Overview (MSH) is committed to providing safe, high-quality patient-centred care. Our unwavering focus on improved quality and safety has been driven by a variety of reasons. These include but are not limited to our desire to be known as the hospital of choice; a hospital that provides patients with an extraordinary experience. Our Quality Improvement Plan (QIP) outlines the hospital s priorities in key areas in the upcoming year and sets the stage for establishing MSH as an organization committed to achieving a fully functional culture of safety and quality across the organization. Our areas of focus have been chosen to demonstrate our commitment to improving safety for staff and patients, fostering patient-centredness and delivering high quality services. This plan highlights key initiatives and builds on earlier plans to further improve our performance. With this in mind, the theme for our 2018/19 QIP is Quality in Action : What does quality look and feel like to our patients and their family, the community, staff, physicians and volunteers? What are our patients and their family, the community, staff, physicians and volunteers telling us about the quality of care received and provided? This approach represents an exciting milestone for MSH as we transition to a new strategic plan that aligns seamlessly with our approach to quality improvement. Our refreshed quality improvement agenda is intended to reflect the idea that every person in the organization has the responsibility for and contributes to the quality of care and services. As such, when developing our QIP we engaged and incorporated feedback from our patient advisors, patients and their families, the community, staff, volunteers, physicians and the Quality Committee of the Board. We started by engaging our patient advisors in the development and promotion of the engagement strategy for staff and the community. In 2018/19, MSH will continue to work with the Joint Centres for Transformative Health Care Innovation (The Joint Centres). The Joint Centres is a unique partnership between seven large community hospitals including Mackenzie Health,, Michael Garron Hospital, North York General Hospital, Southlake Regional Health Centre, St. Joseph s Health Centre and Humber River Hospital. The inclusion of the work of The Joint Centres in our QIP is intended to reinforce our commitment to improvement through collaboration and to leverage the knowledge, expertise and experience of our partners to maximize the benefits across all of our hospitals. This year, we will focus on 10 performance indicators, of which five are within the safety dimension. We will continue to work on improving our performance related to medication reconciliation on discharge and reducing our rates of clostridium difficile infections. We will also add a mandatory indicator measuring the overall incidents of workplace violence and add high alert medication errors and falls resulting in harm. Two indicators from the 2017/18 QIP, the number of incidents resulting in lost days and readmissions for selected conditions (HIG), will be removed from the 2018/19 QIP. We will continue to monitor indicators that have been adjusted and/or removed from the QIP internally. In addition, we will monitor six indicators (which are included in the workplan) through our Corporate Quality Committee and actions will be taken as required to ensure sustained improvements. 1
QI Achievements from the Past Year MSH is proud to be focused on quality improvement every day and has undertaken a number of initiatives to improve the quality of our care and services. These initiatives were monitored and progress reported routinely at our Corporate Quality Committee, Quality Committee of the Board and at program/departmental operational committees. Highlights from 2017/18 include: Health Links Program: Since the launch our Health Links program an integrated team of healthcare professionals have worked together to support complex patients. Dedicated resource and standardized processes were a key success factors in helping us to exceed the targeted number of patients we expected to see. Two hundred and sixty-nine patients were referred to the Health Links program, exceeding the target of 195 set out for April to December 2017. Post-Discharge Follow-Up Program: In September 2017, a post-discharge follow-up program was initialized. This pilot program was divided into two phases and was supported by clinical (nurses) and non-clinical staff on modified duties. In phase one, the nurses call to follow-up with patients 72 hrs after discharged home to ensure the patient and family understood and continue to follow post-discharge instructions provided prior to discharge from hospital. In phase two, support staff call patients 10-12 days after the initial phone call to understand and capture their experience of MSH care and services. To-date over 2,650 patients had been called after going home, and feedback from 500 patients has been received and fed back to the units to support improvement activities. This program has been positively received by patients and triggered a change in the way the nurses practice. Spread of Collaborative Care Model: Over the last year, spread of the Collaborative Care Model was initiated on two surgical units and two medicine units. This new model is about working differently while supporting patient and family-centred care. It allows patients to be a key contributor to their plan of care, the goals for their care and their anticipated date of discharge. This is achieved through bedside handover, the use of patient whiteboards and hourly patient rounding. Work continues on sustaining and spreading the model across the organization. Equity At MSH, it is our vision that every person feels respected and welcome when they come through our doors, whether they are MSH employees, patients or community members. It is our desire to achieve an outstanding patient experience. We know this requires a deep understanding of every individual s unique needs. As such, in 2016 MSH launched the Diversity, Equity and Inclusion Collaborative. Over the last year, a strategic plan focused on education and awareness activities, and developing a culture of respect was created. Through extensive internal and external engagement our core values respect, trust, commitment, compassion and courage were established. Next steps include translating these core values into behaviours that will become our code of behaviour and serve as our patient declaration of values. 2
This year s highlights for the Diversity, Equity and Inclusion Collaborative include: York Regional Police International Day for the Elimination of Racial Discrimination (April 2017) This event celebrates diversity while collectively re-affirming our commitment to the eradication of racial discrimination. MSH presented our diversity strategy and sought feedback from the community. Diversity Fair (May 2017) Annual fair to celebrate and enjoy a variety of diversity, equity and inclusion activities. The theme for the 2017 Diversity Fair was Cultures United: Sound and Dance. Places of worship tour (June & September 2017) Our staff joined the York regional police in their tour of places of worship in our area where we learned about the commonalities and differences of various faith communities. Faith and healthcare series (Fall 2017/Spring 2018) Leaders from faith communities present to our staff the various cultural and religious lenses which can influence trust in their care plan and care team. These information sessions help the organization better understand and support our patient needs. Integration and Continuity of Care An important element of how the quality of care is defined is its seamlessness or ease by which patients can transition from one healthcare setting or provider to another. A key goal for MSH is to better integrate and connect care for our patients. As such, we continue to focus on building strong relationships within the health system. A partnership (SHINE) amongst, Southlake Regional Health Centre, and Stevenson Memorial Hospital was launched, to streamline patient records to support patient care across the three organizations. This partnership positions all three organizations to more readily adopt technologies that improve patient care and safety, as well as enhance the patient experience. It marks the first integration of its kind under the province s ehealth 2.0 guidelines. Sunnybrook Health Sciences Centre and have partnered to create a defined model for returning patients to MSH (repatriation) that is safe, timely, and provides an excellent experience for patients and families. Member hospitals will continue with the Joint Centres to share and adapt leading practices of direct relevance to large community hospitals to improve quality, patient safety, value and accountability in healthcare. These shared initiatives include: reducing the rate of clostridium difficile infections, harm reduction developing a playbook for preventing Never Events pressure injuries will be the first prototype and developing a playbook for workplace violence and prevention. 3
Engagement of Leadership, Clinicians, and Staff Studies indicate that employees who are engaged at work, who enjoy what they do and care about the organization they are a part of, deliver better work. At MSH our people (staff, professional staff and volunteers) are our most valuable asset. We believe that a culture where our people are supported and feel honoured to care is the underpinning to providing patients with an extraordinary experience. At MSH, we recognize that fostering a culture that promotes the development of our people and recognizes our champions is critical to keeping our staff, professional staff and volunteers engaged. The development of our QIP involved consultation with a broad range of stakeholders, including endorsement of the Corporate Quality Committee, senior leaders, Quality Committee of the Board and the Board of Directors. We sought input through our QIP staff engagement survey. Multiple staff members responded, over a two week period, with numerous suggestions for improvement/strategies related to preventing falls, improving services in the Emergency Department, asking questions about medications and promoting hand hygiene. On-going engagement of staff is fostered during unit huddles as staff members are empowered to generate ideas to improve their daily work. To-date a number of just do it improvement ideas have been implemented. Go and see activities are now built into the workplan, bi-annually, for the Quality Committee of the Board. This activity serves as a venue for Board members to go and observe quality improvement work and to engage with patients, families, staff, physicians and volunteers about change ideas. We will continue to make linkages between our QIP and the day-to-day activities of our teams. In the upcoming year we will focus on working with teams to identify how the work they do supports the achievement of our goals. As such, we will continue to work on cascading improvement activities and results to all staff. Resident, Patient, Client Engagement Putting patients at the heart of everything we do continues to be a priority for MSH. This is imperative for us as we believe quality improvement is about ensuring the best care and experience for patients and their families. As such, it is imperative that that our approach to quality improvement involves the perspective of patients and their families. At MSH, we continue to actively build and evolve our culture of patient and family engagement to support the delivery of high quality, safe, patient-centred care. Two examples of how we have advanced our work in this area include: Community Engagement QIP video To better engage our patients, family members and our community in the development of the 2018/19 QIP we created a video and launched a survey to gather feedback from patients, family members and the community. The content of the video was created in collaboration with a patient advisor in our Patient Experience Participant (PEP) program and the questions were developed by the members of the PEP program. We received multiple responses, over a two week period, with numerous suggestions for improvement/strategies related to preventing falls, improving services in the Emergency Department, asking questions about medications and promoting hand hygiene. 4
The face and voice of our 2018/19 QIP is that of a patient advisor in our PEP program To promote the importance of and the value we place on engaging our patients, family members and the community in the development of our QIP. App development The diabetic ID iphone app was developed by one of our patients to provide patients with lifestyle management information and prepare them for the transition into our adult diabetes program. Since July 2017, the app is being used by MSH paediatric diabetes clinic patients. To-date there has been over 200 Canadian downloads. Unrestricted visiting Our family presence policy enables 24/7 access for partners in care, allowing them to spend more time with their loved ones. The unrestricted visiting focuses on working with patients and their partners-in-care (family) in care planning and decision making. Organization-wide we continue to implement a patient and family-centred care approach where patients and families are active and equal partners in their care. Thus far, the launch of our PEP program has supported our efforts. In the upcoming year the PEPs will continue to engage in ongoing activities to ensure that we embed the patient voice in all that we do. Staff Safety and Workplace Violence MSH is committed to ensuring a safe, healthy work environment for our staff. We will continue to work with the Joint Centres to implement best practices that will support the prevention of violence and reduction in the number and severity of workplace violence incidents at MSH. In addition we will continue to build on the initiatives already in place across the organization and grow and evolve our approach to staff safety. A few examples are listed below: Electronic incident reporting upgrading the system Workplace violence training for staff including Gentle Persuasive training for staff in high risk areas Code White procedures and regular drills including crisis prevention intervention (CPIT) training for all staff Performance Based Compensation (The information presented below is subject to change after review and approval by the Human Resource Committee of the Board of Directors) The Excellent Care for all Act (ECFAA) requires that the compensation of the CEO and other executives be linked to the achievements of performance improvement targets laid out in the QIP. The purpose of performance based compensation related to ECFAA is to drive accountability for the delivery of the QIP, enhance transparency and motivate executives. The following 10 indicators were selected to be linked to executive compensation as they reflect our commitment to reducing preventable harm for patients and our staff as well as enhancing the patient experience. 1. Readmission for Stroke (QBP cohort) 2. Would you recommend? (ED) 5
3. Alternative level of care rate 4. Implement two choosing wisely recommendations in selected programs/specialities every fiscal year until FY20/21 5. Rate of hospital acquired cases of clostridium difficile infections 6. Medication reconciliation (discharge) for all patients 7. Overall incidents of workplace violence 8. High alert medication errors with harm 9. Number of patient falls which caused harm (mild, moderate) 10. Repatriation of MSH patients from Sunnybrook Health Science Centre within 2.5 days The executives who will participate in the QIP executive compensation program for 2018/19 are: President and Chief Executive Officer Chief of Staff Executive Vice President, Patient Services and Chief Practice Officer Vice President, Finance and Operations Vice President, Support Services and Transformation Vice President, Medical Operations Vice President, Communications and Public Affairs Chief Human Resource Officer The achievement of the annual QIP indicators outlined above account for 10 per cent of the total performance based compensation for the CEO and executives listed above. Accountability Sign-off I have reviewed and approved our organization s 2018/19 Quality Improvement Plan. -------------------------------------------- -------------------------------------------------- ------------------------------------------- Thomas Barlow, Board Chair Drew Gerrard, Quality Committee Chair Jo-anne Marr, President & CEO 6