Stroke Distinction Report. Mackenzie Health. Richmond Hill, ON. On-site Survey Dates: March 23, March 25, 2015

Transcription

1 Stroke Distinction Report Richmond Hill, ON On-site Survey Dates: March 23, March 25, 2015 Report Issued: June 22, 2015

2 About the Distinction Report (referred to in this report as the organization ) is participating in the Accreditation Canada Distinction program. As part of this ongoing process of quality improvement, an on-site survey was conducted. Information from the on-site survey as well as other data obtained from the organization were used to produce this Distinction Report. On-site survey results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the Distinction Report. Confidentiality This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties. In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its Distinction Report to staff, board members, clients, the community, and other stakeholders. Any alteration of this Distinction Report compromises the integrity of the process and is strictly prohibited. Accreditation Canada, 2015

3 A Message from the Accreditation Canada CEO On behalf of Accreditation Canada, I extend my congratulations to on your participation in a program that recognizes organizations that demonstrate clinical excellence and an outstanding commitment to leadership. I hope you find the Distinction process to be an interesting and informative experience, and that it is providing valuable information that you are using to plan your quality and safety initiatives. This Distinction Report shows your decision, as well as final results from your recent on-site survey. I encourage you to use the information in this report to guide your ongoing quality improvement activities. Your Accreditation Specialist is available if you have questions or need guidance. Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating Distinction into your quality improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services. Sincerely, Wendy Nicklin President and Chief Executive Officer Accreditation Canada

4 Table of Contents 1 Introduction 1 2 Executive Summary Distinction Decision On-Site Survey Information Overview of Results Summary of Evaluator Team Observations 5 3 Distinction Standards 7 3 Distinction Standards Standards Set: Acute Stroke Services Standards Set: Inpatient Stroke Rehabilitation Services 15 4 Distinction Protocols 21 5 Performance Indicators Standards Set: Acute Stroke Services Standards Set: Inpatient Stroke Rehabilitation Services Standards Set: Optional 26 6 Client and Family Education 29 7 Excellence and Innovation 31 8 Next Steps 35 i

5 1. Introduction The Accreditation Canada Distinction program recognizes organizations that demonstrate clinical excellence and an outstanding commitment to leadership in a specific field of expertise. The program is developed in close consultation with key stakeholders and content experts to reflect detailed practices and the most up-to-date evidence. It offers rigorous and highly specialized standards of excellence, in-depth performance indicators and protocols, and an on-site survey by expert evaluators with extensive practical experience in the field. The program includes an on-site survey every years. The Distinction program includes the following key components: Standards: Distinction standards are based on the latest research and evidence related to excellence in the field. Protocols: Distinction requires the use of evidence-based protocols to promote a consistent approach to care and increase effectiveness and efficiency. Indicators: A key component of the Distinction program is the requirement to submit data on a regular basis and meet performance thresholds on a core set of performance indicators. Client and Family Education: Client, family and caregiver education and self-management support are integral parts of stroke care that should be addressed at all stages across the continuum of stroke care for both adult and pediatric clients. Education is an ongoing and vital part of the recovery process for stroke, which must reach the survivor, family members and caregivers. Excellence and Innovation: Distinction clients must demonstrate implementation of a project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care. 1

6 2. Executive Summary (referred to in this report as the organization ) is participating in the Accreditation Canada Distinction program. Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations across Canada. As part of the Distinction program, has undergone a rigorous evaluation process. External peer evaluators conducted an on-site survey during which they assessed the organization's programs and services. Results are included in this report and were considered in the Distinction decision. Please see Appendix A for a copy of the Decision Guidelines. This report shows the results to date and is provided to guide the organization as it continues to incorporate the principles of Distinction and quality improvement into its programs and services. is commended on its commitment to using Distinction to improve the quality and safety of the services it offers to its clients and its community. 2.1 Distinction Decision Accreditation Canada is very pleased to recognize for earning Distinction in Stroke Services for the following locations and services: Acute Stroke Services Inpatient Stroke Rehabilitation Services 2

7 2.2 On-Site Survey Information On-Site Survey Dates March 23, 2015 to March 25,

8 2.3 Overview of Results The following is an overview of the organization s results for each component of the Distinction program. Component Achivement Met Unmet Total % Standards Acute Stroke Services Inpatient Stroke Rehabilitation Services Distinction Protocol Indicator Distinction Education Distinction Excellence and Innovation Closing the Communication Gap at :

9 2.4 Summary of Evaluator Team Observations The evaluator team made the following observations about the organization s overall strengths, opportunities for improvement and challenges. MacKenzie Health is a designated stroke centre with responsibility for the provision of stroke care in the York Region and Central Local Health Integrated Network (LHIN) in Ontario. It has established partnerships with Emergency Medical Services (EMS), its referring hospitals and with Sunnybrook Hospital which is a tertiary and quaternary regional stroke centre. This ensures seamless care for stroke patients, no matter the level of care provided. An Integrated Stroke Unit helps streamline the care from admission to acute care, through rehabilitation, to discharge. Repatriation agreements with its partners means that patients are treated at the facility best suited for their care. The stroke program collaborates for planning and evaluation of services with the Ontario Stroke Network through mandated data collection. It is an active member of the planning and evaluation of quality best procedures (QBP) provincially and in the Central LHIN. It has incorporated Canadian Stroke Best Practice Recommendations in its protocols and policies. The organization, through the Chief Executive Officer (CEO), Senior Management and the Board are very supportive and proud of the stroke program. It is planning for a new hospital to open in 2019, which will expand its capacity substantially, and provide the setting for the Integrated Stroke Unit (ISU) and many of the stroke programs. The challenge will be to anticipate and meet the needs of a rapidly expanding and culturally diverse population in its continued planning for stroke services. The organization will need to ensure the maintenance of their efficient, comprehensive and quality oriented approach to stroke care delivery. This organization has been intentional about creating a "Stroke Aware" culture. There are many community partners providing services to discharged patients, especially through the cardiovascular rehabilitation program and other specialized services such as support for patients with aphasia and caregivers. These partners view MacKenzie Health as a real leader in stroke service delivery and work with the stroke program to improve services. Partnerships with local resources like community centres mean that services can be delivered close to home in many cases.however, gaps in service delivery have been recognized, including a deficit in outpatient rehabilitation. Some elderly patients face long distances to services in the northern part of the Central LHIN. These gaps have been identified by the program, and planning to manage these gaps is ongoing in collaboration with community partners. Early supported discharge will improve efficiency and effectiveness as well as patient satisfaction. It is being actively discussed by the program and will follow along with improvements in these identified areas for improvement.the program partners with Heart and Stroke in emphasizing risk reduction and stroke prevention through awareness and education. Heart and Stroke offers learning modules for stroke survivors and their families in this region and are recommended. The leadership of the stroke program is recognized for its expertise, commitment to excellence and passion. The leaders have a regional mandate, and their partners report that they are very supportive of their clinical and educational needs. As a result, the program provides excellence in clinical stroke care through education of all staff involved in stroke care and research, using the Canadian Stroke Best Practice Recommendations as a template for the care they provide. They are supportive of their staff, with continuing educational opportunities supported by the organization. The staff enjoy working in the stroke program, and with these very special patients. Staff turnover is reported to be low, and job satisfaction high. The work environment was observed to be a happy one, focused on their patients and families. The staff demonstrated commitment and passion for their work and patients. They are truly a team! 5

10 The care provided by the stroke program is expert and up-to-date. Innovation in solving problems was observed by the evaluators. In areas like thrombolysis for stroke, the team matches or leads many other programs in Ontario and Canada. There is room for improvement in a couple of core stroke indicators, and challenges related to the rapidly expanding regional population, but overall the delivery of stroke care is excellent. There is an opportunity to share data and results of evaluations of this care with patients and their families, and involve them further in the planning for services. Client satisfaction with stroke services is measured by the organization and is noted to be generally high for this program. Comments made by patients suggest that they would welcome the opportunity to become peer volunteers. The program may wish to explore this opportunity. The evaluators were delighted with the warm reception and friendliness of this very welcoming hospital community. The contribution of very many engaged and happy volunteers to the hospital experience of the patients, their families, staff and evaluators was particularly noted. MacKenzie Health is a community hospital which has carved out a niche of expertise in the area of stroke. It could provide a template for other similar organizations in their quality improvement journey, and is encouraged to continue to share its expertise with the stroke community through presentation and publication of quality improvement initiatives and clinical research. 6

11 3. Distinction Standards The Distinction standards identify policies and practices that contribute to high quality, safe, and effectively managed care in a specific area of expertise. Each standard is followed by a number of criteria that are statements about the activities required to achieve the standard. High priority criteria are foundational requirements for delivering safe and quality services and are identified by a red exclamation mark in the standards. During the on-site survey, the evaluators assessed the organization s compliance with each section of the standards, and provided the following results. The following tables indicate the criteria in the standards that were rated unmet during the on-site survey. As part of ongoing quality improvement, the organization is encouraged to address these criteria. High Priority Criteria Other Crietria All Criteria Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Acute Stroke Services 25 (100.0%) 0 (0.0%) 0 75 (98.7.%) 1 (1.3%) (99.0%) 1 (1.0%) 1 Inpatient Stroke Rehabilitation Services 19 (95.0%) 1 (5.0%) 0 67 (100.0%) 0 (0.0%) 0 86 (98.9%) 1 (1.1%) 0 Total 44 (97.8%) 1 (2.2%) (99.3%) 1 (0.7%) (98.9%) 2 (1.1%) 1 7

12 3.1 Standards Set: Acute Stroke Services Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: There is a dedicated stroke team, led by passionate experts committed to excellence in stroke care delivery. This team includes leaders from every stage of the acute care experience, including stroke neurologists. The team is very aware of the cultural diversity and the associated risk factors of the community it serves. Enhanced hypertension screening for the South East Asian community was cited as an improvement related to the information it has collected. The team works with Southlake Hospital to support the aboriginal community in the northern part of their district. There is a district coordinator and a clinical nurse specialist who are based at MacKenzie Health but provide outreach to the district. Both were complimented by hospital partners in the wider region for their educational support for the Nurse Practitioners and staff. There is an integrated stroke unit. Appropriate rehabilitation patients are all looked after in this unit. Rehabilitation patient length of stay (LOS) has decreased. An opportunity for earlier discharge of rehabilitation patients, such as is possible with an early supported discharge (ESD), may improve access for acute stroke patients. Resources for the program other than bed availability are reported to be adequate. The program enjoys an excellent relationship with the MacKenzie Health Foundation who supports them with regular fundraising activities. Telehealth services are delivered in conjunction with the regional stroke centre. Education across the district for primary and secondary prevention is currently the main focus. Using telehealth to improve opportunities for thrombolysis is an area for improvement. Strong internal partnerships with all relevant departments ensure highly coordinated care for stroke patients. There is a well defined pathway for tertiary and quaternary services with Sunnybrook Hospital and well defined policies for repatriation of appropriate patients in both directions are in place. Emergency Medical Services (EMS), Community Care Access Centre (CCAC) and The Heart and Stroke Foundation of Ontario are strong partners for this organization. The Stroke Prevention Clinic is aware of, and refers patients to external partners such as aphasia programs in the community. A meeting with the community partners revealed the rich partnerships with other hospitals and community assets such as community centres used for the delivery of the cardiovascular rehabilitation program for stroke patients 8

13 The leadership is regularly invited to speak on stroke prevention and awareness to the public in various ways. The new Face, Arms, Speech, Time (FAST) guidelines are on the public website. 9

14 Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The stroke team is comprehensive, with every discipline represented. The team has expertise in stroke care. Continuing education is encouraged and supported by the organization. The "I learn" modules are an example of the internal resources available. Team members are encouraged to attend meetings, conferences and courses. Access to funding is through a variety of sources, including the MacKenzie Health Foundation. There was evidence that the orientation for new staff emphasizes the unique aspects of stroke care. Staff performance evaluations are completed regularly. Staff feedback and goal setting are part of the evaluation process. Examples of how the leadership responds to staff needs as articulated in these evaluations was provided. Staff appreciation such as "kudos" adds to the positive attitude of staff working on the Integrated Stroke Unit. 10

15 Episode of Care: Acute Stroke Services Acute stroke services provided for hyperacute and acute phases, from the onset of signs and symptoms to completion of initial assessment and management in the Emergency Department (ED), until the client is stable and able to begin participation in rehabilitation and proceeding to an alternate level of care. Criteria (Unmet) High Priority Criteria 7.0 The stroke team provides comprehensive inpatient acute stroke services. 7.2 When clients are not managed on a dedicated stroke unit, there is a process for clustering stroke clients. Evaluator Comments: Clustering is not deliberately used for stroke patients who are not on the integrated unit. However, there is a process for managing these patients, including care pathways and daily audits, which ensure that patients receive the same care they would get on the stroke unit. The team identifies all of these patients daily, and follows their care, and the organization actively works to move them to the stroke unit. The evaluators provided the following overall comments for this section: There are well developed protocols for managing hyper acute and acute stroke patients for their pre-hospital and emergency department care at MacKenzie Health. The evaluators were told of significant improvements in timely access to an emergency care space, and activation of the acute stroke team. There is a documented improvement in rates of thrombolysis. Door-to-needle times are reported through the Ontario Stroke Network to be amongst the best in the province, and the team reports continued improvement in these times. A stroke code was observed during the evaluation. The stroke protocols up to and including thrombolysis were observed in action. The door-to-needle time (onset of the bolus of Alteplase) was 26 minutes. The process was well coordinated and executed. The patient was a candidate for thrombectomy and so the quaternary referral to Sunnybrook Hospital was instituted. The only stumble in this process was the need to go back to computerized tomography (CT) for a second time for a CT angiogram as required by the protocol for thrombectomy. While this second trip did not affect the door-to-needle time, it did require nursing preparation and additional travel which could have been avoided had the CT angiogram been done at the time of the initial CT. This may have resulted in a short delay in the transfer of the patient to Sunnybrook. The evaluator is aware that other stroke teams are performing the CT angiogram where possible at the same time as the unenhanced CT. Consideration of this by the team is suggested. Access to diagnostics has improved through the partnerships and support of all parties for the acute stroke program. The team is considering how to best offer access to endovascular therapy for its patients in its partnership with Sunnybrook Hospital, after release of the "ESCAPE" trial. 11

16 There are variable "admission to inpatient bed" times, which can result in patients remaining in the emergency department (ED) for up to two days. The stroke team supports the ED staff in the event this occurs. This is a reflection of the significant increases in ED numbers which will not likely resolve until the new hospital is open. There is an inpatient unit which acts as an observation extension of the ED for some transient ischemic attack (TIA) patients. This unit institutes the same pathways, screening and education as the other medical units where TIA and stroke patients are cared for. TIA patients who have an early discharge are referred to the Stroke Prevention Clinic. Dysphagia screening is variable, although there is documented significant improvement in rates. There has been considerable education for staff, and other interventions such as huddles, and the number and availability of certified staff to administer the screen. These interventions have contributed to this improvement. Screening is a core indicator for stroke, and continued improvement in screening for all patients, including those with TIAs and minor stokes is encouraged. Documentation of testing by any provider in a consistent location in the patient record would allow for more accurate reporting of this indicator. Smoking history is documented in the electronic record which should trigger a conversation about smoking cessation. The Canadian Cancer Society booklets are available to patients who may be interested in quitting. There is an opportunity to embed standardized screening questions and associated care plans as part of the routine assessments for all stroke patients. Patients from both the ED and inpatient units are referred to the Stroke Prevention Clinic for modification of risk factors and follow-up. A nurse practitioner and neurologist provide assessment, treatment and risk modification advice to all patients referred from the ED and the inpatient units in a timely way. This clinic has resulted in deferred admissions for patients with TIAs. It also serves as an access point to community services for many patients after discharge. While the nurse practitioner is a critical member of the SPC team, she does not work to her full scope of practice. The team is encouraged to consider this as a possible improvement. The evaluators would like to commend the stroke team for consistent application of stroke protocols and care management pathways across the acute care services. The team is up to date on best practice guidelines and incorporates them in the care of their patients. There is a comprehensive education package provided for patients and families. There is no early supported discharge program at this time, although this is identified as a gap by the LHIN Quality Best Practice Committee. This is related to a deficiency in outpatient rehabilitation and community services. This is an area for improvement, which is being planned for in conjunction with the Ontario Stroke Network. 12

17 Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Information systems provide local real time data as well as provincial data and comparisons with other provincial stroke programs. These data are used by the district stroke program to improve efficiency and enhance services. The data are shared with the team to allow improvement of service to patients and families. The information systems team is able to support team initiatives based on data already collected to improve effectiveness. An example was a project to measure timeliness of assessment of the AlphaFIM score to allow comparison of the length-of-stay data and the Rehabilitation Patient Group (RPG) scores. This is aiding the conversation about the setting and continuing need for rehabilitation care. The clinical information system contains information about the best practices in stroke care. Some screening tools are also available within the system. Links are provided to other stroke related information. Privacy is rigorously respected and systems are in place and are effective in preventing breaches of privacy. 13

18 Impact on Outcomes for Stroke The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The stroke team reviews clinical and service utilization data. Improvements are demonstrated in the 2014 report of the Ontario Stroke Network including comparisons with the other provincial Local Health Integration Networks (LHINs). The team also monitors performance indicators, and has developed action plans for those indicators which currently do not meet best practice thresholds. Patient satisfaction surveys are conducted on a regular basis and are monitored by the Board of Directors. Four key areas for improvement across the organization were identified and are being addressed through their organizational goals, including one of their WIGs. The stroke neurologists are actively involved in stroke research through partnerships with Sunnybrook Hospital and the University Health Network. This community stroke program is uniquely placed, because of its volumes, cultural diversity and rural and urban perspective to contribute in a significant way to practical clinical advances in stroke treatment. 14

19 3.2 Standards Set: Inpatient Stroke Rehabilitation Services Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The clinical leadership team demonstrates commitment to delivery of evidence based, effective stroke care with the intent of achieving the best outcomes for patients in its catchment area. The team also used the clinical information system and health record data to monitor key indicators for strategic program planning. The use of an integrated unit to provide acute and rehabilitation care for patients with stroke offers a service delivery model that allows unique opportunities for sharing of expertise and collaboration in the delivery of this care. This allows for consistency of care and an enhanced patient experience as they do not need to change units when status and focus shifts from acute inpatient to inpatient rehabilitation. Of note, the use of telehealth for stroke neurologist/neurosurgical triage and assessment of patients with acute stroke symptoms is utilized in care and treatment. A suggestion is made for the team to look for opportunities to use telehealth in discharge planning and ongoing patient assessments, perhaps as planning unfolds for early supported discharge program. The integrated unit is ideally situated to provide inpatient stroke rehabilitation, thus maintaining continuity and access for patient care. It is noted that an independent daily living suite is being planned to supplement the current structure of the unit, notably in providing discharge planning and practice elements prior to sending patients home. 15

20 Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Discussion with staff and management supports the training and maintenance of skills and knowledge needed to provide good care to patients/families with stroke. It is noted that rehabilitation therapists are currently employed on a contractual basis - while not common, it is evident that these staff feel very connected with the unit and patients. Staff do indicate they feel that they are part of the fabric of the unit and their expertise and assessments/contributions are valued, with roles and responsibilities clearly defined. Confidential review of the human resources files provides evidence of credentialing from regulatory bodies while annual performance reviews highlight ongoing training undertaken by staff. Discussion with rehabilitation nursing and therapy staff suggests ongoing professional development based on best practices in stroke rehabilitation is supported, encouraged and expected. 16

21 Episode of Care: Inpatient Stroke Rehabilitation Services Stroke inpatient rehabilitation services from the first encounter with a rehabilitation health care provider through the completion of the last encounter related to stroke. Criteria (Unmet) High Priority Criteria 7.0 The stroke team provides comprehensive, safe and timely inpatient stroke rehabilitation. 7.2 When clients are not managed on a dedicated stroke unit, there is a process for clustering stroke clients. Evaluator Comments: The majority of stroke patients are admitted to the stroke unit for acute and rehabilitation care. For those requiring cardiac monitoring or close observation, beds are available on CCU/ICU, with patients typically transferred within hours. For those off-service, clustering for rehabilitation is not an option; however, all patients are placed on the stroke pathway and stroke unit staff monitor regularly. The evaluators provided the following overall comments for this section: Pre-hospital care is provided by Emergency Medical Service (EMS) staff trained in the use of stroke triage tools. This enables rapid transport to the most appropriate setting for patients presenting with stroke symptoms. Nursing and in-hospital processes, policies and procedures to manage rehabilitation services for patients with stroke are coordinated and managed effectively by the rehabilitation team. Awareness and responsiveness to the needs of the population in the catchment area are evident in assessment and planning of services, present and future - for example, planning of the second tertiary care facility designated for The leadership team is aware of the increasing demands, due to population growth and changing demographic profile of the population, being placed on staff and programs to provide the level of care needed to ensure patient needs are met and excellence in care provision continues. In-hospital care of patients with stroke is a well-coordinated process, with the transition between acute care and rehabilitation care virtually seamless (given the co-location of services). For patients 'off-service', the care team goes to the patient to ensure stroke protocols are being implemented and care remains consistent. It is evident that the team works closely with community groups to raise awareness about stroke rehabilitation services available in the community, the impact of stroke and living with stroke. Collaboration with internal partners in the delivery of rehabilitation care is evident (e.g. acute stroke services, inpatient rehabilitation); collaboration with Community Care and Access Centres (CCACs) for post-discharge service delivery is also evident. Use of home care services, outreach and community action programs, stroke survivor groups and caregiver support groups is less evident in the documentation provided, however discussion with community care partners illustrates ongoing commitment to efficient transitions in care. As need for services will continue to rise in this region, partnerships such as these will become increasingly important in delivering a coordinated stroke rehabilitation program. Of note is the unique pairing of Markham-Stouffville with a community centre, in which a patient can go across a 17

22 walkway to have outpatient rehabilitation. The team uses AlphaFIM score data to inform discharge timing, location for ongoing, and amount of services needed. Referrals to internal and external resources/services are made as appropriate and team members are encouraged to offer necessary supports and services to improve care and outcomes. It is evident from discussion with patients that each patient feels comfortable in the care provided by the interprofessional care team and management staff. The integrated unit structure also supports ease of transition between acute and rehabilitation care to ensure care is not interrupted. Situating the rehabilitation therapy space right on the unit ensures time is not lost in transporting patients, and that rehabilitation specialists and nursing staff share responsibility for ensuring optimal rehabilitation experiences. The quality based performance metric in place at Mackenzie Health is reflected in continuous evaluation of rehabilitation patient care processes with improvement planning based on real data. 18

23 Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: This is a very strong evidence-based program of care and service. Canadian best practice standards are utilized in planning care and support for patients, families and staff and data generated from clinical information systems are used to monitor and assess care delivery and outcomes during in-hospital acute and rehabilitation phases of recovery. The information system is used to obtain information about client risk factors, stroke management and follow-up care delivery. Reports related to effectiveness and efficiency of care provision are shared with staff members to allow input into program development. The team works with health record analysts to track and monitor indicator data, examine outliers, and assess efficiency of the program. 19

24 Impact on Outcomes for Stroke The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The team bases improvement initiatives on evidence available from performance indicator data, leading practices from national centres, and team feedback. Action plans based on LEAN Quality Improvement processes are developed, increasing family, patient and staff and individual awareness of the organizational and unit level commitment to provision of quality care. Effective use of available resources is evident, as is awareness of need for changes to maintain and maximize access and delivery of the highest level of care needed. Discussion with management and care teams around unmet performance indictors (i.e. days to inpatient rehabilitation admissions and dysphagia screening) demonstrated awareness of contributing factors and development of action plans to address these issues. 20

25 4. Distinction Protocols Implementing protocols ensures that services are delivered in a consistent manner across the organization. Protocols can be in the form of Clinical Practice Guidelines (CPGs), algorithms or checklists. The Distinction standards cover the protocols that need to be in place to ensure safe and quality services across the care continuum. Accreditation Canada highlighted a list of high-risk protocols from the standards that were evaluated using the following criteria during the on-site visit: Acute Stroke Services Protocol Met / Unmet The team contributes to ongoing education for EMS providers about assessment and management of suspected stroke clients at the pick-up site and during transport. The team has protocols and memorandums of understanding with EMS providers for direct transport to stroke centres, bypass of smaller centres, use of air ambulance services, and screening tools for suspected stroke clients. The team has protocols with EMS providers to receive pre-notification of suspected acute stroke clients in transit. The ED and stroke team initiate stroke protocols when stroke pre-notification is received from EMS so that suspected stroke clients are received efficiently from EMS personnel when they arrive. The stroke team or ED personnel follow established protocols for clients with suspected acute stroke to undergo brain imaging immediately upon arrival to hospital. The acute stroke team or ED staff evaluate stroke clients to determine their eligibility for treatment with tpa using the current criteria in the Canadian Best Practice Recommendations for Stroke Care. 21

26 The acute stroke team screens and documents the client's swallowing ability using a simple valid and reliable bedside testing protocol as part of their initial assessment, and prior to initiating oral intake of medications, fluids, or food. The acute stroke team administers at least 160 mg of acetylsalicylic acid (ASA) to all acute adult stroke clients after brain imaging has ruled out intracranial hemorrhage. The stroke team assesses the client's stroke rehabilitation needs within the first 48 hours after admission. The team implements and evaluates a falls prevention strategy specific to stroke clients to minimize the risk of falls in this population. The team has established protocols to assess and manage diabetes in clients admitted following a stroke. The team uses formal referral criteria to identify stroke clients who are ready for inpatient rehabilitation, and makes a referral for inpatient rehabilitation services. The acute stroke team or ED staff administer tpa in accordance with the current Canadian best practice guidelines for tpa with respect to mode of administration, dosage, and infusion time. NEW FOR 2015 SURVEYS: The team assesses each client's risk for developing a pressure ulcer and implements interventions to prevent pressure ulcer development. 22

27 Inpatient Stroke Rehabilitation Services Protocol Met / Unmet The team has formal intake criteria and processes based on standardized assessments. The team assesses the client's stroke-related impairments and functional status within 24 to 48 hours of admission. The team implements and evaluates a falls prevention strategy specific to stroke clients to minimize the risk of falls in this population. The team assesses and manages diabetes in clients admitted to rehabilitation in accordance with the current Canadian Diabetes Association recommendations for the management of Diabetes. The team screens and documents the client's swallowing ability using a simple valid reliable testing protocol as part of their initial rehabilitation assessment. NEW FOR 2015 SURVEYS: The team assesses each client's risk for developing a pressure ulcer and implements interventions to prevent pressure ulcer development. 23

28 Acute Stroke Services The evaluators provided the following overall comments for this section: The acute stroke care protocols are well understood and applied by staff across all aspects of acute stroke care. The only concern noted is with consistent application and documentation of the dysphagia screen. Comments regarding this concern are articulated in the acute episode of care. Consistent application of the new skin care assessment protocol was noted by the evaluators. The team is commended for the awareness of the importance of the protocols in the delivery of excellent stroke care. 24

29 Inpatient Stroke Rehabilitation Services The evaluators provided the following overall comments for this section: Admission criteria and intake processes are clearly identified and supported by the integrated service model used at. As such, the integrated unit ensures clients' individual risks and functional status are addressed without delay. Regular team meetings ensure patients are transferred between acute and rehab services when appropriate. As with other integrated programs, supply and demand must be closely monitored. As the number of beds utilized for the rehabilitation component of the patient stay varies depending on need, it is important to ensure flow of new acute stroke patients is not compromised by ready access and overuse of rehabilitation-designated stays. Thus community partnerships become increasingly important. Use of visibility board highlights risks applicable to appropriate patients; the staff use appropriate validated tools to monitor and assess risks such as falls, dysphagia, and pressure ulcers and measures/resources are in place to help manage identified risks. Use of appropriate best practice guidelines are also supported in prevention and treatment strategies for pressure ulcer prevention (e.g. Registered Nurses' Association of Ontario [RNAO], American National Pressure Ulcer Advisory Panel [PUP]), with corresponding assessments and documentation in place. 25

30 5. Performance Indicators The following section provides a list of the performance indicators collected in the Distinction program. Overall performance is based on data submitted by the organization for each indicator. A key component of the Distinction program is the requirement to submit data on a regular basis and meet thresholds on a core set of performance indicators. Organizations are also expected to report on additional indicators chosen from a list of optional indicators. For optional indicators there are no thresholds to be met. This table shows the organization s indicator results. 5.1 Standards Set: Acute Stroke Services Performance Indicators Reported Data Threshold Met Core 1. Stroke / TIA mortality rates 4.7 % 2. Proportion of ischemic stroke clients who receive acute thrombolytic therapy 14.6 % 3. Time to administration of acute thrombolytic agent 7,197.0 % 4a.Proportion of clients treated on dedicated stroke unit 72.7 % 5. Length of stay in an acute care hospital setting for clients admitted following an acute stroke event 7.0 days 6. Readmission to acute care for stroke related causes 2.2 % 26

31 Performance Indicators Reported Data Threshold Met Core 7. Proportion of acute stroke clients discharged to inpatient rehabilitation 16.4 % 8. Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy 91.4 % 9. Proportion of clients with initial dysphagia screening at admission 57.9 % 5.2 Standards Set: Inpatient Stroke Rehabilitation Services Performance Indicators Reported Data Threshold Met Core 1a. Proportion of clients treated on dedicated stroke unit % 2. Length of stay in an inpatient rehabilitation setting for clients admitted following an acute stroke event 30.0 days 3. Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy 90.6 % 27

32 Performance Indicators Reported Data Threshold Met Optional 4. Proportion of clients with initial dysphagia screening at admission 50.0 % 5.3 Standards Set: Optional Performance Indicators Reported Data Threshold Met Optional 2. Proportion of acute stroke and TIA clients who receive brain CT or MRI within % N/A 8. Median number of days from stroke onset to admission to inpatient rehabilitation 11.5 days N/A 28

33 6. Client and Family Education Client, family and caregiver education is an integral part of stroke care that should be addressed at all stages across the continuum of stroke care. In order to achieve Stroke Services Distinction, the following targets for providing client and family education that is an integrated component of stroke care and is consistently documented must be met. Requirements Met / Unmet Client education is an integrated component of stroke care delivery. Client educational materials are available and accessible on the ward (e.g., posters, display boards, booklets given to clients, etc). Client educational materials are available in a variety of languages appropriate to the client population mix. Client educational materials are available in formats for that are appropriate for persons with special communicative needs. In interviews with clients and family members during tracers, clients report receiving education regarding their stroke, recovery, and self-management from the healthcare professionals that care for them. Target: 4/4 There is consistent documentation in the client medical record that client and family education has been provided. A standardized tool (e.g. checklist) is used to document components of education provided to ensure all critical elements are addressed prior to client discharge. There is a consistent location in the client chart for documentation of education provided. Each healthcare profession involved in the client's care documents the education provided within the discipline notes or common progress notes. The specific content addressed during an educational session (e.g., skills taught and demonstrated, discharge preparation, etc) is documented. Target: 2/4 The organization s project or initiative meet the requirements for client and family education. The evaluators provided the following comments. 29

34 Patient and family education materials related to stroke services are widely available on the clinical units, in particular the Integrated Stroke Unit (ISU). The ISU has a patient and family resource station, which pulls together resources from a variety of internal and external sources, including the Heart and Stroke Foundation. Resources are also available on the website, in printable formats and You Tube video vignettes. There is an opportunity to improve the video content to include alternate languages as well as communication methods for those patients who may have communication deficits. This opportunity has been recognized by the staff on the ISU. The ISU hosts a series of education sessions for patients and their families/caregivers, which take place weekly and cover topics such as recreation therapy, mood, exercise, and living with stroke - for example. Each patient was noted to have a 'yellow folder' which included a base and standardized set of resources as well as a checklist.this was in place regardless of the unit the patient was admitted to. The Registered Nurse (RN) reviews the resources in this folder with patients and families, who are then encouraged to identify specific areas that require follow up or that they have more questions around. The RN then connects back to the families and patients to review the questions. In addition, each individual team member has discipline specific education that they review with patients and families. Patients report that they have ample opportunity to ask questions and clarify the information provided. There is a location on the ISU to house laminated resources that are specifically designed for individuals who have communication deficits. As well, the Speech-Language Pathologist (SLP) is cited as being a key resource for staff to assist with these clients. The electronic record has a specific location for nursing to document education provided, and this is embedded in the stroke pathway. Other disciplines will document in their discipline specific notes. 30

35 7. Excellence and Innovation Organizations must demonstrate implementation of at least one project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care. The organization s project or initiative was evaluated against the following criteria during the on-site visit: 31

36 Closing the Communication Gap at : The stroke project or initiative is evidence based, e.g. aligned with accreditation standards and current Canadian Best Practice Recommendations for Stroke. The stroke project or initiative adds to the overall quality of stroke services within the facility or the region. The stroke project or initiative includes a completed evaluation, and measures sustainability of the project or initiative. The stroke project or initiative communicates findings within the organization and externally. The stroke project or initiative is notable for what it could contribute to the delivery of stroke services. 32

37 The organization s project or initiative meet the requirements for excellence and innovation. The evaluators provided the following comments. The innovation project, Closing the Communication Gap at : Becoming Aphasia Friendly, is an initiative that was conceived by front line staff who identified an opportunity to improve communication between staff on the Integrated Stroke Unit (ISU) and the patients who are experiencing aphasia as a result of their stroke. The project involved conducting a needs assessment of the ISU staff to identify where the communications gaps existed. This pre-survey highlighted the need to develop enhanced communication tools and resources for staff and families, as well as provide additional education and information. One specific area of opportunity was in the ability of patients with aphasia to actively participate in the food services processes around food selection. The potential to more effectively engage patients with aphasia in the food selection process, was immediately supported by the Dieticians and Food Services Staff who joined the project team. This project is aligned with the 2013 Stroke Best Practice, Rehabilitation to Improve Communication. Specifically, the project aims to create awareness, provide training about aphasia and access to associated communication tools to all staff on the ISU. Phase 1 of the project included the design of a logo to indicate that a patient is experiencing aphasia, and this logo is used on the spines of charts as well as on the patient white boards so that all staff are aware of the need to use alternate communication strategies with these patients. In addition, the project has developed aphasia-friendly communication tools for menu selection. The organization is to be commended for highlighting a project that is local, and comes from ideas generated by front line staff. The project is practical and was able to be implemented in a relatively short time frame, with an immediate and measurable impact on staff education levels and availability of the developed communication tools and resources. The food services staff, and notably the 'hostess' reports a significant improvement in the ability to communicate directly with patients who have aphasia in order to identify their food preferences. The tools that have been designed to achieve this include simple drawings and are provided to patients in a spiral bound laminated format that is convenient and applicable to the both the hospital and the home environment. The anticipated outcomes include enhanced patient satisfaction and enjoyment as well as nutrition and recovery. Since the inception of the project, the 'hostess' notes a reduction of food waste from the ISU. To date forty-two staff have been trained and the post survey results are extremely positive. Presently, the speech-language pathologist is the primary instructor for the three hour education session. In order to ensure sustainability for this project, a core group of individuals who complete both the core training and trainer education will be identified as 'train the trainers'. In addition, the organization is building a 're-credentialing' strategy into their training program which will require staff to complete regular updates. The early success of the project has sparked interest among other programs in the organization, and plans are already underway to expand the scope within. Another potential opportunity for future development, would be to include culturally aware menu options in the picture menu. The project team is waiting for the finalization of a provincial patient satisfaction tool that utilizes strategies for communicating with patients who have aphasia, and once this tool is ready will complete a more fulsome evaluation. This project team has been invited to present at the upcoming Innovation Expo at North York General, which anticipates up to six-hundred participants from across the LHIN as well as representatives from the Ministry of Health. As this project has the potential to translate into any patient care environment, we would encourage 33