Excellent Care for All Quality Improvement Plans (QIP): Report for 201/14 QIP The following template has been provided to assist with completion of reporting on the progress of your organization s QIP. Please review the information provided in the first row of the template which outlines the requirements for each reporting parameter. Priority Indicator ED Wait times: 90th percentile ED length of stay for Admitted patients. Hours ED patients Q4 2011/12 Q 2012/1 CCO iport Access Improve 25.90 20.70 21.50 : January to December 201 Improvement: Achieved 85 of the goal. Projection: Target will be achieved within -5 months. Lessons learned: To further improve this indicator, we will focus efforts on improving the physician initial assessment (PIA) wait time in QIP 2014-15. Like our community partners, we struggled with high occupancy levels during peak times over the year. We continue to work on our patient flow processes to optimize the flow of patients being discharged from the inpatient units. Over the next year, we will be reviewing our consultant response policy, practices for the admission of patients to the unit, and a practice of conducting a detailed analysis of patients exceeding this target. We will also be reviewing processes within the ED geared to further improving flow across the board. Hip Arthroplasties : waiting time in the 90th percentile for replacement of the hip (April 1st, 2012 to October 1, 2012) Days 220.00 180.00 178.00 : January to December 201 Improvement: Exceeded the target by 2 days for an overall reduction of 42 days of wait time. Projection: Increasing number of referrals will make maintaining gains very challenging.
Lessons learned: Requiring central intake reference number as a criteria for booking made a significant difference in our ability to reduce wait time. Knee Arthroplasties : Waiting at the 90th percentile for knee replacement (April 1st, 2012 to October 1, 2012) Days Oncologic surgeries: waiting time in the 90th percentile for oncologic surgery (April 1st, 2012 to October 1, 2012) Days HSMR: Number of observed deaths/number of expected deaths x 100. Ratio (No unit) All patients 2011/12 DAD, CIHI 44.00 196.00 258.00 : January to December 201 Improvement: Achieved 58 of the goal representing a significant reduction of 86 days of wait time. Projection: Trending positively downward. Target achievable within 6-8 months Lessons learned: Requiring central intake reference number as a criteria for booking made a significant difference in our ability to reduce wait time. 50.00 4.00 50.00 : January to December 201 Improvement: Overall target not achieved. Projection: We are meeting most of the individual case type targets with the exception of thyroid and endocrinology cases. We exceeded provincial target of 90 by 5 and we ranked 7 th in the province. Lessons learned: Improved process of bookings of cases for colorectal cancer screening is increasing number of referrals. Given other surgical priorities at Montfort, should we consider experts recommended target of 85 days? 100.00 90.00 95.00 : January to December 201 Improvement: Achieved 50 of target Projection: Target will be achieved within 6 months Lessons learned: Integrating more detailed HSMR data in our quality and performance monitoring process highlighted importance and triggered need for a more
focussed interdisciplinary preventable death chart review process, aiming at specific quality initiatives. Registered Nurses Retention: rates of voluntary departures of registered nurses with less than one year of service (definition of Saratoga-OHA) Percentage 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 2012/1 Ministry of Health Portal.90 20.0 2.9 : January to December 201 Improvement: Achieved 74 of target Projection: Target will be achieved within 6 months. Lessons learned: An analysis of 201 exit interview results was communicated immediately to Nurse Managers in order to make them aware of areas of improvement they have an impact on. Since November 201, nurses leaving the hospital are asked to meet with the Director of Planning and Talent Acquisition for a face-to-face exit interview, allowing for more detailed and comprehensive information to be gathered. No single root cause has been identified and it appears that working conditions such as work schedules, work climate, manager feedback and recognition need to be improved upon (as learnt from the follow up discussion groups from the annual Pulse survey). Focus groups planned in mid-march will be instrumental in shedding more light on the factors that need to be addressed to reach our retention goal, as well as the strategies that need to be implemented. 12.20 12.20 1.60 : January to December 201 Improvement: None (limited community capacity) Projection: Outlook is not positive without additional community-based resources. Increase in number of ALC patients with long length of stay. Increase in number of patients with behaviors and mental health disorders with limited to no community resources/support available. Increase in wait time for publicly funded convalescent beds (vs. private), and
decrease in number of all type of long term beds (interim and IDLE beds) in the community. Increase in number of patients that require redirection to retirement homes (1 in June). Long processes for discharge planning of ALC patients with complex needs: multiple meetings with families, multiple interventions with multidisciplinary team members and CCACs. Lessons learned: Continue the education of staff on Home First initiatives and their implementation; continue early escalation process of new cases with complex discharge barriers. Immediate actions taken, and good results have been seen in September; Continue early physician engagement in the discharge planning process. "Would you recommend this hospital (inpatient care) to your friends and family?" NRC Picker Patient Satisfaction Survey (add together of those who responded "Definitely Yes" or "Yes, definitely"). All patients Oct 2011- Sept 2012 NRC Picker Improve Would you recommend this hospital (emergency department) to your friends and family? 79.60 85.00 78.98 : October 2012 to September 201 Improvement: No marked improvement as efforts and major interventions implemented in September 201 are not yet captured due to lag in data reporting. Projection: Results from latest quarter indicate significant improvement to 84. Remains high priority for QIP 2014-15 Lessons learned: Based on the success of hand hygiene experience, a similar strategy of focussed organizational commitment to improving this indicator was put in place in September 201 (i.e. 90 days action plan). It s too early to tell if this will be a permanent shift, with minimizing variability and lasting effects. 72.9 75 71 : October 2012 to September 201 Improvement: Observed variability over a 12-month period
NRC Picker Patient Satisfactory Survey (add together of those who responded Definitely Yes or Yes, definitely ). NRC Picker EMERGENCY Projection: Over the next 6 months, concentrated efforts on patient experience and wait-time for initial physician assessment will assist in improving our results. Lessons learned: Emergency patient satisfaction relies heavily on wait-time. Our capacity to reduce wait-time vs the initial physician assessment (PIA) has been restrained by a lack of recruitment. 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. All patients Most recent quarter available (e.g. Q2 2012/1, Q 2012/1 etc.) Hospital collected data C-Difficile infection 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, and multiplied by 1,000 - Average for Jan-Dec. 201, consistent with publicly reportable patient safety data. Rate per 1,000 patient days All patients 2012 Publicly Reported, MOH 78.50 100.00 82.40 : January to December 201 Improvement: 18 of target achieved. Recently trending much more favorably. Projection: 100 compliance by Dec 2014 Lessons learned: process works well, we need to focus on exceptions and on involvement by all physicians. We have experienced improved results with recent improvements associated with a chart without med rec analysis resulting in focussed follow-ups with numerous specific clinicians (i.e. rehab for direct admissions, surgeons for admissions via ED, each psychiatrist, and, pharmacy with the OBS-GYN department). 0.27 0.2 0.40 : January to December 201 Improvement: None. Projection: 25 improvement by the end of 2014 as committed to in the QIP 2014-15 Lessons learned: Reducing Clostridim difficile transmission is challenging in view of the increasing incidence of non-nosocomial cases (26 in 2011, 4 in 2012 and 60 in 201). A multi-faceted approach for improvement must include concerted efforts towards early detection, treatment, enhanced environmental
cleaning, antimicrobial stewardship and patient and personnel hand hygiene practices. 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 2012 Publicly Reported, MOH Improve Percent of complex continuing care (CCC) residents with a new pressure ulcer in the last three months (stage 2 or higher). Complex continuing care residents Q2, 2012/1 CCRS, CIHI (ereports) Rate of falls: no. of falls by 1 000 days of presence for all the inpatients (excluding the CFN, SU and the patients admitted in the SU) CORE - POPULATION CHANGED Percentage 78.90 85.00 86.80 : January to December 201 Improvement: Target exceeded by 1.8 Projection: Hospital averaging around 90 for past 6 months. Practice is well adopted but will require continuous monitoring to maintain. Lessons learned: Only a corporate wide leadership committed patient-centered focus on achieving results for the right reasons, coupled with concrete support to front line staff for adoption of meaningful hand practices within their specific setting, can get you from one of the worst in province hand hygiene performances to one of the most comprehensive and validated conformity with peer recognition for its communication strategies (i.e. CPSI - Hand hygiene It s in my hands). 5.40 4.90 Complex continuing care unit discontinued. Not applicable. 4.56.65.91 : January to December 201 Improvement: 71 of target achieved Projection: Target will be achieved within 6 months Lessons learned: Developing a standardized method of identifying, capturing, analysing and sharing root causes analysis data on high risk patient falls patients
improves staff awareness. Renewed Falls Prevention Program and dedicated resources facilitated implementation of validated falls prevention tools in the right environment (e.g. bed alarms in medicine 4C) and applied to the correct set of criteria will reduce avoidable patient falls. Pressure ulcers: Number of pressure ulcers (stage 2 or higher) acquired during hospitalization and present on discharge or at patient transfer divided par the # of radiation completed in trimester. New indicator <5 0,70 : April to December 201 Improvement: Significant Projection: Surpassed target Lessons learned: While defining a new indicator, time to establish a strong baseline to better identify a target should have occurred. New reports from electronic clinical documents will enable us to follow performance and target new paths for improvement. Days of therapy by 100 days of stay using certain antibiotics (méropénem IV, piptazo IV (pipéracilline-tazobactam), vancomycine IV, ciprofloxacine IV) used in the intensive care Days Improve Severity rate of workplace injuries (employees of the hospital, excluding doctors and contractors): Number of days of absence divided by the number of hours worked x 200,000. Percentage 51.00 48.00 50.54 : January to December 201 Improvement: 15 of target achieved. Projection: Target to be achieved within 8 months Lessons learned: Taking the risk of measuring something new, without a baseline, draws attention and gets people engaged. Selection of right indicator is also influencing performance. Benefits include increased awareness and changes in prescribing practices. 11.70 10.5 2.19 : January to December 201 Improvement: Target was exceeded significantly Projection: Well under threshold. Will simply continue to monitor. Lessons learned: To put lost time as an organizational metric has increased manager s awareness to fulfill their WSIB obligation to accommodate modified
workers, dedicating time and efforts in following up on WSIB cases in collaboration with the Occupational Health and Safety interdisciplinary team.