data Source: Risk Event and Feedback System (Report 06-003) 60 50 40 30 20 10 0 Severity Level Near Miss Low Risk Medium Risk High Risk APR MAY Number of Risk Events by Severity Level R12 Apr-13 to Mar-14 JUN JUL AUG SEP OCT Month, Year NOV DEC Definitions JAN FEB MAR High Risk Medium Risk Low Risk Near Miss An event or deviation that is detected and remedied before an incident occurs, avoiding harm/injury/impact to the patient, CCAC, or to the service provider/organization. The event has actual, or potential for minimal harm/injury/impact to the patient, the CCAC, or to the service provider/organization. The event has actual, or potential to result in some harm/injury/impact to the patient, the CCAC, or to the service provider/organization. The occurrence has caused a delay in service or resulted in additional costs or dissatisfaction with CCAC services. The event has actual or potential for significant harm/injury/impact to the patient, the CCAC, or to the service provider/organization, has the potential for litigation and/or lack of confidence in CCAC services. Analysis: Of the 82 patient risk events reported in, 25 were reported as high (30.4%), 27 reported as medium (32.9%) and 26 reported as low (31.7%). The remaining 4 reports were near miss (4.9%). The 25 reported as high were categorized as follows: Medication/Fluid Error (6) Service Delivery-Other (4) Service Delivery-Missed Visit (3) Treatment (3) Communication/Reporting (2) Fall (1) Medical Equipment/Supplies (1) Suicide Attempted/Threat (1) Unsafe Client Environment (1) Verbal/Physical Abuse (1) Other (2) Note: Missed visits causing patient harm are documented in the Risk Event and Feedback System (REFS) whereas missed visits where there is no patient harm are captured in CHRIS. Ideas for Improvement: Each patient risk event is reviewed for accuracy and appropriate follow-up when submitted. A review of patient safety risk events that remain unresolved occurs regularly with follow-up with Quality, Risk and Patient Safety Report, Fiscal Year 20, Fourth Quarter Page 25 of 44