Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/30/2017 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 The 2017-2018 Annual Quality Improvement Plan (QIP) is part of our ongoing commitment to patients, caregivers, community and funders to provide the best quality care in a fiscally responsible manner. Building on the learnings from Central CCAC s three previous QIPs, the 2017-2018 QIP focuses on further integrating quality within our planning process. In addition to capitalizing on opportunities for ongoing improvement, we have aligned our QIP to the Patients First Act, 2016. As part of our commitment to quality, safety and excellence in quality improvement, Central CCAC participates in a rigorous Qmentum accreditation program through Accreditation Canada and received the highest award of Exemplary Standing in December 2015. We utilize accreditation standards and best practices in the development of quality improvement initiatives, quality improvement plans and strategic initiatives. The six common areas of focus for CCACs are: Maintaining the percentage of patients who experienced a fall in the home Reducing Emergency Department visits by Central CCAC patients within 30 days of hospital discharge Reducing hospital readmission by Central CCAC patients within 30 days of hospital discharge Maintaining the percentage of patients who receive nursing within five days of being admitted to CCAC services Increasing the percentage of complex patients who receive personal support services within five days of being admitted to CCAC services Improving the overall patient experience Improving the experience of palliative/end-of-life patients by supporting them in their preferred place of death We engaged a broad range of stakeholders to help inform our QIP and used Health Quality Ontario s Appendix A: Approaches to Setting Targets for Quality Improvement Plans to determine our targets for 2017-18. We also incorporated learnings from our three previous QIPs to streamline the process for soliciting change ideas and prioritizing improvements. As we continue our quality improvement journey, we anticipate challenges in the coming year. With more than half of our patients now coming directly from hospital, we are coordinating care for an increasingly complex group of patients. We have the highest number of patients with high and very high needs of any CCAC. We also provide services in one of the most diverse and fastest-growing regions in the province. Some of the anticipated challenges include: Transformation year: As part of the Patients First Act, 2016, Central CCAC will become part of the Central LHIN as determined by the transfer order issued by the Minister of Health and Long-Term Care. After the transfer, accountability for the monitoring of the QIPs will rest with the new Central LHIN. There are four main challenges in the following order as follows: Levels of Care Increased Caregiver Respite Funding Inequity Transformation Funding Inequity: Inequity in per capita funding continues to be a significant challenge for Central CCAC patients. Of the 14 CCACs in Ontario, the Central CCAC consistently ranks in the bottom three in relation to per capita funding. This results in Central region patients consistently receiving fewer hours of care compared to patients in other regions of the province. Demographics in the Central region compound this challenge, and include a rapidly growing and aging population, and higher complexity of patients receiving care in the community than in other regions of Ontario. QI Achievements From the Past Year One of Central CCAC s priorities in 2016-17 was to participate in initiatives that would improve the patient experience across the continuum of care. The Central CCAC is a partner in two Integrated Funding Model (IFM) initiatives. The IFM initiatives receive a single payment for an episode of care spanning multiple care settings and providers. IFM pilot projects 2
are underway in six sites across Ontario, and incorporate governance and partnerships, integrated funding, data management, patient care pathways and virtual care. The two IFM pilots that Central CCAC is participating in include: Integrating Specialized and Primary Care: The North York Central Collaborative for Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) Patients One Client, One Team: Central and Toronto Central LHIN Integrated Stroke Care In 2016/17 there was a significant amount of activity related to these initiatives. However, most notable for Central CCAC was our involvement in the One Client, One Team pilot targeting patients who have suffered a stroke. The Quality Based Procedures (QBPs) for stroke care recommends that intensive community rehabilitation be provided by a single and consistent stroke team. The goal for this pilot is to have one community stroke team deliver rehabilitation services to patients while in-hospital and after they are discharged home. This model of care is expected to improve the patients experience and outcomes while creating seamless transitions from hospital to home and building trust between care partners. The single community team in our IFM pilot provided care to stroke patients on a defined pathway of services. Stroke QBPs and best practice elements included the use of essential professional conversations (warm hand-offs between referring and admitting clinicians), the My Guide to Stroke Recovery resource and the Canadian Occupational Performance Measure tool. The results of this pilot showed increased communication along the care continuum. This led to decreased likelihood of patients answering the same questions multiple times and an increase in system partners working as a team. In fact, patient and caregiver survey results showed that 100% of patients: Felt that the CCAC care coordinator role was very good/excellent throughout the pilot Felt that the home care team and CCAC care coordinator had strong expertise in stroke care Would definitely recommend this model of care to others The impact of the social determinants of health was also observed during this pilot, with patients of lower socio-economic status especially benefiting from the smooth transitions. Our system-wide collaboration led to the implementation of an integrated pathway, which provided enhanced in-home services through a single community team. This pilot demonstrated positive outcomes for patients and showcased the success of the stroke IFM to enhance the patient experience as they transition across the continuum of care. Population Health Demographics, patient complexity and system issues in the Central LHIN are resulting in more patients requiring key CCAC health services to ensure they can remain healthier and living more independently in their own home for as long as possible. Central CCAC s unique populations include: Children Patients with developmental delay Palliative Mental Health Patients with chronic obstructive pulmonary disease and congestive heart failure Wound patients Acquired Brain Injury Adults, and Seniors The key areas of focus for our quality improvement efforts to better serve our unique populations include: 3
Focus on five day wait times One way we are working to meet the needs of our complex patients is improving the five-day wait time results for the 2017-2018 fiscal, increasing the number of complex patients who receive their first personal support visit within five days of service authorization. Telewound initiative An innovative project that Central CCAC is participating in is the Telewoundcare project for patients with complex chronic and acute wounds who rely on treatment from community service providers to maintain their quality of life. Patients will be placed on a best practice outcome-based or service pathway that is supported by a wound care technology solution. This solution will enhance assessment, management and selection of appropriate wound care supplies. The wound care digital technology will track progression/delays in wound healing; thereby supporting timely consultation with expert wound care teams/specialists. Using technology to manage chronic diseases Central CCAC s Telehomecare program leverages technology to improve care for patients with chronic obstructive pulmonary disease and congestive heart failure. The service provides weekly health coaching and daily monitoring of vital signs to patients in their own home via the Ontario Telemedicine Network. Results are monitored by Central CCAC s highly skilled nurses, who watch for trends requiring medical help and share data with the patient s primary care provider. This program helps patients gain confidence in managing their chronic disease, thereby enhancing quality of life. By supporting patients to manage their symptoms, in partnership with their primary care provider, Telehomecare also helps prevent acute flare-ups and health crises that can result in emergency department visits and hospitalizations. In the last fiscal year, Central CCAC worked with LOFT Community Services to establish Telehomecare at LOFT Bradford House, a residential facility for seniors with mental health issues. Providing respite for palliative patients and children A percentage of the new funding that Central CCAC received for 2016-2017 was allocated to providing respite for caregivers of complex and palliative patients, and for parents of children with very complex needs. This included respite hours added to regular service plans for those who were in need of extra support, and specific respite hours that, along with enhanced nursing and personal support, enabled some patients to return home and spend the holidays at home with their families, and provided relief for parents at Christmas and over March Break. Equity An increasing proportion of people with complex health needs receive Central CCAC services in the community last year 75% of our patients had high or very high needs, up from 35% in 2009-10. In addition, we deliver services in one of the most diverse and fastest-growing regions in the province. The following are some of the strategies and quality improvement initiatives undertaken in support of enhancing equitable access and equitable services for patients and their families in our region. Supporting cultural competency Operating in the most diverse LHIN in the province (48% of residents are immigrants), Central CCAC strives to provide culturally and ethnically sensitive services. For example, we provide information to patients and families in a variety of languages (including French, Chinese, Italian, Punjabi and Russian). Our staff speak a wide range of languages and they are supported by policies, information and training on the use of interpretation and translation services. We promote respect for each patient and family s ethnic and cultural background and preferences, strive to deliver services in the patient s preferred language and work hard to ensure the patient fully understands the information we provide so they can make informed choices about their health and services. Targeting new funding to enhance service levels Central CCAC s new funding for the 2016-2017 fiscal year was targeted in part to increasing service levels for patients in the Central region, who have historically been disadvantaged due to funding inequities. By enhancing services and service levels for our most complex patients, we have been able to better support them and their families and bring their service levels closer to those of patients in our jurisdictions in Ontario. Increasing the percentage of up-to-date patient assessments The patient service plan is a fundamental tool to support equity of services and service levels. This past year, Central CCAC focused on increasing the percentage of patients with up- 4
to-date assessments achieving a 10% improvement over the previous fiscal year. Updated assessments ensure that patients are receiving the right services and service levels for their current assessed needs and that patients with similar needs get similar services. Integration and Continuity of Care Health Links Health Links are an approach to providing coordinated, integrated care at lower costs for patients considered high users of the health system. The Central CCAC is an active partner for the following Health Links: North York West Health Link North York Central Health Link Southwest and York Region Health Link Southeast and York Region Health Link South Simcoe and Northern York Region Health Link Health Links aim to improve access to care for seniors and patients with complex conditions and reduce avoidable emergency department and hospital admissions. The Health Links model improves the patient s experience during their journey through integration of care within the health care system. It also improves outcomes for patients, with intensive case management to coordinate, navigate, advocate and develop an individualized care plan, ultimately supporting them to better self-manage in the community with the right supports, at the right place and at the right time. Enhancing our role as point of access for hospice palliative care beds in Central region Last year, Central CCAC worked with the hospice palliative care facilities, palliative care clinicians and service providers to make access to hospice palliative care beds more equitable. Central CCAC is now the single point of access for all hospice palliative care beds in the region, ensuring equitable access for patients based on standardized criteria and assessed need. This new role for Central CCAC is in addition to already managing eligibility determination and waitlists for Adult Day Programs and assisted living spots in the Central region. Access to the Right Level of Care - Addressing ALC Issues The Central CCAC is collaborating with the Central LHIN and Central LHIN hospitals on a number of initiatives aimed at increasing patient access to the right level of care. One area of the ALC Collaborative is the development and implementation of an ALC dashboard, which will give care providers real-time information, assisting in the timely access of appropriate services for ALC patients. An ALC framework has been established and the collaborative selected two ALC indicators to monitor: escalation process and involving the substitute decision maker in early planning. In addition, Central CCAC is working with North York General Hospital to arrange joint family meetings earlier in the process as a first step in supporting timely and appropriate discharge planning. Additional resources from Health Quality Ontario (HQO) have been used to improve transition. Engagement of Clinicians, Leadership & Staff The Central CCAC engages everyone in the organization in our quality improvement efforts to support and improve patient and caregiver experiences. The monitoring of the QIP is built into operations, and with the same core indicators year-overyear, we have been able to gain greater insight and engagement in the development and implementation of the change ideas. As part of the development of this year QIP s, we reviewed the QIPs of all Central LHIN Hospital and the 14 CCACs. We benchmarked our performance against the other 13 CCACs using HQO s domains for target setting. We had discussions with key stakeholders for each of the quality dimensions of the QIP effectiveness, patient-centered, safety, timeliness and palliative care. Participants included frontline staff, managers, senior leadership, hospitals, and contracted service providers. We continue to engage our Professional Practice Advisory Council and our CCAC/service provider falls prevention working group for our falls strategies. Frontline, management and service provider feedback has been instrumental in the 5
development, implementation and sustainability of our 5-Day wait time measures for both nursing and complex personal support services. We have also engaged palliative stakeholders in improvement initiatives as we work to develop a palliative hub model. Similar to last year, each of the change ideas will have assigned leads who work closely in the area of focus to ensure the changes are being implemented. Oversight for this work will be provided by the quality and safety committee, including monitoring the implementation of each change idea and how it contributes to the overall measure. This process has worked well over the past two years and supports accountability. How does staff/clinician experience impact your quality improvement initiatives? Staff and clinician experience can help drive the successful development, implementation, evaluation and sustainability of QIP initiatives. In the Falls Notification Pilot, managers, supervisors, care coordinators and contracted service providers helped shape the design of the falls notification process, identified which indicators were most meaningful to them in their daily practice and provided practical recommendations about process adjustments to support expansion of the process across all teams/patient populations. The Professional Practice Advisory Council conducted a survey with service providers and internal staff to determine learning needs and opportunities for topics for the professional practice scenario. Staff and clinicians have worked to create the scenarios. Central CCAC also engaged staff to better understand issues that prevented patients from being seen within 5 days for nursing services and complex PSW. Outlining these issues was instrumental in developing an improvement plan to help achieve our goal. Resident, Patient, Client Engagement A proven way to enhance care quality is to engage directly with patients and family and embed their voice into everything we do. We see patients and families as an integral part of the care team and work hard to listen and respond to their preferences and personal goals. Last year, Central CCAC made progress on our multi-year strategy to increase patient and caregiver involvement in key decisions, for example through participation in focus groups and steering committees. In 2016-17, Central CCAC held 9 quality events with over 150 patients, caregivers, staff and health and community partners to find better ways of working together to meet patient needs. In addition, 5 patients/caregivers participated in telephone interviews to help develop Central CCAC s 2016-17 quality improvement work plan regarding wait times and patients choice for delaying the start of services. We continue to use patient stories to start each committee meeting to help focus us on what is really important the patient. To support continuous quality improvement, Central CCAC has a comprehensive, mandatory reporting system that is used by our employees and contracted service providers to track and monitor risks and complaints. We systematically analyze this information and thoroughly investigate issues, using what we learn to drive quality improvements in collaboration with everyone involved in the patient s care. We also track compliments, giving us a better understanding of what we need to do more of in our day-to-day work. Third party patient and caregiver experience surveys are conducted and analyzed to understand how to better deliver care and services. Central CCAC also conducts surveys in-house for patients receiving services in clinics or through our direct nursing programs including rapid response nursing, nurse practitioners and Telehomecare. These surveys ultimately inform action plans and quality improvement initiatives. Over the coming year we will continue to proactively engage with patients and caregivers through focus groups, interviews, quality improvement events and surveys. We will also continue to use our active roster of patients and caregivers who will be called upon to provide input and guidance to help Central CCAC improve the care experience for all patients and families. 6
Staff Safety & Workplace Violence The Central CCAC is committed to providing a safe and respectful working environment. We support a zero-tolerance philosophy towards violence in the workplace and every effort is made to identify potential sources of violence in order to eliminate or minimize the risks. At the Central CCAC, prevention of potential workplace violence is a responsibility shared by all employees. And all employees receive comprehensive training so they understand their roles and responsibilities relating to violence prevention in the workplace. Policies and procedures are in place to support employees in the reporting of violence, threats of violence or other volatile situations. The Central CCAC s Quality Reporting System is used to report events and gives us the ability to track and monitor incidents and trends. Central CCAC s Occupational Health Nurse and its Joint Health and Safety Committee (JHSC) provide guidance on prevention and mitigation strategies. Staff receives training on the prevention of workplace violence and harassment and discrimination policies are reviewed. Staff who provide direct service also receive non-violent crisis prevention training. Prevention strategies include completing a police records check for all new hires and vulnerable sector screens are conducted for new hires working directly with patients. JHSC members also receive training in risk/hazard assessment. In addition, staff is supported with resources such as Central CCAC s Safety in the Community online booklet, which provides guidelines for working safely in the community and while conducting home visits and strategies for managing risks. Contact Information Joe Figliomeni Acting Director of Organizational Effectiveness, OHPI Central Community Care Access Centre 9050 Yonge Street, Suite 400 Richmond Hill, ON L4C 9S6 Tel: 905 763 9928 ext. 4607 / Cell: 905 751 4555 Fax: 905 707 2419 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 Joe Parker Quality Committee Chair or delegate Al Luciani/Charles Schade Chief Executive Officer Megan Allen-Lamb CEO/Executive Director/Admin. Lead (signature) Other leadership as appropriate (signature) 7
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