Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 4/1/2014 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 HQO (if required) in the format described herein. 1
Click here to enter text.overview Quinte Health Care (QHC) is dedicated to the delivery of exceptional and compassionate care and to continually enhancing the quality and safety of care in an environment that reduces risk for patients and staff. We are accountable for and committed to providing care and services to our patients and families that reflect our values: Compassion Imagine It s You Respect Respect everyone Accountability Take ownership Teamwork We all help provide care Learning Always strive to improve QHC s quality improvement goals for 2014/15 support our strategic plan and directions including: 1. Enhance the quality and safety of care 2. Create an exceptional patient experience 3. Provide effective care transitions 4. Be an exceptional workplace What we will be focusing on and how these objectives will be achieved Over the course of the next year QHC will continue to build on the initiatives in 2013/14 to further enhance the quality and safety of care and services delivered at all four hospitals. The hospital s overall quality improvement agenda, of which the 2014/15 QIP is a subset of, has been built on clear priorities, leadership accountability, process improvement methodology and setting measurable targets and clear action plans. In order to support these priorities QHC will support the following actions to significantly improve the capacity of the organization to monitor, sustain and create further improvements: program based Quality and Patient Safety Committees team leader development curriculum focused on critical thinking, problem-solving, improvement methodology, patient safety science and mentorship the Human Resources tactical plan focused on leadership development and capacity building focus on working relationships and joint process improvements with significant partners such as the Community Care Access Centre By March 31st, 2015 QHC will achieve the following aims and measures indicated on our 2014/15 QIP and aligned with our four strategic directions. Enhance the quality and safety of care Our aim is to improve the overall safety of care we deliver to our patients. Medication reconciliation is one strategy that contributes to safer prescribing and administration of medications and thus safer care. Increasing the number of admitted patients with completed medication reconciliation on admission was a corporate priority in 2013/14. We successfully increased our completion of medication reconciliation on admission by over 30%, year to date. However, due to the importance medication reconciliation has in safe medication practices, discharge planning, decreasing unnecessary readmission and opportunity for further improvement, QHC will continue a corporate focus on increasing the number of admitted patients receiving medication reconciliation. The full implementation of an electronic medication reconciliation program will provide a more efficient process and provide the necessary processes to complete medication reconciliation at transfer and discharge. 2
Create an exceptional patient experience Our aim is to create an exceptional patient experience through seamless patient flow and reduced wait times in the Emergency Department (ED). QHC measures the amount of time patients wait in our ED s from the time the patient is triaged to the time they are either discharged home or admitted to the hospital and moved to an inpatient bed. Extended lengths of stay in the ED are a common and significant issue for most hospitals and require multiple years of work to significantly impact. To date QHC has exceeded the target of a 5% reduction in ER wait times from 21.4 hours to less than 19 hours. Despite this progress there remains significant room for improvement. Therefore QHC will continue to implement focused improvement projects led by emergency and inpatient staff and physicians to further reduce emergency wait times by an additional 10% in 2014/15. In order to achieve a reduction in our ED wait times we will focus on several improvement strategies including: Further development and implementation of clinical pathways to reduce lengths of stay on inpatient units and increase capacity for admitted patients Improve physician initial assessment time at all four emergency departments Early identification and care planning for patients with dementia and delirium, who have a higher length of stay than the average patient without dementia or delirium Increase the completion rate of diagnostic tests on in-patients over the weekend to support consistent patient flow and discharge planning Ensure all medicine patients in QHC Belleville General Hospital have predictive discharge dates to strengthen the healthcare team s ability to discharge patients in an appropriate timeframe Ensuring sustainability of the nurse practitioner model of care to support consistent operation of the fast track Green Zone at QHC Trenton Memorial Hospital Provide effective care transitions Our aim is to ensure that we are consistently seeking integration opportunities with our community partners so that patients experience effective care transitions within QHC and between QHC and other health care providers. This will result in patients and their families finding it easier to move through the healthcare system and access the care they need. We achieved considerable success in 2013/14 to date and will continue to focus on increasing the availability of inpatient beds by reducing the number of patients with chronic obstructive pulmonary disease, congestive heart failure and pneumonia who are readmitted to hospital thirty days after discharge. Further integration and uptake of clinical pathways for all three diagnosis are essential to our success as they include the various health care services (acute and community) that patients with these conditions require to optimize their ability to self manage their care. In addition to these three clinical pathways we will also focus on ensuring all in-patient medicine patients are placed on the general medicine admission order set; providing a standard path for patients to follow leading to improved efficiencies and meeting expected length of stay goals. Be an exceptional workplace Our aim is to provide an exceptional workplace at QHC where staff, physicians and volunteers are proud to recommend QHC as a place to work. This involves providing opportunities for all to learn and grow. Part of our success in achieving this objective in 2014/15 will be through the involvement and active participation of staff, physicians and volunteers in the improvement initiatives tied to our 2014/15 QIP. Participation in the above activities by staff, volunteers and physicians will lead to improved systems to provide care within, better quality of care for our patients and continued opportunities to learn and grow. 3
Key enablers Balanced fiscal position QHC believes that a strong and balanced fiscal environment is key to providing sustainable, quality care. To that end, the total margin continues to be a priority for the 2014/15 QIP. Several key initiatives, such as renegotiating several service contracts, standardizing and reducing variation in practice such as lab and drug utilization and achieving further reductions in length of stay and additional materials management efficiencies will all contribute to an efficient and effective organization. Staff, physicians and volunteers are encouraged to find ideas for cost savings in their various departments and teams have been formed to develop these ideas into tangible plans. Regular huddles at the unit and department level discuss progress toward achieving savings and further ideas for further efficiencies. How the plan aligns with the other planning processes The QIP is one of several key components that contribute to the achievement of the QHC strategic plan. As stated, the 2014/15 QIP was informed by this strategic plan and specifically links to our four key strategic directions. The QIP also aligns with several requirements from the Hospital Service Accountability Agreement (HSAA), key improvement strategies through the South East Local Health Integration Network (SELHIN) and Accreditation Canada. The strategic plan priorities inform the development of the operating plan (budget), the Quality Improvement Plan and the annual project plan, encompassing the HSAA, SELHIN and accreditation priorities. This process begins in August and permits time for discussion, development and approval of plans, as outlined in the following table. Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Board Planning Retreat PLANNING Operating Plan Principles Identification of QIP Opportunities ANALYSIS Development of Operating Plan Investigation of QIP Opportunities Strategic Priority Review APPROVAL Operating Plan Approval 4
QIP Approval Annual Project Plan IMPLEMENTATION Improvement initiatives start-up Implementation Integration & Continuity of Care As the new health care funding model is being implemented, all members of the health care system are becoming more reliant on each other s services. As hospitals are the first sector impacted, we are seeing this requirement more than others. In order to maintain provision of safe, high-quality care with the current financial pressures, we need to review the services we provide and rely more on our partners to provide this care at home or in other health care settings. We are most dependent on the Community Care Access Centre (CCAC) to provide services to assist in timely, efficient discharge; primary care to support the diversion of patients from the emergency rooms and the transition of patients out of the hospital; and other hospitals and community agencies to provide specialized care. The mechanisms we have to influence these providers include the development of one-to-one relationships, health links and the SELHIN led clinical services roadmap. QHC believes that relationships with primary and community care partners are key in achieving health for all our communities. This is reflected in the QHC strategic plan and direction to improve transitions of care. QHC is an active partner in two Health Links initiatives, Rural Hastings and Quinte Health Links. The priorities for each of these health ink initiatives support QHC s strategic directions and the QIP indicators: medication reconciliation and reducing readmissions for patients with chronic obstructive pulmonary disease, congestive heart failure and pneumonia. Furthermore, the focus on improving care for complex patients with dementia and/or delirium actively engages the CCAC, long-term care and retirement homes, together with Behavior Support Ontario to develop organizational capacity and individualized clinical and discharge plans. These initiatives are based on a philosophy that the hospital is only one player in a larger patient journey and includes both the admission and discharge processes as part of that continuum of care. Challenges, Risks & Mitigation Strategies Throughout our QIP planning process project charters are developed for each initiative to identify challenges and opportunities and strategies to mitigate risks. While our organization has the ability to respond to the ever changing healthcare environment, the following challenges and risks are noted and will be kept in the forefront as we proceed with implementing our 2014/15 QIP. 5
Continuing to adapt and improve at a pace commensurate with the demands from further budget reductions The ability to mount and sustain significant projects to achieve the corporate goals and priorities The ability to gather timely, accurate data from a variety of complex data sources. Unavoidable external risks exist that are often outside of QHC s control, such as the availability of long-term care home beds and capacity of the primary care and community care systems, such as behavioural support resources in the region. Beyond these ongoing challenges and risks inherent to the healthcare environment we have taken several steps to proactively mitigate risks to achieving our goals and objectives as outlined in the 2014/15 QIP through the following measures: Ensure resources are maximized in the clinical support departments Continued focus on building capacity in frontline leadership, managers and directors Maximize staff engagement to build a truly patient focused organization that will continue to deliver quality care in a culture of improvement Asses organizational readiness for additional changes and its implications on the targets and projects for next year Assign corporate improvement teams to each indicator noted as an improve on our QIP Provide improvement teams with resources, knowledge and skills to successfully apply the QHC improvement model and achieve our set targets Share team progress reports with the senior leadership team on a monthly basis using a visual management tool comprised of red, yellow and green colour codes; indicating distance from achieving set targets. This provides the ability to quickly identify challenges and roadblocks and the necessary strategies to remove the roadblocks Provide quarterly reports with the corporate Quality and Patient Safety Committee, the Board Quality of Patient Care Committee, the Board of Directors and the Medical Advisory Committee using the same visual management tool as noted above The alignment of our 2014/15 QIP with the strategic plan along with processes and structures to identify and mitigate risks places QHC in a good position to make improvements to the care and services we provide in accordance with our goals, objectives and targets as outlined in our QIP. Information Management Systems QHC employs an electronic medical record which feeds into a corporate Decision Support information management system supported by Business Intelligence software. Through this system we are able to access data in a timely fashion to facilitate strategic, tactical and operational decision making. This overall system provides the ability to answer questions such as: what happened, where is the problem and what actions are required to mitigate any risks. Furthermore we are able to look at why a trend is occurring and predict what will happen next. Several tools are available for management to use daily in finding data to inform decisions, identify issues and track progress. These include: corporate and unit based scorecards, self-service data on the corporate website and standard reports. All of this information is used to support not only corporate priorities related to quality, patient safety and performance but also our decision making during operational and budget planning cycles. As an example, our ability to document the use of clinical pathways for Chronic Obstructive Pulmonary Disease and Congestive Heart Failure in the electronic documentation system allows us to link the compliance with these pathways with our readmission rates for these diagnoses and make inferences as to whether the pathways are improving care and reducing readmissions. Without our electronic documentation system and information management system creating this type of data would be labour intensive and not timely enough to take corrective actions. In 14/15 we are committed to furthering the ability for units and departments to have data readily available to support their quality improvement work. 6
Engagement of Clinical Staff & Broader Leadership Our aim is to provide an exceptional workplace at QHC where staff, physicians and volunteers are proud to recommend QHC as a place to work. This involves providing opportunities for all to learn and grow. Part of our success in achieving this objective in 2014/15 will be through the involvement and active participation of staff, physicians and volunteers in the improvement initiatives tied to our 2014/15 QIP as well as our preparation for Accreditation in May 2015. In order to support this QHC has committed to creating a Culture of Staff Engagement in 14/15. The goal of this priority is to engage the minds and creativity of staff and physicians leading to improved quality of care and patient satisfaction. This will be achieved by focusing on six key elements: autonomy, feeling valued, reduced frustration, collaboration, well-being and development. By focusing on these elements we will be able to support frontline staff in identifying and solving problems and thus further engage them in delivering high quality care. This work will be led by the Senior Leadership Team and has full endorsement from the QHC Board of Directors. Accountability Management As part of the annual planning process, the Senior Leadership Team (SLT) develops performance goals linked to compensation that are derived from the QHC strategic directions and initiatives or other key performance areas important to QHC success. As per the requirements under Excellent Care for All Act (ECFAA) legislation, there must be a linkage between the QIP performance goals and Senior Leadership Team compensation. The following table describes the Senior Leadership performance goals linked to compensation and the QIP goals. This was approved by the Board of Directors on March 25th, 2014. Strategic Direction Outcome Measure/Indicator Weight 2013/14 Performance 2014/15 Target Enhance the Quality and Safety of Care *Medication Reconciliation on Admission: Percentage of patients who have received medication reconciliation on admission (excluding labour and delivery patients) 20% 62.7 (Q3) Quality Improvement Plan (QIP) Target Create an Exceptional Patient Experience *ER Wait Times: 90 th percentile ER lengthof-stay for admitted patients 20% 17.6 (Q3) Target 20 QIP Target Improve Strategic Enablers Total Margin: Percentage by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization in a given year 20% -0.25% (Q3 2013/14 YTD) QIP Target The following describes the percentage of pay for performance compensation and the process for selection of goals. i. The percentage of pay for performance compensation for Senior Leadership Team members for 2014/15 is: CEO and COS 5% of salary; Vice Presidents 3% of salary; and Directors (Communications, Strategic Planning and Projects) 1% of salary. The total amount of the payfor-performance compensation in 2014/15 cannot exceed the total amount of pay-at risk distributed to SLT members in 2011/12. ii. The process for selection of goals: Priority indicators are identified by the Quality of Patient Care Committee. The Senior Leadership Team reviews the priority indicators, strategic and system 7
iii. initiatives and makes recommendation regarding the performance goals linked to compensation to the Human Resources Committee of the Board. In the event that there has been significant achievement of the objective specified but the identified targets have not been achieved, the Board has the discretion to modify the amount of the performance based compensation. Health System Funding Reform Ontario s healthcare system is experiencing a major transformation through the Health System Funding Reform. Selected procedures, referred to as Quality Based Procedures have a target cost and hospitals are challenged to provide care within that cost while meeting required quality outcomes. Hospital funding is adjusted to reflect these lower costs. This change in the basic allocation of resources will continue to drive value and effectiveness in the provision of hospital care. QHC has already implemented six Quality Based Procedures over 2013/14 and will be introducing an additional three in 2014/15. A corporate Quality Based Procedure Steering Committee is in development and will provide a forum to continue a focused approach to the introduction of additional quality based procedures to optimize the impact on our ability to balance efficiencies and quality. In the 2014/15 QIP, there are several indicators that are targeted toward assisting the organization to meet the challenges of the HSFR. Reducing readmissions for patients with chronic obstructive pulmonary disease, congestive heart failure and pneumonia three of the quality based procedures, will require QHC to implement evidence based clinical pathways to reduce variation in care between care providers. This will also link patients back to the community with more timely and uniform data. 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: Steve Blakely Board Chair Mary Clare Egberts Chief Executive Officer Instructions: Enter the person s name. Once the QIP is complete, please export the QIP from Navigator and have each participant sign on the line. Organizations are not required to submit the signed QIP to HQO. Upon submission of the QIP, organizations will be asked to confirm that they have signed their QIP, and the signed QIP will be posted publically. 8
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