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

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 2/13/2018 Brockville General Hospital 1

Overview At Brockville General Hospital (BGH), we provide Acute Care (Emergency, Intensive Care, Medical/Surgical Care), Complex Continuing Care, Rehabilitation, Palliative Care, Mental Health and Additions, and a Women and Children s Program. We offer ambulatory and specialty clinics, including Orthopaedics, the Brockville Cardiovascular Program, Acute Stroke Clinic, and Ontario Breast Screening. Our Mental Health program includes Inpatient Care, the Mental Health Crisis Team of Leeds and Grenville, and the Assertive Community Treatment Team of Leeds, Grenville and South Lanark. We are national leaders in Restorative Care/Enhanced Activation, innovators in Post-episode Cardiovascular Rehabilitation, regional partners in our Acute Stroke Unit, and pioneers in providing community-based Hospice Palliative Care. At BGH we are committed to patient-centred care. As a result of the appointment of a Provincial Supervisor, we are stronger. We have improved the alignment of our financial and operating needs to support the delivery of safe, quality patient care. Further, we are building on this promise and expanding our services through our Phase 2 Redevelopment Project, where we will see all services and programs on a single campus. We are committed to the continuous advancement of our care and services. This year s Quality Improvement Plan is a reflection of that promise as we build on the targets outlined in our 2017/18 Plan. In our 2018/19 Quality Improvement Plan, we will focus on the following Mandatory, Priority, and Additional Indicators: Mandatory: Incidents of Workplace Violence Priority: 30 Day Readmission Rate for patients with COPD 30 Day Readmission Rate for patients with a Mental Illness or Addiction Patient Experience: Did you receive enough information when you left the hospital? Patient Experience: Would you recommend our Emergency Department? Additional: Percent Discharge Summaries sent from hospital to community care provider within 48 hours of discharge Describe your organization's greatest QI achievements from the past year Quality Improvement Project: Standardize hospital Rainbow Carts (neonatal & pediatric resuscitation carts) ORGANIZATIONAL ASSESSMENT: Every second counts in a pediatric emergency. Therefore the equipment and supplies used during a Code Pink need to be ready and in the hands of clinical and medical staff at a moment s notice. The potential for a negative outcome grows when time is consumed searching for supplies and equipment. Brockville General Hospital 2

PHYSICIAN/STAFF ASSESSMENT: During a code the environment can be chaotic, confusing and frustrating especially when equipment isn't readily available or working properly. The current process lacks standardization and there is no system in place to support the team. Using Continuous Improvement processes, a multidisciplinary team was established to examine the current practice and identify and remove non-value added work to create a more efficient and effective working environment during a crisis situation. Goals: 1. Optimize the process during a code situation by improving systems pertaining to stocking, workflow and quality assurance 2. Improve post code process to ensure readiness for another. 3. Reduce work variation by assigning accountabilities using Lean concepts. 4. Reduce cost and non-value added work PROCESS FOR IMPLEMENTATION: A Pediatric Working Group was convened, comprised with representation from: Emergency, Women & Children's & Surgical Services Nursing Materials Management Respiratory Therapy Pediatricians Professional Practice Pharmacy Security Maintenance - Multidisciplinary teams met weekly over the course of 4 months - Sub-groups were established to focus on Supplies, Medication, Policy, Education - Strong Physician and Leadership commitment throughout the process Walk a Mile in my Shoes The team made sure that no rock was left unturned. They designed and reviewed the process many times, always referring to the subject matter experts of each particular step to help understand best practices and remove any non-value added steps until they felt that all gaps were closed. Shared multidisciplinary accountability through the process Standardized system that can be used in any location of the Hospital Regular quality assurance Improved standards of practice Brockville General Hospital 3

Improved accountability structures were instituted: The right person doing the right work at the right time Colour coordinated trays and drawers based on the Broeslow System Standardized process for checking supplies and equipment in, around and supporting the carts Process for bringing the cart to a non-clinical area Resource Binder for reference and ongoing education Overall engagement was improved. In total there was over 380 multidisciplinary hours dedicated to this improvement. An implementation group helped to educate staff on these new processes Ultimately, a Pediatric Rainbow Cart policy was created and signed off by staff to enable leadership to ensure compliance with new processes. PROJECT CHALLENGES: Meeting timelines due to other projects Obtaining supplies (having to order many supplies in left us at the mercy of the seller) Technological difficulties Project occurred over Summer months so we had to contend with Holidays Supporting teams through change Current Emergency Preparedness processes looked at the response plan from an organizational perspective post code which left gaps of Clinical expertise during a code situation. This ultimately led to the creation of the Pediatric Rainbow Cart Policy to support the Code Pink Response Plan OUTCOMES: Policies & Procedures: Pediatric Rainbow Cart Policy, Code Pink Response Plan Education: Pediatric Rainbow Cart Resource Binder, Creation of Pediatric Rainbow Cart Video, and Development of Champion Education, Staff Education and Physician Education EVALUATION: Post-Redesign Impact: Pediatric Rainbow Cart process is organized, consistent across the organization, and easy to follow. Allows for safer response and quality assurance tracking: The completed checklists are scanned into a file on Share Point for quarterly review. Post code, an unusual occurrence report is completed by the recorder for debrief, review, and continuous improvement purposes. Brockville General Hospital 4

Resident, Patient, Client Engagement and relations The Quality Improvement Plan is a standing agenda item for our Patient and Family Advisory Council (PFAC). Results are shared regularly with the PFAC, and discussion takes place with respect to successes and challenges with meeting the targets. The PFAC is invited to give feedback during the QIP development process each year. We also review our patient satisfaction data, specifically reviewing all comments submitted via NRC Health Patient Experience Surveying. Some of our Emergency Department patients are telling us that they feel our wait times are too long, they feel rushed during their visit, and they do not get enough attention from staff during their visit. However, other patients are telling us that they had short waits, received excellent service (welcomed and respected), and have noticed that our service has improved. This tells us that our improvement efforts are on the right track, and that we should continue with these efforts in order to provide consistently positive experiences to our patients. Our Acute Inpatient patients are telling us that while we mostly are doing a great job with providing high quality care by wonderful staff, some areas of improvement are with providing enough information during their stay and at discharge, not discharging too soon, wait times for call bell response, and level of noise and distraction on the unit. This feedback lead to the continued inclusion of the 2 Patient Experience indicators from 2017/18 for our 2018/19 QIP. Collaboration and Integration Acute Stroke Unit: BGH continues to dedicate six beds on 1East as an Acute Stroke Unit. The purpose of these beds is to better allocate stroke specific resources to improve our patient outcomes. The Lanark, Leeds & Grenville (LL&G) Integrated Stroke Care Project implemented a collaborative approach to stroke care, by having patients come to BGH for their acute care stay. This change was made in collaboration with the Stroke Network of Southeastern Ontario to meet the recommendations for the Best Practice Guidelines for Acute Stroke care. Thousand Islands Health Link (TILH) Community Table: BGH is committed to participating in the TILH Community Table, which is an Advisory Committee to support building a health care system within the TILH. The Community Table brings together BGH, local primary care physicians, the Upper Canada Family Health Team, the Prescott Family Health Team, the Athens District Family Health Team, the Comstock Family Health Organization, and Brockville Community Family Health Team. The Eastern Ontario Clinical Document Repository (EOCDR): Hospitals within the SE LHIN continue to work towards migrating off the former Eastern Ontario Clinical Document Repository (EOCDR) hosted at BGH to the permanent Connecting Ontario Electronic Brockville General Hospital 5

Health Record solution hosted by ehealth. It is anticipated that all hospitals, including BGH, will be contributing to Connecting Ontario Electronic Health Record by May 2018. Addictions and Mental Health Redesign: The South East LHIN led the Addictions and Mental Health Redesign resulting in the development of three Governance Transition Teams (GTTs), which have been established in Hastings Prince-Edward, Kingston Frontenac Lennox & Addington, and Lanark Leeds & Grenville. Phase 1 is complete, which amalgamated 3 Mental Health service providers (Brock Cottage, TriCas, and Leeds Grenville Mental Health) in the Lanark Leeds & Grenville catchment area. Phase 2, Operationalization, is underway. The work of the SE LHIN AMH Redesign, as an example of successful integration and implementation, was presented at the Addictions and Mental Health Ontario (AMHO) provincial conference by the SE LHIN at the end of May 2017. Very positive response was received related to the overall design and implementation strategy, with inquiries on how to spread to other LHINs and service jurisdictions. Over the last year significant progress has been made. The following work has been achieved: 1. PART C has been signed by Brockville General Hospital. 2. Centralized Intake and Waitlist Structure Phase 1 has been approved and is progressing in Hastings Prince Edward. 3. Common Basket of Services case management, clinical counseling and addictions counseling alignment has begun implementation across the three AMH Agencies. 4. Professional Advisory Committee and Clinical and Quality Sub-committees have been established across SE LHIN and terms of reference either developed or well underway. 5. Lanark Leeds and Grenville Professional Advisory Committee and sub-committee Clinical and Quality committees are well established and meeting regularly. 6. Clinical and Quality Sub-Committee to the Strategic Alliance have been working on Access and Discharge protocols for the Acute Schedule 1 facilities and are also looking at the operationalization of the Part C Contracts. 7. SE LHIN met with lead psychiatrists to discuss the System Psychiatry model implementation on December 7th, with implementation beginning to occur in the new year. 8. In the spring, a Chief Financial/Regional Corporate Services Officer was hired to oversee the operationalization of all Regional Back Office functions and performance. Regional Back Office continues to work towards full operationalization and production for the three AMH Agencies. 9. The new CEO of Peer Support South East Ontario has been identified and is meeting with the AMH agencies across the region regarding the alignment of intentional Peer Support and the AMH Redesign plan. Regional Systemic Treatment Program: Ongoing collaboration with the Regional Systemic Treatment Program, hosted by the South East Regional Cancer program out of Kingston General Hospital, which optimizes chemotherapy delivery to patients. Recently, BGH was able to begin providing more chemotherapy in its Ambulatory Care Unit. This allows patients to receive treatment closer to home. Brockville General Hospital 6

Engagement of Clinicians, Leadership & Staff Over the past year, the 2017/18 Quality Improvement Plan updates have been provided regularly to the Hospital Supervisor, and Senior Leadership Team. In the development of the 2018/19 QIP, we have engaged the Leadership Team and the Medical Advisory Committee to help choose our indicators and develop change ideas. Last year, our Nursing Practice Council drafted a new Vision, Mission, and Values document, which affirms their focus on nursing responsibility and accountability through goals for promoting nursing leadership and a healthy workplace as well as improving patient- and family-centered care through education and communication. These goals align with the quality initiatives included in this QIP. To ensure that everyone in the organization is aware of the 2018-19 Quality Improvement Plan and related objectives, the Senior Leadership Team will communicate regular updates for front line staff, physicians, and volunteers. As well, formal updates for the objectives will be provided by Senior Leadership to the Medical Advisory Committee and Leadership Team. Senior Leadership will assist Managers and Directors in solving challenges or barriers to meet objectives. We believe quality and patient safety is a shared responsibility. We must all work together to achieve our goals and to have a culture that fosters excellence to provide the safest possible care and service for patients. Population Health and Equity Considerations The South East LHIN has established 5 sub-region planning areas as part of the Patients First provincial mandate to focus on population based planning, service alignment and integration, quality improvement and partnership building. The Lanark, Leeds and Grenville Sub-region Integrated Table will provide high level planning, input and oversight related to the priorities and activities of the sub-region that will lead to more patient focused, integrated and responsive care and services at a system level. It will be a driving force of vertical integration in concert with other LHIN-wide initiatives focused on horizontal integration and service delivery. BGH has representation at this table. In the meantime, we are continuing our efforts at providing creative services to help one of our most vulnerable populations, those with Mental Health and Addictions issues. Last year we launched our "Craving Change" dietary program that helped clients understand how their thinking habits affect their eating habits. This year, we launched a Music Therapy for Psychosis program for our Assertive Community Treatment Team (ACTT) clients. The CBT Music Therapy for Psychosis for ACTT clients commenced on March 21, 2017. The group was designated for 9 weeks; the end date was May 16, 2017. Each session was allocated for 1 hour 1500hr to 1600hr. The sessions were taken place at a rental hall, a neutral location. The instructor was a doctorate student from Queen s University. Brockville General Hospital 7

Initially, the group commenced with 17 clients. Similarly to other groups, clients had gradually withdrawn from the group. As such, the group had ended with 8 participants. The content of group consisted of lyric composure, learning of music rhythm, learning and playing various musical instruments, and discussion of psychoeducation on the effects of music on psychosis. All instruments were brought in by the instructor. On a weekly basis, snacks and drinks were provided for the group. Towards the end of the group, evaluation questionnaire were completed. The results given by clients were all positive and qualitative. The results of the group were so favourable that a music group was formed. Clients had joined to perform on the day of the ACTT Annual Talent Show, March 08, 2017. It was an amazing experience for clients to surpass their own personal psychological struggles in positioning themselves before a live audience. It was truly a sight to behold. Certainly, it was a privilege for staff to be part of this process. Since the initial group for CBT Music Therapy for Psychosis was a success, a second round of group had commenced on September 26, 2017. This group was opened to clients from a couple of community programs, however they unfortunately did not gravitate to CBT Music Therapy for Psychosis. Nevertheless, 3 clients had continued to attend group from beginning to end. Due to a few attendees, the group was shortened to 5 weeks, ending on October 24, 2017. Despite the above, the group was able to complete a creation of music lyrics and rhythm of a song, identified as The White Storm. Participants were quite proud of their work. Access to the Right Level of Care - Addressing ALC As of 2011, the Leeds, Grenville, Lanark (LGL) Public Health Unit (PHU) had 24.3% of the population 65+ living alone in a private dwelling. In Brockville, this subpopulation amounts to 34.2% of the total population, the third highest rate of individuals 65+ living alone in the SELHIN, which holds an average of 24.1%. Both regionally and the SELHIN have higher rates than Ontario s average of 22.8%. (sedatacentre.ca, Retrieved March 29, 2016) Anecdotally, we are seeing patients who are on average older, more frail, more complex medically, and with fewer social supports. This presents a challenge with managing ALC rates, as the hospital and the Southeast LHIN Home and Community Care (SELHINHCC) need to ensure all possible avenues for community supports are accessed in order to discharge elderly patients back to their home, rather than staying in hospital awaiting a long-term care bed. At BGH, the SELHINHCC Care Coordinator and the Patient Flow Coordinator work closely together on transitioning patients back to community settings. When a patient is at risk for remaining in hospital, a Home First meeting occurs involving the patient, family and caregivers. During this meeting we examine returning to the pre-admit destination with increased home supports (Waiting at Home, Extraordinary Circumstances Programs) and Community Services and beginning the application process to LTC from home. When home is not an option, we review alternate discharge destinations including Retirement Home or family member home. Brockville General Hospital 8

In the event that all discharge destinations are fully reviewed and no appropriate location is available we begin the discussion of applying to Idle Beds in LTC as well as completing an application to the facilities of their choice. The hospital requests patients to apply to the maximum number of facilities (5) and patients are encouraged to apply to at least one short wait-listed facility. We also review with patients that if function improves over a longer stay in hospital, we will need to re-assess for an appropriate discharge plan. All patients who are Alternate Level of Care are called when an appropriate Idle Bed becomes available to offer this as an option. Those who remain in hospital longer term are reviewed by Patient Flow and SELHINHCC monthly for discharge potential. Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder On January 31, 2018, BGH held a community education session on the Quality Standards for Opioid Use Disorder (Opioid Addiction) from Health Quality Ontario (HQO). Co-presenters were Dr. Malone, our Chief of Staff, and Dr. Everett, a community family physician. We had approximately 65 attendees to this event, from various community partners such as Lanark Leeds Grenville Addictions and Mental Health, Upper Canada Family Health Team, Change Health, Grenville OPP, Brockville Police, Health Unit, Brockville Mental Health Centre, and LHIN Home Care, in addition to BGH employees and various family doctors from the area. Informal feedback from participants was that they enjoyed the presentation and the information presented. The presentation slide deck, which included the Quality Standards for Opioid Use Disorder from HQO, was sent to the participants after the event for widespread distribution of the Standards. Canadian Institute for Health Information (CIHI) released a bulletin on February 14, 2018 which provides guidance to physicians for how cases of opioid overdose should be documented in the patient's health record. Properly documenting cases of opioid overdose ensures that all cases are captured by the coding team, and are therefore reported to CIHI as required. These guidelines were shared with our credentialed staff so that we can be sure we are reporting completely and accurately to assist with national data collection about this serious health issue. Workplace Violence Prevention The Brockville General Hospital is committed to providing a safe, healthy, and supportive working environment for our employees/staff and affiliates in accordance with the provisions of the Occupational Health & Safety Act. Our relevant policies include F-80 Violence in the Workplace Prevention Program, F-85 Harassment and Discrimination policy, and Code White- Violent/ behavioural situation response. Our policies apply to all hospital employees, volunteers and affiliates carrying out business on behalf of the hospital wherever that business may be conducted in the workplace. The Violence in the Workplace Prevention Program is a core component of the hospitals Civility and Respect for Everyone (C.A.R.E) program. Brockville General Hospital 9

In 2017, the hospital s workplace violence and harassment policies were updated using Code of Practice guidance documents issued from the Ministry of Labour. A Behaviour Alert Policy for identifying and managing potentially aggressive client behaviour was revised in 2017, in collaboration with various hospital parties, and approved in January 2018. The Hospital completed updated violence risk assessments for all areas/ departments in the Hospital in 2016. Violence risk assessments have also been periodically conducted throughout 2017 where a department s physical layout, patient characteristics, or conditions of work have changed. Zero Tolerance signage has been posted in prominent areas throughout the hospital, which stipulates that abusive/aggressive behaviour and/or coarse language will not be tolerated by the hospital. No Trespass letters and employee safety plans are issued upon necessity for employee safety in the workplace. Employee Incident Reports and Unusual Occurrence forms are monitored to ensure that correct, prompt reporting and investigations are conducted (if the situation warrants). Performance Based Compensation Executive compensation is linked to Operational Targets and to the Quality Improvement Plan targets and initiatives within that plan. Each Executive, including the Chief Executive Officer, Chief of Staff, and Vice-Presidents, has performance-related pay tied to achieving our QIP plan targets for fiscal 2018/2019. The maximum available performance-related pay for each Executive is five percent (5%) of base salary. The payment of performance-related pay occurs following the fiscal year-end evaluation of performance against targets and determination of results achieved. Targets that are only partially met shall result in (reduced) prorated performance-related pay. Achievement of the targets within the selected Change Idea for each Indicator shall be a shared responsibility of all Executives. Sign-off It is recommended that the following individuals review and sign-off on your organization s Quality Improvement Plan (where applicable): I have reviewed and approved our organization s Quality Improvement Plan Board Co-Chairs (signature) (signature) Jim Cooper Kevin Empey, Supervisor Quality Committee Chair (signature) Denise Kall Chief Executive Officer (signature) Nick Vlacholias Brockville General Hospital 10