Quality Imprvement Plan 2016-2017 April 1, 2016
Overview Health Sciences Nrth (HSN) 2016-2017 Quality Imprvement Plan (QIP) Mnthly reprt-ut sessins n HSN imprvement wrk Brainstrming sessin with HSN Patient Advisrs
Overview HSN is the leading academic health sciences centre in Nrtheastern Ontari devted t HEALTH. We are a netwrk f integrated facilities and prgrams wrking tgether fr the benefit f ur patients, cmmunities, physicians, researchers, staff, and learners t prvide safe and effective patient-centred care in an efficient and timely manner. Our missin, visin and values guide ur care delivery each day. Missin: Imprve the health f nrtherners by wrking with ur partners t advance quality care, health educatin, research and health prmtin Visin: Glbally recgnized fr patient-centered innvatin Values: Excellence Respect Accuntability Engagement Fundatinal Drivers: Quality and safe patient-centred care; Advanced research and educatin; Enduring imprvement; and Accuntability fr all 3
HSN cntinues its jurney f cultural transfrmatin in pursuit f excellence with significant prgress since the launch f the Strategic Plan in December 2012. HSN s 2013-2018 Strategic Plan identifies three Strategic Pririties, which prvide the necessary fcus t drive achievement: 1. Excellence in Evidence-Based Care We will lead in the prvisin f high-value, cst effective and efficient patient-centered care. Key Initiatives: Delivering reliable and safe care where adherence t evidence-infrmed practice is what we d every day Integrating systems-thinking int the design f delivery systems f care t prduce sustainable results Leading perfrmance in the experience f care f ur patients 2. Innvatrs We will advance ur cmmitment t new r altered innvative health care slutins t imprve health care quality. Key Initiatives: Supprting the design and adptin f innvatin in service delivery and technlgy Building a culture f academic engagement that attracts and retains tp talent in the Nrth Adding knwledge t the glbal cmmunity that will change hw health care is designed and delivered. 3. Leaders in Care Transitin We will be leaders in redesigning systems t enhance the delivery f patient-centred care acrss the cntinuum f care. Our gal is t create a hspital withut walls where patients receive the care they need, where and when they need it. Key Initiatives: Creating and translating ur knwledge int best practice t imprve the quality, safety and care transitin f ur patients within ur walls and beynd Engaging ur patients and ur prviders in the re-design necessary t facilitate seamless care delivery Leveraging funding refrm t enable system re-design that makes care transitin a pririty 4
Defining True Nrth at HSN (Lng-term Perspective) Fllwing the develpment f the 2013 2018 Strategic Plan, HSN began its strategy deplyment prcess. At HSN, strategy deplyment includes fur steps: 1. Develp the Plan 2. Deply the Plan 3. Execute (Mnitr and Check/Adjust) 4. Imprve the System Fr 2013-2018 fur key fcus areas were identified that if breakthrugh imprvements can be achieved; will enable HSN t achieve its strategic gals including: Our Peple Prvide safe care and a safe envirnment fr ur staff and ur patients with Zer Harm Quality Imprve access t care fr all patients at the right time and place Our Patients and Families Imprve the quality f care at transitin within ur walls and beynd with enhanced cmmunicatin Financial Health T sustain a psitive Operating Margin The five year targets fr these fcus areas are as fllws: 5
Annual Perspective (2016-2017) Imprving rganizatinal perfrmance cntinues t be the primary driving frce within HSN t achieve rganizatinal gals defined within ur Strategic Plan. Fr 2016/2017, fur f the six cre prvincial indicatrs align with the internal pririties identified fr HSN. Wrk will cntinue n the fur True Nrth (i.e. pririty fcused areas) with the fllwing annual targets 2016/17: 1. Our Peple Zer Harm; develping Lean inspired management and reduce frequency and severity f lst time events. 2. Quality Patient Access; reduce unnecessary admissins and standardized discharge planning 3. Our Patients and Families Cmmunicatin; increase patient satisfactin with cntinuity and transitin 4. Financial Health Psitive margin; financial surplus 6
QI Achievements frm the Past Year Accreditatin The 2015/2016 year marked significant rganizatinal achievement related t quality imprvement. HSN received Accreditatin with Cmmendatin, recgnizing an rganizatinal cmmitment t imprving quality and safety f care thrugh a culture f cntinuus imprvement. This recgnitin highlights HSN s cmmitment t integrating accreditatin standards int its peratins. In cnjunctin with a strategic plan built upn the cntinuus mnitring and reprting f pririty indicatrs, HSN remains cmmitted t building a strng and sustainable culture f quality and safety. 48/5 Initiative Additinally, with the expertise f Dr. Janet McElhaney, Geriatrician Researcher with Advanced Medical Research Institute f Canada (AMRIC) and Chair in Healthy Aging with Health Sciences Nrth, we began wrking n the 48/5 initiative in July f 2014 with ne f the Medicine units targeting a specific ppulatin grup. As the evidence suggests, a hspital admissin fr an acute illness in an elderly patient can have a negative impact n their functinal mbility at discharge. Sme f these patients will never recver t their functinal baseline pre their acute illness and sme may develp a new disability while in hspital. Pst discharge, a number f these patients may experience ptential cmplicatins, resulting in death. This initiative fcused n the imprtance f develping a standard practice arund screening, assessing and where necessary intervening within 48 hurs, in five key care areas fr patients 65 years ld and lder wh are the frail elderly. Evidence shws that a fcus n putting in place apprpriate interventins arund medicatins, nutritin, cgnitin, bwel/bladder and mbility within the first 48 hurs f hspital admissin will imprve r sustain ur patients functinal ability at the time f discharge. The aim was t have an increase in the number f patients discharged that sustained r had an imprvement in their level f functin frm their frailty scale baseline. 7
Measures were put in place t assess the cmpletin f the screening, assessment and/r interventins fr the five key care areas. Initial data frm August December 2014, as shwn in Table 1, identified that staff adhered t the practice n average 94% f the time. A cmprehensive educatin and cmmunicatin campaign was executed, tls, including the geriatric screening tl and the clinical activity sheet, were in place t supprt the new practice alng with the implementatin f a rbust audit and measurement plan. These cuntermeasures, as well as the check/adjust plan, resulted in an adherence t the new practice n Table 1 average f 100% f the time between January and June 2015. This initiative was then spread t all patients n the Medicine unit. Results frm the implementatin f 48/5 n the Medical unit were psitive as we saw a 10% increase in the number f patients wh sustained r imprved their functinal mbility (See Table 1). T further imprve the utcme f ur patients, HSN will nw wrk twards spreading this initiative in the Emergency Department. We knw frm the evidence that the screening, assessment and interventin f the 5 key care areas shuld take place within the first 48 hurs f the patients hspital admissin. Due t the bed situatin at HSN, patients may wait in the Emergency Department fr up t 24 hurs r mre until they get admitted int an inpatient bed. At this time wrk cntinues n the 48/5 initiative in the Emergency Department. 48/5 imprvement team 8
Integratin and Cntinuity f Care One f HSN s mst significant accmplishments related t cntinuity f care is demnstrated in the nging pursuit f a hspital withut walls. This represents HSN s cmmitment t imprving the health f nrtherners by wrking with partners t advance quality care, health educatin, and research and health prmtin. This is truly reflective f the cmmunity we serve. In additin t the city f Sudbury, HSN serves many small cmmunities within its catchment area wh rely n the prvisin f secndary and tertiary services. In respnse t the needs f ur cmmunity, the Virtual Critical Care (VCC) Unit ffers an innvative cllabratin that allws Intensivists and multidisciplinary critical care teams t remtely cnsult and care fr patients in remte Members f the VCC unit receive award at Health Quality Transfrmatin cnference in Trnt lcatins acrss the Nrth. In Octber 2015, HSN received the 2015 Minister s Medal hnuring excellence in health, quality and safety. This initiative is just ne example f HSN s nging cmmitment t prviding cntinuus patient care. HSN recgnizes that the hspital stay is nly ne part f the patient s jurney and cntinues t emphasize the imprtance f cmmunity partnerships in imprving the cntinuum f care fr patients. Develpment f strng relatinships with cmmunity partners has played a vital rle in ensuring safe transitin f patients frm hspital t cmmunity. In 2016/17, we will cntinue t priritize imprvements related t discharge planning fr patients that require nging care in the cmmunity, in additin t planning apprpriate placement fr patients with alternate level f care (ALC). HSN s True Nrth fcus is enhanced cmmunicatin with patients and families. In alignment with the Patient Declaratin f Values, we remain dedicated t imprving patient and family satisfactin thrugh imprved cmmunicatin f imprtant infrmatin and allw nging pprtunities t express cncerns and have questins answered. The fcus fr 2016/17 will be imprving satisfactin with cntinuity and transitin by preparing patients fr discharge. Thrugh cmprehensive discharge planning standards that include patient educatin prir t discharge, we cntinue t place patient-centred care and listening t the vice f the patient at the frefrnt f imprvement effrts. 9
Engagement Leadership, Clinicians and Staff As HSN cntinues alng its jurney twards Organizatinal Excellence (OE), we are building capability and capacity in ur leadership, frntline staff, physicians, and patient and family advisrs. Staff may participate in an Intr t OE as well as varius Lunch and Learn sessins. Management and physicians are ffered a three day Bt Camp t learn abut prcess imprvement using 4-Step Prblem Slving and ther Lean tls. HSN has trained and develped Prgram specific Prcess Imprvement Leads wh receive guidance frm Prcess Imprvement Cnsultants in the OE Office. Thrughut HSN, level 1 huddle bards engage the frntline teams in the daily management f their unit/department. Level 1 huddles prvide staff with the pprtunity t identify pririties, pprtunities and challenges, manage their day and review the status f their imprvement initiatives. Staff have the pprtunity t be engaged in cntinuus imprvement and prblem slving Physicians attend Lean Bt Camp thrugh the idea bards psted in their wrk areas. Level 2 huddles assist teams in rapidly executing their initiatives that are linked t HSN s strategic gals/true Nrth fcus areas. Senir Leaders are present at all levels in the rganizatin and attend bth level 1 and 2 huddles as part f their cnnected checking t cach teams, s that the rganizatin cntinues t imprve n its Lean jurney. Imprvement wrk is ccurring at HSN each and every day. Staff share their learnings at mnthly reprt ut sessins. Mnthly reprt ut sessin Our OE jurney is truly abut Imprving Wrk. Imprving Care. 10
Patient/Resident/Client Engagement HSN is cmmitted t partnering with patients and families t integrate their vice and perspective int hw we deliver care. We believe having patients as part f ur team will lead t better health utcmes, and greater patient and family satisfactin. We engage frmer patients and family members thrugh ur Patient and Family Advisry Prgram cmprised f the CEO Patient and Family Advisry Cuncil (PFAC), the Nrtheast Cancer Centre PFAC and specialty grups. Their perspectives help us t reflect n what is imprtant t ur patients and their partnership helps us t create a better healthcare system. Patient engagement pprtunities acrss all levels f the system are linked t the rganizatin s strategic visin and True Nrth fcus areas: Patients and Families (Cmmunicatin); Financial Health (Psitive Margin); Our Peple (Zer Harm); Quality (Patient Access). Patient and Family Advisry Prgram Structure at HSN Patient engagement ccurs at varius levels belw ranging frm the direct care setting t rganizatinal level: Enhancing Direct Care Prcess Patient advisrs are invlved in the fllwing ways: review and decisin making t expand visiting hurs t meet the needs f family members/visitrs prvide direct input in making enhancements t patient educatin materials Quality Imprvement Activities and Daily Operatins Here are sme f the ways patients are engaged at this level: They are serving n the Quality Cmmittee f the Bard, Medical Advisry Cuncil, Patient Access and Flw, Senir Quality f Care Review Cmmittee, Prgram Cuncils and Human Resurces Interview Panels t name a few. They are wrking n imprvement teams and making recmmendatins fr service enhancements such as shrtening wait times fr pacemaker insertins, prviding input n hw t imprve cmmunicatin abut the purpse and pssible side effects f medicatins, and whitebard standardizatin. Planning and Redesign f Services At the LHIN level: engage in planning, delivery, imprvement and evaluatin f healthcare Patient engagement in HSN s strategic planning prcess Patients wven int all activities 11
Perfrmance Based Cmpensatin The Excellent Care fr All Act, 2010 requires that the cmpensatin f the CEO, Chief f Staff, Chief Nursing Executive and any senir executive wh reprt directly t the CEO be linked t the achievement f perfrmance imprvement targets laid ut in the rganizatin s QIP. HSN QIP PRIORITY AREA 2016-2017 PERFORMANCE GOALS ASSOCIATED PROCESS MEASURES Aligned with HSN True Nrth: Quality/Safety Aligned with HSN True Nrth: Peple MEASURE: Emergency Department (ED) Wait Times: 90 th percentile ED length f stay fr admitted patients TARGET: 25 hrs MEASURE: Frequency f Lst Time Events TARGET: Frequency: 1.1 Gals f Care: Implement Gals f Care discussin fr ppulatin greater than 85 years ALOS:ELOS: Standardize discharge planning target ALC: Reduce ALC Readmissin Expected:Actual: reduce readmissins Severity: 25% reductin thrugh hazard analysis and registry cmpletin Management Capacity Building: 80% f managers have successful cmpleted their develpment in the sustain & perate categry f Lean Fundamentals Aligned with HSN True Nrth: Financial Health Aligned with HSN True Nrth: Patients/Families MEASURE: Ttal Revenue Less Expenses TARGET: $4.5 M Surplus MEASURE: Overall Patient Satisfactin Cntinuity and Transitin TARGET: 75.2 % Efficiency Initiatives Implementatin: Maintain Prgram Spending fr 16/17 (net spending) t prir years actual less 0.25% - imprvement wrk will = 1.75% r 0.25% + 1.5% Implement Rlling Frecasts: Implement rlling frecast system including management learning hw t manage with these new tl in this new system Patient Satisfactin: Overall Patient Satisfactin in Cntinuity and Transitin **Percent f respndents wh respnd psitively t During yur hspital stay, did yu get the infrmatin in writing abut what symptms r health prblems t lk ut fr after yu left the hspital **Percentage f respndents wh respnd psitively t Did yu receive enugh infrmatin frm hspital staff abut what t d if were wrried abut yur cnditin r treatment after yu left the hspital **NOTE: Natinal Research Crpratin Canada (NRCC) has changed survey questins effective April 1 st 2016 therefre there will be n cmparatr data. Data will be mnitred during the first quarter t identify targets fr each survey questin fr 2016-2017. 12
The table n the previus page details the key perfrmance measures related t each pririty fcus area f the QIP which will be integrated int the HSN Senir Leadership Perfrmance Management Prgram (PMP). The HSN Senir Leadership PMP integrates the evaluatin f the executive s jb related perfrmance with the achievement f the hspital s missin, visin and gals that frms the justificatin fr determining the executive s cmpensatin. The HSN prgram integrates and aligns fur key cmpnents int ne prgram; (1) Perfrmance Evaluatin Prgram; (2) Prfessinal Develpment Prgram; (3) Perfrmance Gals (team and individual) and (4) Cmpensatin Prgram. The PMP has been deplyed at all management levels f the rganizatin t fster the creatin f shared accuntability and fcus n the strategic pririties. 13
2016-2017 QIP Imprvement Indicatrs Measure/Indicatr Current Perfrmance Target fr 2016/2017 Target Justificatin Aligned with HSN True Nrth: Quality/Safety 1. Safety: Clstridium Difficile Infectin (CDI) per 1,000 patient days 2. Safety: Medicatin Recnciliatin at Admissin (Medicine & Cardilgy Prgrams) 0.36 (Jan. - Dec. 2015) Surce: MOHLTC 91.71% 1 (Q3 2015/16) Surce: Internal 0.33 Prvincial Median 85% 2 Internal Target 3. Access: 90th percentile Emergency Department (ED) Length f Stay fr Admitted Patients 35.5 hrs (Q4 2014/15-Q3 2015/16 Surce: NACRS, CIHI 25 hrs NE-LHIN Target Prvincial Target 4. Patient-Centred: Patient Satisfactin Acute Care Cntinuity and Transitin 70.9% Overall Satisfactin Cntinuity and Transitin 68.7% discussed danger signals t watch 59.4% discussed when t resume nrmal activities 79.8% knew wh t call with questins (FY Q3 2015) Surce: NRC Picker 75.2% Overall Patient Satisfactin in Cntinuity and Transitin Receive written infrmatin n symptms t lk ut fr after left hspital 3 Receive enugh infrmatin if wrried abut yur cnditin r treatment after left hspital 3 Ontari Academic Hsp Avg. with Benchmark Hspital Aligned with HSN True Nrth: Peple 5. Lst Time Events Frequency f Events: 1.22 Frequency f Events: 1.1 Internal Target Aligned with HSN True Nrth: Financial Health 6. Hspital Ttal Margin $3.451 M deficit (February 2016) $4.5 M surplus Prvincial Average (Benchmark range 0-2%) 1 Current Perfrmance data fr Medicatin Recnciliatin Pilt in Medicine Prgram 2 Target data fr Medicatin Recnciliatin Spread in Medicine and Surgical Prgrams 3 Natinal Research Crpratin Canada (NRCC) has changed survey questins effective April 1st 2016 therefre there will n cmparatr data. Data will be mnitred during the first quarter t identify targets fr 2016-2017. 14
Other Quality Indicatrs Oversight f Ontari Patient Safety Indicatrs Health Quality Ontari (HQO) currently reprts n nine patient safety quality indicatrs fr the prvince f Ontari fcused n: Hspital-assciated infectins Surgical site infectin preventin Hand hygiene cmpliance Surgical Safety Checklist cmpliance These indicatrs will be reviewed at the Quality Cmmittee f the Bard, alng with ther key leadership frums at least quarterly: Clstridium Difficile Infectin (CDI) Methicillin Resistant Staphylcccus Aureus (MRSA) Vancmycin Resistant Enterccci (VRE) Central-Line Primary Bld Stream Infectin (CLI) Ventilatr-Assciated Pneumnia (VAP) Surgical Site Infectin (SSI) Preventin Hand Hygiene Cmpliance (HHC) Surgical Safety Checklist Cmpliance (SSCC) Hspital Standardized Mrtality Rati (HSMR) 15
Sign-ff I have reviewed and apprved ur rganizatin's Quality Imprvement Plan. Nicle Everest Steve Petrvic Dr. Denis-Richard Ry Bard Chair Quality Cmmittee Chair President and Chief Executive Officer 16
Appendix 1: Wrkplan Imprvement Targets & Initiatives 2016/17 Quality Imprvement Plan fr Ontari Hspitals "Imprvement Targets and Initiatives" Sectin f HSN 2016-2017 QIP Wrkplan 17