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

Transcription

1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/26/2015 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

2 Overview Overview of Our Organization s Quality Improvement Plan Providence Care places the highest priority on patient safety, sustainability of service, and the quality of care and services for patients with complex, chronic illness and disability. Our mission commitment to enhance the Quality of Life for each person, results in a commitment to: Ensure safe care Achieve sustained quality outcomes for clients across all programs and services Show respect, dignity and compassion in all we do Demonstrate effective stewardship in the responsible management of all that is entrusted to our care. Employees throughout Providence Care participate in our quality improvement efforts. We focus on patient care delivery and support processes, improving patient outcomes and effective practices. Providence Care s Quality Improvement goals derive from our commitment to improve quality and ensure patient safety, delivering optimal care, and achieving high levels of patient satisfaction. Focus: Our goals are: 1.We will ensure high levels of patient, client, and staff safety: We will work to further improve our hand hygiene rate before patient/patient environment contact to 86.3%. We will maintain low C-Difficile infection rates to 0.25/1,000 patient days and work to reduce them further to remain below the Provincial average. We will work to maintain a low rate of new pressure ulcers in Complex Care. We will work to further reduce the use of physical restraints with a focus on reducing restraints on admission in Seniors Mental Health to the provincial average of 4.7 %. We will work to maintain a low rate of patient falls in the last 30 days in Complex Care patients. 2. We will maintain our effectiveness by managing our financial health, maintaining a total margin of 0.0%. 3. We will be patient-centered, maintaining patient satisfaction levels that are above the average for peer specialty hospitals. 4. We will improve integration of patient care; We will work to achieve effective transitions for mental health clients to home and the community by maintaining a readmission rate of 2.3% or lower. We will work to reduce unnecessary days spent in hospital to 25% for mental health clients and 11% for complex care and rehabilitative patients. Providence Care will accomplish this by examining its performance against existing and accepted provincial benchmarks for peer specialty health service providers. This screening will identify priorities to measurably improve quality. Alignment: Providence Care s Quality Improvement Plan is aligned with and was based on: 2

3 Our core values of Respect & Dignity, Compassion and Stewardship; Our 3 operational priorities: 1. Delivering top quality, efficient and effective care: Optimizing new models of funding (i.e. HBAM) 2. Working in community, to provide seamless and accessible care: Collaborating with partners, community organizations and patients & families to engage all individuals in their health care 3. Being new hospital ready by 2017: Ensure a safe and positive transition to the new Providence Care Hospital for all patients, families, staff and community members; Our Hospital Service Accountability Agreement; Our commitment to support the objectives of multiple government priorities: - Patients First MOHLTC Health Action Plan (Minister Eric Hoskins) - Commission on the Reform of Ontario s Public Services (Don Drummond) - Provincial strategies including Seniors, Residents First and Aging at Home - Excellent Care for All Act - The South East LHIN s Integrated Health Service Plan 3 Integration & Continuity of Care As a leading health care provider of specialized aging, mental health, and rehabilitative care in hospital, long-term care, community and home care programs, Providence Care manages transitions and integrates care to a broad range of medically complex patients, and clients. Well planned care results in high rates of client satisfaction and low readmission relative to peer specialty hospitals. Developing Providence Care s quality improvement plans is multi-sectoral, and requires pan-organizational involvement, as well as consultation with the South East Local Health Integration Network and local peer providers focusing on effective patient transitions and effective collaboration with Primary Health Care Services and providers. Providence Care and the region are actively involved in Health Links. The SE LHIN has seven Health Links that are encouraging greater collaboration and co-ordination between a patient s health care providers, as well as the development of personalized care plans. The Kingston and Kingston Rural Health Link will develop plans and measure results to: Improve access to care for seniors and patients with complex conditions Reduce avoidable emergency room visits Reduce unnecessary readmission to hospitals shortly after discharge Reduce the wait time for referral from the primary care doctor to a specialist Improve the patient s experience during their journey through the health care system. Challenges, Risks & Mitigation Strategies Providence Care is committed to providing the highest quality care within our available resources. Like other providers our ongoing challenge is managing the increasing needs and requirements of the people and communities we serve, while maintaining the financial health of the organization. We have identified a number of potential risks that will need to be monitored and mitigated to the extent possible as we implement our QIP. Key challenges, risks and mitigation strategies include: 3

4 Challenge / Risk The impact of Health System Funding Reform is a significant challenge to maintaining a balanced operating plan. Higher actual to expected costs in the new Health- Based Allocation Model (HBAM) funding formula for complex care and physical rehabilitation and uncertainty related to future volumes for clinical quality-based procedures Providence Care s will be significantly challenged to reduce the current rate of ALC days in Mental Health Services and Complex Care due to systemic issue of limited access to long term care beds. Risk of not achieving 2015/16 performance targets set for patient experience indicators due to consistently high satisfaction rates. Although the total number of Complex Care patients experiencing a fall in the past 30 days is the lowest it has been in the past 5 years, it will be challenging to maintain the current low falls rate and there is a risk that the rate will increase from the current performance due to a changing patient population in Complex Care. Mitigation Strategy Providence Care s mitigation strategy is to be accountable for all of its resources. We will continue to strive to attain the expected cost for Rehabilitation, Complex Care, and Mental Health Services and reaching the 25 th percentile benchmark for corporate and support services. To meet the volumes and costs of QBP s impacting rehab, each will be reviewed against the MOHLTC QBP Clinical Handbook and a gap analysis will be conducted along with a review of Best practice guidelines. Continue to work with community partners and the LHIN to address systemic issues and advocate for equitable access to LTC beds for inpatient mental health clients. Development of Internal transfer process to improve flow for ALC patients from Rehab to Complex Care beds to wait for placement. Targets for those indicators where Providence Care has consistently achieved high performance have been set to maintain current high performance however the target justification indicates it is likely that performance rates will be within a high performance range due to small sample sizes. We will continue to implement the Falls Prevention Program and associated strategies and best practices aimed at preventing patient falls and reducing injury severity. Information Management Implementing a comprehensive electronic patient record (epr) system has been a key priority designed to support improved care both internally and health systems efficiency and effectiveness regionally. Between October 2014 and July 2015, Providence Care successfully implemented the first phase of its electronic patient record (epr) for its hospital operations and extended it to include registrations for its long term care home and community services. It has provided a significant advancement in the standardization and improvement in patient care and the continuity of records. The epr is directly connected to Kingston General Hospital and Hotel Dieu Hospital which provides for a comprehensive electronic documentation system for patient care in the Kingston region. Providence Care is beginning to work on the second phase of the epr implementation which will further advance the on-line documentation and advances in patient scheduling and nurse applications. This will advance our progression towards a fully electronic patient record which provides for better care management. At the same time, the SE LHIN region has embarked on a proposal to purchase and implement a single Health Information System (HIS). The purpose is to advance the integration of patient information in seamless fashion and provide a common platform for staff and physicians. Providence Care has been part of this process, but given its recent decision it will look to interface its epr product with whatever system is chosen. 4

5 Engagement of Clinicians & Leadership The development, endorsement and approval process of Providence Care s hospital Quality Improvement Plan is a shared responsibility and includes involvement and engagement at all levels of the organization and takes into account the needs of our patients and clients. Priority Indicators reflect organizational and sector specific priorities as well as system wide, transformational priorities where improvement is co-dependent on collaboration with other sectors. These indicators are reviewed with all clinical and administrative quality teams and those determined to be relevant to Providence Care are selected for inclusion in the annual Quality Improvement Plan. Additional indicators which are determined to be important to the hospital s quality improvement goals are also selected and included in the Quality Improvement Plan. Targets within the Plan are set by the clinical and support service teams most responsible for the indicators and includes consultation with team members as well as endorsement and approval of key committees within the hospital. This process incorporates medical staff input and ensures that the medical staff of departments representing Queen s University School of Medicine are committed to and held accountable to the same quality improvement results as hospital staff and leadership. Following the endorsement and approval of the various indicators and targets, the most responsible clinical and support service teams identify planned improvement initiatives, methods, process measures and goals for change ideas in the Quality Workplan. Consultation and approval is sought at the departmental, organizational and board levels through the Quality and Patient Safety Committee, Senior Clinical Operations Committee, Medical Advisory Committee, Senior Leadership, Performance and Quality Committee of the Board and the Board of Directors. Core systemic goals are established in collaboration with community and hospital partners, and the Southeast Local Health Integration Network (SE LHIN). Patient/Resident/Client Engagement Providence Care facilitates a fully confidential process by which patients, clients, and their families can provide compliments or complaints about our quality of care and services. Complaints help us track and resolve any issues that arise in the context of care and service delivery. Providence Care management reviews and responds to the complaints of clients, families/significant others/substitute Decision-Makers in a timely, thorough and impartial manner. The process respects confidentiality and is equitable for the complainant and Providence Care personnel. Tracking and addressing complaints is an important means by which we improve our care and services. Compliments made about care and service delivery, are indications of satisfaction and are an important way to acknowledge contributions of Providence Care staff. The reporting of actual or potential incidents is an important strategy for enhancing the safety of clients, visitors, staff and volunteers. Safety reporting provides an opportunity to identify trends and track their follow-up. The knowledge generated through this process allows us to learn from past experience so that system improvements can be made. Accurate and timely reporting of incidents permits Providence Care to identify potential issues, communicate effectively with the people involved, including disclosure to patients, clients and families. As part of our commitment to quality improvement for our patient, clients and their families, it is important to hear from the people we serve about how we are doing. Providence Care regularly administers patient, client and family satisfaction surveys through NRC Canada. We then use the survey results to identify our strengths and our opportunities for improvement and include related quality improvement initiatives in corporate, program and service level Quality Improvement Plans. Another important way in which Providence Care engages patients is through Patient & Family Councils. The Councils provide constructive input into issues that affect the quality of life of patients and assist in finding solutions. Providence Care has engaged with patients, clients and their families since first embarking on the hospital redevelopment project. The patients, clients and their families continue to provide valuable input and feedback in the design of our new hospital through their active participation in various focus and working groups. 5

6 Accountability Management Purpose The purpose of Providence Care s performance based compensation plan as defined by the Excellent Care for All Act, 2010 is: 1. To drive performance and improve quality care 2. To establish clear performance expectations 3. To create clarity about expected outcomes 4. To ensure consistency in application of the performance incentive 5. To drive transparency in the performance incentive process 6. To drive accountability of the team to deliver on the Quality Improvement Plan (QIP) 7. To enable team work and a shared purpose Positions Included The following positions at Providence Care are included in the Performance Based Compensation Plan as described herein: President & CEO Vice President, Medical & Academic Programs Vice President, Mission, Values & People Vice President, Operations & CFO Vice President, Patient and Client Care & CNE Director, Communications Pay at Risk Each of the above-named executive s compensation is linked to the achievement of specified performance improvement targets. These performance targets are reflected in the annual Quality Improvement Plan (QIP). Effective April 1, 2012, a predetermined percentage of the executive s compensation was placed at risk. Achievement of performance targets is evaluated annually for the period April 1st to March 31st of the given year to determine executive compensation. All of the executives are evaluated against the same performance indicators and targets. Four (4) performance indicators have been selected to apply to executive compensation. The performance indicators that have been selected are those determined to be priorities for the organization. The percentage of pay at risk is as follows: CEO 3% VP s 3% Director 3% Performance Based Compensation [As part of Accountability Management] Quality Dimension Performance Measure/Indicator* Target for 2015/16* Results Accomplished Weighting 6

7 Quality Dimension Performance Measure/Indicator* Target for 2015/16* Results Accomplished Weighting Safety Hand Hygiene compliance before patient/patient environment contact 86.3% 30 Effectiveness Total Margin (consolidated) 0.0% 30 Patient-centered Patient Satisfaction response to question: Would you recommend this hospital to your friends and family? In-patient Rehab: 93.4% 10 Integrated Percentage of mental health patients readmitted to the same facility within 30 days for the period 2.3% 30 Health System Funding Reform (HSFR) In developing the quality improvement opportunities and targets outlined in this Plan, Providence Care reviewed leading practice evidence and experience related to more cost effective models of care and service delivery. Providence Care remains focused on ensuring that our patients continue to receive high quality care. In developing a Quality Improvement Plan which sets targets for improved patient care within the available resources significant attention has been and will be paid to evidence-informed practice in balancing cost and quality as indicated in the Health Based Allocation Methodology (HBAM), Quality-Based Procedures (QBP), and Resource Matching and Referral (RM&R) Initiatives. 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: Peter Merkley Quality Committee Chair: Jay Wirsig President & Chief Executive Officer : Cathy Szabo 7

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