Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario April 1, 2016

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1 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario April 1, 2016 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 Baycrest is pleased to share our Quality Improvement Plan (QIP) with our clients, family members and broader community. This plan describes the key actions we are committed to taking to make improvements to the care and services you receive. As in previous years, these improvement priorities are rooted in our strategic goal to deliver exceptional quality of care and quality of life for our patients and residents. It is important to know that this plan is just one of the tools we use to capture our top improvement priorities and monitor our performance. There are many other active quality improvement activities underway across all of our clinical, residential and community programs. This plan, however, signals to the organization our top quality improvement priorities that have been committed to at all levels of the organization. For , we decided that given the complexity of our improvement goals and desire to truly improve our performance and sustain this improvement, required continued focus on the three main areas for improvement from the previous year. Although our teams have worked hard to make progress in these areas, it will require continued effort and energy and focussed resources over a multi-year timeframe to meet the targets we set for ourselves. This gives us the opportunity to maintain a continuity of activities and strive for even greater improvement. Our main improvement objectives for this year include: improving the client experience; reducing serious harm from falls; and reducing potentially preventable transfers to the Emergency Department from Long-Term Care. For each objective, we identified revised targets and new change ideas that have been informed from our quality improvement work in previous years. Why these priorities matter Improving the client experience: Baycrest s mission is to provide an exemplary care experience for our clients. Recognizing that every client perceives and experiences care differently, we want to improve how we work in partnership with our clients and their families to truly understand their needs and deliver individualized care to provide the highest quality of care at every encounter. Our plan includes activities that, based on client and family input, we believe will contribute to an improved experience. As well, we know how much staff satisfaction impacts our clients experience. This is why we continue to monitor our employee engagement levels and have identified activities that we believe will contribute to a highly engaged workforce. Reducing serious harm from falls: Falls are a significant cause of harm and the leading cause of preventable injury for our clients. A fall that results in a serious injury can lead to a number of complexities including worsening mobility, decreased quality of life, transfers to the Emergency Department and need for higher level of care. While not all falls are preventable, it is our job to make sure our patients and residents are always free from injury and harm. Reducing potentially preventable transfers to the Emergency Department: Residents living in longterm care homes are being admitted with high functional dependence and increasing levels of complexity: a large number have multiple chronic conditions, need monitoring for acute conditions, are living with Alzheimer s disease or other dementias and many have severe cognitive impairment. For LTC Home residents, visits to the Emergency Department can cause additional health care risks, breakdowns 2

3 in coordination and undue anxiety for them and their families. Preventing our residents from unnecessary visits to the Emergency Department is one of our most important priorities for our residents care and safety. QI Achievements from the Past Year 2015/16 was an exciting yet challenging year for Baycrest. Not only did we face similar fiscal challenges as other health organizations, we underwent a campus-wide Accreditation, receiving Accreditation with Exemplary Standing in June Given a significant number of efficiency and budget related activities coupled with Accreditation preparation, we found that our QIP (with over 20 change ideas) was a stretch for the organization. Despite this, we did have a number of QI successes. As outlined in our QIP last year, one of key priority areas was to improve access to the rehabilitation program. Driven by a significant gap in the funding of rehabilitation services and an overall desire to improve how patient s access and experience rehabilitation, a quality improvement project was initiated. Key achievements in this project included: Developing clear intake and admission processes to improve access to the program, resulting in an increase in the number of admissions while reducing overall lengths of stay. Improving the process and timelines to ensure patients functional improvement measurements are complete within 72 hours of admission. Standardizing the process for setting and communicating length of stay with patients, families and within the team. Improving the patients level of functioning from admission to discharge. Developing improved discharge planning and communication strategies between the interdisciplinary care team, patients and families through the introduction of communication boards and rapid rounds. The electronic bed board captures lengths of stay and expected discharge date and can be accessed by the entire interdisciplinary team. Building partnerships with acute care through regular site visits conducted by the RN Utilization Coordinator. Financial savings. Throughout the project, patient and family feedback was obtained and used to guide improvements. In particular, there was a heavy reliance on surveys throughout the process to obtain patient and family feedback on current communication practices and on the proposed changes. A former patient was also included in the two day work out event with the team. Their feedback and input was invaluable to the team. Success of this project can be attributed to strong senior leadership support, an engaged clinical team and heavy reliance on real-time data and regular auditing to guide improvements and patient involvement. Integration & Continuity of Care We value the power of partnerships in achieving system-wide improvements and as such, have a number of quality improvement initiatives underway which demonstrate this shared responsibility. Of particular note is our leadership in the North West Toronto Health Link, which involves working with over 30 other community partners to deliver coordinated, patient-focused and integrated services. One area of focus for our Health Link and one that is reflected on our quality improvement plan is our commitment to reduce potentially preventable transfers to the Emergency Department from Long Term Care. Working with the LHIN, other Long Term Care facilities, acute care partners and Toronto 3

4 Emergency Medical Services, we are committed to developing local actions, resources and broader health system recommendations to reduce avoidable ED transfers. In addition, Baycrest is leading a review of TC-LHIN LTC Home Outreach Teams with a view to improve access to and satisfaction with outreach teams who are assisting Homes with the management of residents with complex behaviours. Engagement of Leadership, Clinicians and Staff Quality improvement and monitoring performance are very much integrated into clinical operations at Baycrest. Quality and improvement is everyone s responsibility from our Board members to our point of care staff. We continue to work towards building knowledge and use of quality improvement methods with leadership and point of care staff to guide decision making. Teams regularly review their performance relative to the targets they set every three months. Through point of care participation in quality meetings and quality huddles, we have also been informing and teaching point of care staff about the relationship between the care they provide every day and the performance we monitor. Accountability for quality is supported by our quality committee structure which includes service-level quality subcommittees, an operational Quality Steering Committee and our Board Quality Committee. At all levels of the organization, quality, safety and performance are routinely discussed and prioritized. We are proud to have met all of the requirements for quality established by Accreditation Canada during our on-site survey in June Patient/Resident/Client Engagement We know how important it is to be engaging with our clients and families and working in partnership to provide the highest quality of care and experience. In the past, we have consulted with our Long Term Care resident and family advisory councils on many of our quality improvement activities. This year, in addition to these engagement opportunities, clients and families participated in several quality improvement working groups and committees. Specifically to inform our QIP, we were very pleased to meet individually with many of our clients and families through informal experience rounding which helped identify and refine some of the specific changes and activities outlined on our improvement plan this year. Baycrest also implemented a Client Relations Office in Feedback received through this office was also used to inform the QIP. Recognizing we can always be doing more to engage and partner with those that receive our care and services, we are very excited to be building a formal Baycrest Family Advisor Program in The advisors engaged in this program will be instrumental in helping us implement our top improvement priorities as outlined in our QIP this year, as well as other more local improvement work taking place across all programs and services. Performance Based Compensation Each Executive listed below has 40% of their performance/at risk compensation linked to achieving the following measures: % of clients treated with respect % of clients who get the help they need % of care plans (for clients that are at high risk of falls/injury) with individualized falls interventions in place 4

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