Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

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1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/26/2015 This document is intended to provide health care s 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 s should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, s 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

2 Overview The Kingston Family Health Teams (KFHT)2015/2016 Quality Improvement Plan (QIP) outlines the team's commitment to providing excellent primary care to patients while aligning with Ministry of Health and regional priorities and initiatives including access, integration, patient-centered care and health. KFHT serves approximately 30,000 patients, has five locations across the Kingston region and includes twenty-one family physicians plus interdisciplinary health professionals including nurse practitioners, a physician assistant, registered nurses, social workers, a dietitian, and a part-time psychologist and pharmacist. KFHT has taken a number of steps over the past five years to advance efforts around formalizing quality improvement. This has included participation by physician leads and senior staff in training and workshops on Quality Improvement Innovation Project and Effective Governance for Quality in Primary Care. Most recently four members of the QI Committee participated in the 9 day Improving and Driving Excellence Across Sectors (IDEAS) program with Health Quality Ontario (HQO)and the University of Toronto. Through the Quality Improvement (QI) Committee we have been able to formalize and develop a structure to identify and support QI projects across the team. The main focus of 2014/2015 was to survey 3% of KFHT patients using a standardized survey tool developed in collaboration with five other FHTs in the region. This tool was inclusive of the four HQO recommended questions and results were above provincial and South East LHIN averages. With suggestions from patient feedback, KFHT has recently updated their website and has included a Quality Improvement section where the QIP plan, status reports and patient survey results will be posted for the first time. Integration & Continuity of Care The Kingston Health Link (KHL) has made significant progress in identifying patients with four or more active chronic conditions, completing Coordinated Care Plans (CCPs) and reducing the number of inpatient, emergency department (ED) and urgent care visits at both local hospitals for these complex patients. The President of KFHT is a member of the KHL Steering Committee and will implement a trial of CCPs for KFHT patients at one site in 2015/16. The implementation of Hospital Report Manager (HRM) by Kingston and area hospitals in 2014 has improved the transmission of Discharge Summaries to KFHT. The transmission of reports from the Kingston General Hospital Emergency Department and Hotel Dieu Hospital (HDH) Urgent Care Center (UCC) continues to be slow, however the KGH and HDH leadership inform us that they are working with the Primary Care Lead in the SELHIN on a regional solution to this problem. KFHT has partnered with the Maple (Community) Diabetes program, which increases access to care for KFHT diabetic patients through group sessions. Over the coming year we will work with Kingston Health Links and partner agencies to identify a common indicator to measure integration across the continuum of care. Challenges, Risks & Mitigation Strategies Some of the challenges include communicating QI initiatives and engaging staff across multiple (5) sites. The mitigation strategy is the development of a 2

3 Communications Working Group. The QI physician lead and the Quality Improvement Decision Support Specialist (QIDSS) are travelling to each site to talk about QI projects, the Quality Improvement Plan (QIP) and to share the results of the patient survey. A "dashboard" performance report has been created and tested by the QI committee in 2014/2015 and will be updated and posted at each site every quarter. There were also some challenges at the KFHT Board and Executive Director (ED) level in 2014/15. The governance structure of KFHT and Kingston Family Health Organization (FHO) is undergoing renewal. A new Executive Director joined the team on March 2, 2015 and a new strategic plan for the KFHT is being developed. Information Management Systems KFHT transitioned to Telus Practice Solutions Suite (PSS) in KFHT takes full advantage of the EMR in the ongoing monitoring of quality data across patient care services and programs. This is achieved by implementing standardized data entry processes that will capture data within the EMR for measurable outcomes. Although this is an ongoing long-term process, it remains a team priority and continues to be discussed and worked on through the QI Committee. KFHT is constantly working to produce electronic versions of paper forms which are requested by all the services our patients are referred to, and to educate KFHT staff in the use of these electronic forms. KFHT is learning how to customize PSS to improve efficiency of clinical care based on best practice standards. Engagement of Clinical Staff & Broader Leadership KFHT has embraced the support of our new QIDSS in developing an enhanced QI Plan for 2015/16. We formed working groups inclusive of multiple staff disciplines and all KFHT sites to address specific components of the QIP Plan e.g. patient experience survey. Efforts include a schedule of meetings at each of our five sites to further engage staff in the requirements of the QIP Plan and discussion on identifying additional QI initiatives. Quality Improvement is a standing item on the Board of Directors agenda. In addition, all members of the QI Committee are responsible for reporting the results of each QI initiative to their site. A quarterly performance report will be shared with all Team staff. Patient/Resident/Client Engagement The QI Committee includes patient membership. In addition, our Depression Initiative has engaged patients in a number of ways. We are using "storyboarding", a patient-centered experience design method, to guide the creation of a care pathway for patients with depression. Through focus groups and surveys, patients' input is central to the development of this care pathway. The aim of the project is to ensure that patients with depression have access to optimal, seamless care. A poster for this project was presented at the October 2014 Association of Family Health Teams Conference. Since then it has been rotating among the waiting rooms of the five Team sites. Patients are invited to post their comments/suggestions for improvement using a marker and post-it notes. This activity has been very helpful in identifying what the patients view as being important to their care. We would like to build on lessons learned from this initiative and spread it across other KFHT programs and services. 3

4 Accountability Management KFHT created a QI Committee one year ago, with attendees from each of the five sites and from multiple disciplines. The Committee has formed three sub-committee working groups that will work directly on the initiatives outlined in our QIP plan. i.e., Patient Survey Working Group and a Communications Working Group. The QI Committee reports to the KFHT Board of Directors who oversee the QIP Plan. Sign-off It is recommended that the following individuals review and sign-off on your s Quality Improvement Plan (where applicable): I have reviewed and approved our s Quality Improvement Plan Board Chair Clinician Lead Executive Director / Administrative Lead CEO/Executive Director/Admin. Lead (signature) Other leadership as appropriate (signature) 4

5 AIM Measure Change Quality dimension Objective Measure/Indicator Unit / Population Source / Period Organization Id Current performance Target Target justification Planned improvement initiatives (Change Ideas) Methods Process measures Access Access to primary Percent of In-house survey / 92280* )Obtain 1.)Develop, review and approve a Patient Experience care when needed patients/clients able April patients through a regional Questionnaire, survey patients, analyze the data and to see a doctor or March Patient Experience report results to patients and providers. 2.) Add patient nurse practitioner on (surveyed experience survey to the KFHT website the same day or next sample) day, when needed. 61 Ontario provincial average is (Measuring Up Report, page 35). Site results range from 39.7% to 80.85%. The goal will be to have all sites achieve current performance in # of patient experience questionnaires completed from website # of patient experience questionnaires completed through survey blitz Goal for change ideas Minimum 3% of Comments Integrated Reduce ED use by increasing access to primary care Timely access to primary care appointments postdischarge through coordination with hospital(s). Reduce unnecessary hospital readmissions Percent of visited the ED for conditions best managed elsewhere (BME). Percent of saw their primary care provider within 7 days after discharge from hospital for selected conditions (based on CMGs). Percentage of acute hospital inpatients discharged with selected CMGs that are readmitted to any acute inpatient hospital for nonelective patient care within 30 days of the discharge for index org visiting ED (for conditions BME) org discharged from hospital org discharged from hospital Ministry of Health Portal / April March Ministry of Health Portal / April March Ministry of Health Portal / April March * Current performance based on 2012/13 MOHLTC Health Data Branch report; 678 of Conditions BME are: conjunctivitis, cystitis, otitis media, and upper respiratory infections (example common cold, acute or chronic sinusitis, tonsillitis, acute pharyngitis, laryngitis or tracheitis, and others.) There is a lag between the source 92280* 92280* Current performance based on 2012/13 MOHLTC Health Data Portal (DAD records) 29% of patients with selected conditions saw their primary care provider within 7 days of discharge (120 out of 443 discharged patients). There is a lag between the source data and the current activities,therefore, target remains conservative as more current data (2013/14) still will not reflect activities occurring this (or even last) year. Note: CMGs include stroke, COPD, pneumonia, congestive heart failure, cardiac conditions, 15 Current performance is based on 2012/2013 results obtained from the Health Data Branch Portal. This represents 80 of 440 patients who were readmitted within 30 days. Kingston General Hospital's current overall readmission rate is 19% with a goal of reaching 12.9%. 1)Increase patient awareness of primary care access and services. 1)Participate in the Kingston Health Link initiative through the development of Coordinated Care Plans for patients with four or more active chronic conditions. 2)The South East LHIN is developing a single, centralized web interface and data source for all providers in the SE LHIN that is called South East Health Integration Information Portal (SHIIP). SHIIP will house discharge 1)Participate in the Kingston Health Link initiative through the development of Coordinated Care Plans for patients with four or 2)Work with local hospital re: data sharing to evaluate cases readmitted within 30 days and whether there are ways to reduce this 1. Communication campaign; patient education of access and services through various methods (e.g. website, waiting room monitors, handouts, posters, newsletters, etc.) 2. Review 2014/2015 Patient Survey Qualitative comments related to "weekend access" Identify health link patients with four or more active chronic conditions and complete Coordinated Care Plans for patients. Implement the SHIIP portal at by March 31st, Obtain physician logins, train users and test the SHIIP functionalities. Identify health link patients with four or more active chronic conditions and complete Coordinated Care Plans for patients. 1) Contact local hospital decision support team and director of patient care 2) Assess cases readmitted and reasons for readmissions, discuss potential changes to reduce readmission rates 1. % of patients who stated they are aware and/or have used KFHT's After Hours Clinic 2. Compile qualitative access report 1) Total # of Coordinated Care Plans Completed. 2) 3 and 6 month IP readmission rate, KGH ED and HDH Urgent Care Clinic Visit Rate pre and post CCP 1. 80% of patients Gathering are aware and/or baseline data. have used KFHT's After Hours Clinic by March 31st, Qualitative Access Report compiled by April 30th, patients of will have a Coordinated Care Plan documented in their chart by March 31st, 2016 (Approximately 2 per month) 2. 10% reduction in IP % of physicians that adopt SHIIP 50% of physicians adopt SHIIP by March 31st, ) Total # of Coordinated Care Plans Completed. 2) 3 and 6 month IP readmission rate, KGH ED and HDH Urgent Care Clinic Visit Rate pre and post CCP 1) Local hospital contacted 2) Data reviewed and discussed with primary care patients of will have a Coordinated Care Plan documented Determine targets and change ideas as process evolves Patients are identified in collaboration with healthcare partners including CCAC and local hospitals. Patients are identified in collaboration with healthcare partners

6 Patient-centred Receiving and utilizing feedback regarding patient/client experience with the primary health care. Percent of patients who stated that when they see the doctor or nurse practitioner, they or someone else in the office (always/often) give them an opportunity to ask Percent of patients who stated that when they see the doctor or nurse practitioner, they or someone else in the office (always/often) (surveyed sample) (surveyed sample) Percent involve them of patients as who stated that when they see the doctor or nurse (surveyed practitioner, they or sample) someone else in the office (always/often) spend enough time with them? In-house survey / April March In-house survey / April March In-house survey / April March * * Maintain current performance. Ontario provincial average 83.8% (Measuring Up Report, page 40) * Maintain current performance. Ontario Provincial average 85%. (Measuring Up Report, page 42). 87 Maintain current performance. Ontario provincial average 82%. (Measuring Up Report, Page 41). 1)Obtain patients through a regional Patient Experience 1)Obtain patients through a regional Patient Experience 1)Obtain patients through a regional Patient Experience Develop, review and approve a Patient Experience Questionnaire, survey patients, analyze the data and report results to patients and providers. Develop, review and approve a Patient Experience Questionnaire, survey patients, analyze the data and report results to patients and providers. Develop, review and approve a Patient Experience Questionnaire, survey patients, analyze the data and report results to patients and providers. # of patient experience questionnaires completed Minimum 3% of # of patient experience questionnaires completed Minimum 3% of # of patient experience questionnaires completed Minimum 3% of Population health Reduce influenza rates in older adults by increasing access to the influenza vaccine. Percent of patient/client over age 65 that influenza immunizations. aged 65 and older Review / na 92280* The South East LHIN flu shot challenge target is 70%. KFHT has exceeded this target and 1)Maintain current performance SE LHIN and/or provincial plans to maintain results in the averages and targets 2015/16 flu season. through maintenance of current processes and systems that support flu immunization including flu clinics. Contact patients by telephone that are due for a flu % of KFHT sites that report results SE LHIN shot. Encourage patients to report to their primary care averages on a quarterly basis provider if they had a flub shot at a pharmacy. as reported SE LHIN. Reduce Cancer mortality through regular screening. Percent of eligible are up-to-date in screening for breast cancer. eligible for screening Review / n/a 92280* The provincial average according to Cancer Care Ontario is 68%. KFHT is attempting to increase their result to meet the provincial target of 80% by March 31st, )Maintain current cancer screening reconciliation system where patient is contacted by telephone by reception if due for screening. Reconcile MOHLTC reports with EMR as needed. Contact patients by telephone that are due for screening. Book patient appointment. % of KFHT sites that report results on a quarterly basis as reported by Cancer Care Percent of eligible are up-to-date in screening for colorectal cancer. eligible for screening Review / n/a 92280* Current provincial average is 65% according to Cancer Care KFHT plans to reach provincial average. 1)Maintain current reconciliation processes and systems that encourages regular screening. Reconcile MOHLTC reports with EMR as needed. Contact patients by telephone that are due for screening. Book patient appointment. Review FOBT kit compliance rate and gather baseline data. % of KFHT sites that report results on a quarterly basis as reported by Cancer Care

7 Percent of eligible are up-to-date in screening for cervical eligible for cancer. screening Review / n/a 92280* Current provincial average is 70%, provincial target is 80% according to Cancer Care 1)Maintain current performance SE LHIN and/or provincial averages and targets through maintenance of current processes and systems that encourages regular screening. Reconcile MOHLTC reports with EMR as needed. Contact patients by telephone that are due for screening. Book patient appointment. % of KFHT sites that report results on a quarterly basis as reported by Cancer Care Other Depression Initiative *NEW INITIATIVE # of PHQ9's completed by the team # of new diagnosis of depression (measured weekly by site) % / All patients Review / Measured Weekly by Site 92280* CB 10 Target is 10 PHQ9's completed per week across the KFHT team. The 5 month pilot project with Norwest site was able to increase their rate from 1.5 per week to 5 per week. 1)Spread the Depression Initiative (use of electronic PHQ9 assessment tool) across other KFHT sites (4) Gather baseline data at four other sites, educate providers on the project, train providers on how to use the tool, establish process measures and PDSA's to increase uptake of usage across KFHT as needed # of new sites participating in the Depression Initiative using the PHQ9 % of Physicians/Nurse Practitioners who have utilized the PHQ9 4 remaining sites are participating in the Depression Initiative by March 31st, % of Physicians/Nurse Practitioners are using the PHQ9 by March 31st, 2016

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