Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/26/2018 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. Insert Organization Name 1
Overview The University of Ottawa Heart Institute is a unique academic facility with a responsibility to provide specialized cardiac care to patients of the Champlain region, the province of Ontario and nationally for selected procedures. We believe excellent care is achieved by supporting a full continuum of care from prevention, to acute care and rehabilitation. We work in partnership with facilities in our Local Health Integration Network to ensure all patients have access to care while continuing to support care close to home. Supporting excellent care, leadership in ground breaking research and the education of future health care professionals are our main goals. The objectives of this plan are as follows: -Ensuring all patients in the Champlain Local Health Integration Network have access to a similar high standard of cardiac care regardless of location through the support of our regional partners -Improving access to our specialty services -Improving the patient experience through patient and family centered programs -Ensuring patient safety In 2018, our focus is on improving access to care, patient safety, patient centered care and exploring innovative ways to treat our patients. Describe your organization's greatest QI achievements from the past year There were number of QI successes in the past year, not only in relation to the quality improvement plan but also as a result of our accreditation preparation, enhanced patient engagement strategy and our extensive work with heart teams. A highlight of the last year was receiving an exemplary standing through Accreditation Canada. We expanded our Key Learner project to all admitted patients in the Institute. This program has demonstrated improvements in knowledge translation and transitional care for patients and families. We have had a significant improvement in discharge medication reconciliation through the engagement of physicians. We have expanded our telehome monitoring program to highrisk surgical patients. Finally we have rolled out a LHIN-wide atrial fibrillation program including standardized resources and patient education materials. Resident, Patient, Client Engagement and relations Our University of Ottawa Heart Institute Patient Partnership Committee (UPP) continues to be very involved in the development of the QIP, providing insight and advice on all of the selected projects. This year we have also included a patient member on our Board Quality of Care Committee to ensure that the patient voice is heard at all levels of our organization. Collaboration and Integration As the regional provider of tertiary cardiac services, we will continue to enhance our hub and spoke model for the region. We will continue to support our Regional Guidelines Applied to Practice program for heart failure and ACS, our Regional Smoking Cessation program, our Regional Telehome Monitoring program. We will expand the tools and resources for atrial fibrillation. We will provide LHIN-wide education via our annual cardiac educational symposium, which is free of charge for all of our LHIN partners, and continue to look for new opportunities to work with our partners to improve cardiac care in our region. Engagement of Clinicians, Leadership & Staff This year s QIP was informed by several multidisciplinary committees, particularly our heart teams, which all have a quality mandate. Senior management approved the specific priorities of the QIP based on alignment with our strategic priorities. Finally, our multidisciplinary Board Quality of Care Committee had the opportunity to review, make suggestions and provide final approval of the plan. Insert Organization Name 2
Population Health and Equity Considerations The UOHI continues its commitment to population health through the work of the Prevention and Rehabilitation Department, our Canadian Woman s Heart Health Centre and through heart health advocacy work. In Prevention and Rehabilitation, we continue to expand the Ottawa Model for Smoking Cessation internationally. We have a regional Cardiovascular Disease Prevention Network, which has expanded its Healthy Foods in Hospitals program. A heart health education series was developed and will be implemented; and a Healthy You program (group weight management intervention) has been launched in collaboration with a family health team. Our Canadian Women s Heart Health Centre is a multi-level, women and healthcare provider focused centre created to improve the perception, understanding, care and outcomes related to cardiovascular health and disease in women. They have launched the IMPROVE Post-partum Pilot program to improve cardiovascular risk screening, education and follow up in post-partum women at risk. We have launched a women@heart peer mentoring program. UOHI is hosting their second Ottawa Women s Heart Health Summit, which will bring together approximately 250 national and international experts and stakeholders to further advance women s heart health. The summit is focused on transforming and enhancing Canadian women s lives through research, awareness, policy development and care. Access to the Right Level of Care - Addressing ALC Our ALC rate is quite low. We continue to monitor it and participate in the Home First program. Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder This year we are putting an educational focus on opioid prescribing and treatment of patients with substance use disorders. Our physicians will be completing an education module developed by an expert in opioid prescribing. Our nursing and physician staff will be offered several educational sessions focused on issues, best practices and considerations when treating patients with substance use disorders. Workplace Violence Prevention We continue to make staff and patient safety a top priority this year. We will standardize our violence flagging practices and ensure that non-clinical staff are as informed of risks as the clinical staff when a potential for violence is identified. We will increase staff awareness by promoting available education opportunities on topics related to non-violent crisis intervention. We are embarking in a comprehensive risk assessment of our first floor this year to identify opportunities to improve staff and patient safety. As we continue to develop and roll out our new EMR, we will be researching a validated risk assessment tool that will assist staff in identifying patients who are at a higher risk of displaying aggressive or violent behavior. Our goal is to ensure fair and compassionate care for our patients while decreasing risk to our staff and physicians. Performance Based Compensation We have ensured that our performance based compensation remains consistent with other institutions of our size. For each of our executives, the percentage of salary at risk is as follows: CEO - 10% of base salary is linked to achieving targets set out in our QIP EVP - 5% of base salary is linked to achieving targets set out in our QIP VP - 5% of base salary is linked to achieving targets set out in our QIP Given their importance to the organization and to the delivery and quality of exemplary care, the following indicators are recommended to assess performance: A mandatory indicator related to workplace violence: Insert Organization Name 3
Devise a plan to ensure that non-clinical staff can easily identify patients that have been previously flagged as violent. Current Results: New Target for 2018-19: 80% of staff trained in new process by Dec. 2018 A priority indicator : Risk-adjusted 30-day all-cause readmission rate for patients with heart failure Review each heart failure patient against the American Heart Association checklist to identify improvement opportunities to be added to our 2019-20 Quality Improvement Plan. Current Results: New Target for 2018-19: 80% of Heart Failure patients will be screened with the AHA checklist An additional indicator : Rate of surgical site infections for all major procedures. Review surgical site infection patient population to determine if there were complications from pneumonia. Current Results: new Target for 2018-19: 100% of FY 2017/18 charts reviewed by November 2018 100%= 90 to 100% 50%= 80 to 89% 0= Below 80% A custom indicator : Training on Indigenous patient needs Provide physician and management training on Indigenous patient needs Current Results: new Target for 2018-19: 80% of physicians and management staff will complete Indigenous training by March 2019 Percentage of Compensation Percentage of staff trained Contact Information I have reviewed and approved our organization s Quality Improvement Plan: Mr. Paul LaBarge UOHI Board Chair Mr. Richard L'Abbé UOHI Quality of Care Committee Chair Dr. Thierry Mesana UOHI Chief Executive Officer Insert Organization Name 4
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 Insert Organization Name 5