Progress Report for 201/ /14 Quality ment Plan: Grey Bruce Health Services Priority Indicator ED Wait times: 90th percentile ED length of stay for Admitted patients. Hours ED patients Q4 2011/12 Q / /1 CCO iport Access Maintainn Total Margin (consolid): by which total corporate (consolid) revenues exceed or fall short of total corporate (consolid) expense, excluding the impact of facility amortization, in a given year. N/a Q /1 OHRS, MOH HSMR: Number of observed deaths/number of expected deaths x 100. Ratio (No unit) All patients 2011/122 DAD, CIHI Performance Performa ance 8.10 8.00 2.15 94.00 0.00 94.00 Progress to 9.1 1.12 99.00 This indicator was for the Owen Sound Emergency Department. We have recently added two psychiatrists to our Mental Healthh Service and have started to seee reductions in delays related to admitting this patient population. Multiple Grey and Bruce county weather events that resulted in total road closures contributed to the longer ED wait time averagee in this fiscal year. Creation of a discharge lounge has supportedd a "pull" process to bring patients waiting in ER to our medicall unit. We will be focusing on this performance indicator againn this year. Total Margin is a performance indicator on our Corporate Balanced Scorecard which is posted for the public on our internet site. Our year end report will be available in June 2014 at which time we will up our progress on this document The corporate HSMR rate for 201/14 as of end of January is i 82. We are pleased to see this reduction and will continue our efforts to maintain this lower HSMR
Percent of staff who identify that they are engaged on the employee satisfaction survey engagement score Maintain Percentage ALC days: Total number of acute inpatient days designated as ALC, divided by the total number of acute inpatient days. All acute patients Q 2011/12 Q2 /1 Ministry of Health Portal Readmission to any facility within 0 days for selected CMGs for any cause: The rate of non-elective readmissions to any facility within 0 days of discharge following an admission for select CMG s. All acute patients Q2 2011/12-Q1 /1 DAD, CIHI Progress to 55.00 57.75 100.00 11.50 11.50 7.50 0.00 -.00 17.29 The reduction in this corporate metric reflects in part, the introduction of the Home First program at the Owen Sound Hospital. GBHS has chosen to continue to work on this initiative and will be focusing on reducing the ALC rates in three of our rural hospitals - Markdale, Meaford and Southampton With a population of elderly residents with a higher preponderance of chronic diseases, a higher readmission rate was expected. During this period of time, the actual versus expected rate of admission (readmission ratio)was 89.4 for all CMG's. For COPD, the CMG that we focused on, the readmission ratio was 89.1. At the same time, our length of hospital stay for COPD was reduced and ER visit rates dropped. We have been working with the Canadian Foundation for Healthcare ment on a Triple Aim Initiative that is supporting further work on reducing readmissions for patients with COPD. This work is foundational to our Health Links initiative.
Inpatient Continuity and Transition patient satisfaction score "From NRC Picker / HCAPHS: ""Would you recommend this hospital to your friends and family?"" (add together percent of those who responded ""Definitely Yes"" or Yes, definitely ) (core-overall) " 61.00 71.00 69.90 85.51 85.00 79.82 Multiple initiatives have occurred at GBHS in support of improving continuity and transition for our patients. Some of these include: Significant effort directed toward the establishment of a corporate approach to our patient education literature that will guide our practitioners in the review of current resources and the creation of new ones. Our discharge lounge project provides a focus on "just in time" review of patient discharge information and followup telephone calls after one day. We have reduced our turn around time for patient discharge reports to be sent out to primary care providers. Our COPD project has implemented formal linkages between the family health team and CCAC to provide timely followup and home visits with this patient population. This average is taken from our patient satisfaction surveys for emergency departments and inpatient departments across our 6 hospitals as well as our mental health psychogeriatric, rehabilitation, day surgery and oncology programs within the Owen Sound hospital. In 201 we utilized experience based design models to obtain a deeper understanding of our patients experience in the Emergency Department. An innovative combination of the Accreditation Tracer and experience based design models was used to conduct Senior Tracers at each of our sites. Learnings from these tracers are being used to redesign processes. In addition, we meet with our six Community Advisory Committees quarterly to discuss community and hospital issues.
From NRC Picker: "Overall, how would you rate the care and services you received at the hospital?" (add together percent of those who responded "Excellent, Very Good and Good") (core-overall) 94.96 94.96 95.1 Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital. 90.00 90.00 82.00 All patients Most recent quarter available (e.g. Q2 /1, Q /1 etc) Hospital collected data CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospital-acquired CDI, divided by the number of patient days in that month, multiplied by 1,000 - Average for Jan- Dec. 201, consistent with publicly reportable patient safety data. 0.28 0.28 0.08 Rate per 1,000 patient days All patients This average is taken from our patient satisfaction surveys for emergency departments and inpatient departments across our 6 hospitals as well as our mental health psychogeriatric, rehabilitation, day surgery and oncology programs within the Owen Sound hospital. We will be continuing to focus on improving our medication reconciliation volumes and report quality in 2014/15 as well as expand our medication reconciliation program on discharge. In 201/2014 GBHS continued to focus on hand hygiene compliance and adherence to Provincial Infectious Diseases Advisory Committee environmental guidelines, which we believe has contributed to our low CDI rates. We had no CDI outbreaks in 201. During this year, we partnered with the Epidemiology faculty at the University of Guelph to complete a research study on blueware reprocessing which resulted in our implementation of disposable bedpans and hygie bags. In 2014/15 we will be introducing PCR technology for C. diff lab diagnostics. This will provide us with more sensitive and timely results which will assist our clinicians in determining appropriate treatment.
Hand hygiene compliance before patient contact: The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by 100 - consistent with publicly reportable patient safety data. Health providers in the entire facility VAP rate per 1,000 ventilator days: the total number of newly diagnosed VAP cases in the ICU after at least 48 hours of mechanical ventilation, divided by the number of ventilator days in that reporting period, multiplied by 1,000 - consistent with publicly reportable patient safety data. Rate per 1,000 ventilator days ICU patients 72.67 80.00 81.00 0.00 0.00 6. Introduction of a tablet based hand hygiene audit software has allowed our hand hygiene auditors to complete their observations more quickly and provide staff with just in time reports immediately following their observation period. Data quality has been supported through the implementation of inter-rater reliability testing. Over 9,000 observations have occurred throughout our 6 hospitals in all clinical settings and patient care environments. Reports are provided monthly to unit managers, providing compliance results by each of the four moments of hand hygiene and by observed professional. Run charts provide trending information. Should targets not be met, fact sheets are completed by the manager, identifying actions to be taken to meet target by next report. These fact sheets are monitored by our Quality of Care Committee. We have been successful in implementing a patient driven audit tool within our ambulatory care department and will be expanding this in 2014-15 into other areas. In 2014-2015 we have set a new target of 88 for all four moments of hand hygiene. In 201-2014 GBHS had 2 cases of Ventilator Associated Pneumonia. Each case is investigated and root causes determined. We will continue to apply the SaferHealthCare Now! bundle elements and monitor this carefully.
Rate of central line blood stream infections per 1,000 central line days: total number of newly diagnosed CLI cases in the ICU after at least 48 hours of being placed on a central line, divided by the number of central line days in that reporting period, multiplied by 1,000 - consistent with publicly reportable patient safety data. Rate per 1,000 central line days ICU patients Rate of 5-day in-hospital mortality following major surgery: The rate of inhospital deaths due to all causes occurring within five days of major surgery. Rate per 1,000 major surgical cases All patients with major surgery 2011/12 CIHI ereporting Tool 0.00 0.00 0.00 7.74 7.74 7.70 We will continue to be compliant with the SaferHealthCare Now! central line infection bundle and vigilantly monitor our patients. We will continue to monitor this patient safety initiative through our surgical program balanced scorecard
Surgical Safety Checklist: number of times all three phases of the surgical safety checklist was performed ( briefing, time out and debriefing ) divided by the total number of surgeries performed, multiplied by 100 - consistent with publicly reportable patient safety data. All surgical procedures 99.6 99.6 99.74 The total number of patients with medication reconciled as a proportion of the total number of patients discharged from the hospital percentage 10.00 90.00 96.00 Decrease in functional decline as measured by Health Outcomes for Better Information and Care (HOBIC) and decreased incidence of Delirium functional decline scores Maintain.50.80 We will continue to monitor this patient safety initiative through our surgical program balanced scorecard As planned, we have three units that have implemented this program. We will be continuing this work into the next fiscal year as part of our multi-year plan to fully implement this important patient safety practice. We have found this inititative to be very resource intensive. Challenge with capturing the original metric specified required us to readjust this performance indicator. We have now defined this indicator as: Percentage of patients 65 years of age and older with no decrease in functional decline as measured by Health Outcomes for Better Information & Care (HOBIC). In our Southampton hospital where HOBIC is implemented we were able to move this percentage from 7.9 to 76.8 this year. We will focus our improvement efforts on this important initiative this year at the Meaford hospital