Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/30/2015 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. 1
Overview Dearness Home, a Municipal home with the City of London, managed by Extendicare who has developed a Quality Framework which is comprised of key components. These key components are illustrated by the supporting structure of a house. This framework provides guidance and direction to assist our home to achieve our mission, vision, standards of care and commitment to our residents. The Framework is built on strategically aligned and interdependent blocks of foundational elements which, combined, enables all of us to achieve our overall mission to enrich the lives of others always. The framework is intended to focus our thinking and activities towards advancing Dearness Homes guiding business principles: quality of resident care, safety and a quality of life experience that is meaningful to each resident. Dearness Homes Mission Dearness is about Compassionate people enriching the lives of others always. Dearness Homes Vision We help our residents and clients live better by promoting quality of life We create remarkable moments through highly engaged and motivated team members Stakeholders know this because we continuously measure, improve, and publicly share our performance Performance monitoring will include but not be limited to the following: - Monitoring key quality indicators - Internal audits - External audits - Program evaluations To successfully advance quality, all staff will be involved in data collection, data analysis, satisfaction surveys and resource utilization analysis. Dearness Home measures and monitors our quality initiatives through the use of data accuracy and quality indicator score cards. Overview Dearness Home, managed by Extendicare Assist has a Quality Framework that outlines the way in which our home is supported to achieve success in all aspects of quality, in addition to the focus on quality of life, safety, compliance and resident satisfaction. Extendicare s assisted homes in Ontario are responsible for driving their quality improvement plan and are working closely with specific consultant leads who support homes in their own area of expertise. The focus of consultant support will be falls, restraints, pressure ulcers, continence, antipsychotics, resident experience and Emergency Department visits. Our strategic direction and the initiatives that support it also closely align with CARF standards and meet the requirements of our LSAA. Dearness Home will continue to focus on the reportable indicators identified below that are impacting residents well being and quality of life, striving towards the Health Quality Ontario benchmarks. Falls Restraints Worsening bladder incontinence Antipsychotic drug use ED visits 2
Dearness Home is currently performing better than the provincial average and HQO benchmark on 1. Worsening of Pressure Ulcers, 2. Resident Overall Satisfaction and therefore we have not included them in our quality improvement plan. However, through our regular monitoring, we will continue to track this indicator to ensure we continue to perform at a high level. Integration and Continuity of Care The success of this QIP requires collaboration with multiple partners which CCAC, the LHIN, BSO, OARC, OLTCA, research partners, and vendors such as Medical Mart and Medical Pharmacies. In addition, our partnerships extend to our Medical Advisor and Attending Physicians and as a teaching facility for the University of Western Ontario for physicians. Dearness Home will be participating in an Antipsychotic study with our Medical Director for 2015. Dearness Home currently through the Activation Department is conducting a resident study with the Java Music Club. Challenges, Risks and Mitigation Strategies There are a number of challenges that could impact our ability to achieve our QIP targets: Dearness Home is a Municipal home and all requests for policy changes or resources must go through the appropriate City of London council votes. Ie Obtaining WIFI for home with levels of City Security. The recruitment of qualified staff in our area often proves challenging. Due to the lack of licensed professionals in our community and the need that all of our colleagues within health care have, at times we do struggle to retain staff. Finally, the acuity level of our residents continues to increase resulting in the need for high cost equipment and supplies to care for them using best practices such as high low beds and therapeutic mattresses. It is challenging to absorb these costs within the current funding model. Large home with 243 beds with 9-27 bed units, while conducive to providing an intimate home environment, is a challenge to relieve direct care staff for in house education to ensure that all education is received in a timely manner. As a teaching facility for University of Western Ontario physicians, it will be a challenge addressing ED visits with the residents and we will have to engage our medical team in discussions around this topic. To mitigate these challenges continual advocacy through the Ontario Long Term Care Association (betterseniorscare.ca), Extendicare Canada and the LHIN around funding challenges will be a priority. We continually reference best practices, learn from other Extendicare owned and partnered homes and engage staff and family members in discussions about how we can continue to improve. Information Management Dearness Home utilizes Point Click Care for its electronic health records system. This system draws upon inputs through the Resident Assessment Instrument- Minimum Data Set (RAI-MDS), Resident Assessment Protocols (RAPs), and resident specific assessments to provide outputs or measures such as quality indicators and 3
individual resident outcome scores. Dearness Home is also highly engaged with utilizing the metrics available through CIHI. Dearness Home also utilizes emar for accurate administration of medications. Front line staff utilizes Point of Care (POC) for all day to day documentation that links with PCC to provide for timely documentation of resident care needs and allows for increased communication between levels of nursing staff. A recent purchase of a Computer on Wheels will allow for immediate documentation for resident care conferences and bedside assessments. OTN will be implemented in the home which will allow for participation in focus group meetings. Ie BSO. Dietary department will be implementing Synergy on Demand for all menus and meals. Engagement of Clinicians and Leadership Dearness Home as an Extendicare Assist Home is part of a large organization in which there are many opportunities to engage with staff and leadership in sharing quality improvement goals and commitments. This is achieved through bench marking, using experiences of other homes to share best practices, annual quality and strategic planning conferences and participation in the Ontario Association for Non-Profit Homes and Services for Seniors and annual quality forums. Patient/Resident/Client Engagement Dearness Homes mission is Compassionate People Enriching the Lives of Others Always and we accomplish this by engaging our residents and families. We promote transparency with residents and families by requesting their participation in various activities such as quality improvement projects, satisfaction surveys, various committees, and resident and family councils. We actively share Ministry inspection reports, quarterly indicator results, Accreditation survey results and concerns and successes in the home. On an individual basis we involve residents and/or families by discussing their unique needs, preferences and concerns and then building their plan of case based on these discussions. Accountability Management Dearness Homes Leadership (Regional Director, City of London, Administrator and Director of Care) are held accountable for achieving the targets set out in our QIP by: - reporting quarterly indicators and explaining our progress to achieve the benchmarks - audits conducted around our indicators and data collections - performance reviews - Coding education and data accuracy audits - Completing quality protocols which align closely with the MOHLTC Inspection Protocols 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 Chair Andrea Loft Quality Committee Chair Kelly Elgie Chief Executive Officer Angie Heinz CEO/Executive Director/Admin. Lead (signature) 4
Other leadership as appropriate (signature) 5