Improvement Targets and Initiatives

Transcription

1 Improvement Targets and Initiatives [Insert Hospital Logo] North York General Hospital, 4001 Leslie Street Toronto, Ontario M2K 1E1 Please do not edit or modify provided text in Columns A, B & C AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Current performance Target for 2013/14 Target justification Priority level Planned improvement initiatives (Change Ideas) Methods and process measures Goal for change ideas (2013/14) Comments Safety Reduce hospital acquired infection rates CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospital-acquired CDI, divided by the number of patient days in that month, multiplied by 1,000 - Average for Jan- Dec. 2012, consistent with publicly reportable patient safety data In 2012/13 we exceeded our target by 25 %. In 2013/14 our goal is to maintain the 2012/13 rate at With the introduction of PCR technology there is potential to increase our CDI rates therefore we are looking to sustain for a full year the 2012/13 achievements Year 3 implementation of the Antimicrobial Stewardship Program (ASP). Audit practice and provide feedback will be the method to identify acceptance of recommendations for antibiotic use. Acceptance of recommendations made by the ASP team, including the Critical Care Unit 2. Establish a baseline for Through Cerner documentation track on a monthly days of I.V. therapy for basis days of IV therapy for specific antibiotics antibiotics at high risk for a causing CDI in a Critical Care Unit. In the second year compare NYGH data/baseline with the CAHO data. Monthly average of 85% acceptance rate. 100% of data collected and baseline identified by Critical Care Unit is participating in an ASP - Adopting Research to Improve Care (ARTIC) initiative through the Council of Academic Hospital of Ontario (CAHO). 2. In Year 2 of this program optimize the staff cleaning of mobile equipment between patient use by auditing practice and providing feedback to patient care areas. % of mobile equipment cleaned between patients Monthly average of 75% of equipment cleaned between patients 3. Sustain environmental % of touch points that are identified as having been cleaning with infra-red spot cleaned testing of 6 patient rooms per week. Each patient room will have a minimum of 10 touch points marked and tested. Share and discuss results with Environmental Services staff at Huddles. Monthly average of 98% touch points meet the standards for cleaning. Sustain the excellent work that the Environmental Services team has been doing to ensure that patient rooms are appropriately terminally cleaned.

2 Hand hygiene compliance before patient contact: The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by Jan-Dec. 2012, consistent with publicly reportable patient safety data 88.19% 88.50% In 2012/13 NYGH continued to make improvements in hand hygiene and we are committed to supporting and improving. Sustaining hand hygiene improvement over time is challenging and requires ongoing vigilance and a cultural shift. The 2013/14 target has been set at the 2012/13 performance as this performance exceeded the target set. In 2013/14 we will focus on sustaining results. 3 Review the Hand Hygiene Program including data integrity and identifying current gaps in the program. The review will provide us with an understanding of the program, where compliance with practices may need to be addressed, data capturing concerns and the opportunity to develop action plans. # of components of the program that meet the criteria. 100% completed by Avoid patient falls Avoid Patient Falls: Number of patients who have a fall classified as critical, serious or moderate. Fiscal 2012/ In 2012/13 NYGH achieved a 50% reduction over the 2011/12 baseline and exceeded target by 25%. As there is no target for falls in acute care we strive to continually reduce the number and severity of falls based on previous performance. In 2013/14 a 25% reduction 2 1) Review by the Corporate Falls Prevention Steering Committee all falls classified as critical, serious or moderate. 2. Patient falls to be reviewed quarterly by the hospital Quality of Care Committee. 3. Implement a monthly audit and feedback process for falls risk assessments. Feedback to be communicated to individual units and a program summary compiled into a quarterly corporate report. 4. Develop and implement a unit based interprofessional Falls Champion Program # of monthly reviews completed by the Corporate Falls Prevention Steering Committee Summaries of the Corporate Falls Prevention Steering Committee falls review, including recommendations for improvement, will be presented and discussed at the committee. Monthly audits will be conducted and include a review of the falls assessment scores, documentation of interventions and a visual audit of the interventions. 100% of critical, serious and moderate falls reviewed monthly 100% completion of scheduled presentations 85% of monthly audits complete # of units and # of champions 75% of units will have a minimum of 2 Falls Champions in place by December 31, 2013

3 Increase proportion of patients receiving medication reconciliation upon admission Medication reconciliation at admission: the total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital - Hospital-collected data, most recent quarter available (e.g., Q2 2012/13, Q3 2012/13) 73.70% 80% There is no benchmark for this indicator. NYGH has set a target at 6.6% above 75% which is a peer identified target. 5 Ensure the NYGH falls prevention program meets the standards for a prevention program 1 Medication Reconciliation data indicates that increases in Best Possible Medication History (BPMH) rates correlate with increases in medication reconciliation rates. Complete a corporate self assessment of our Falls Prevention Program comparing with the IHI assessment tool Pharmacy will complete BPMH on patients who attend the Pre-admission Clinic for patients who will be admitted post-surgery. Assessment and recommendations complete by June 30, % BPMH completion rate 2. Communicate medication reconciliation results to the clinical programs 3. Better understand the barriers and opportunities for increasing medication reconciliation at admission. On the surgical units the role of a clinical technician will be implemented to support the pharmacists in completion of BPMH In Mental Health the manual system for medication reconciliation will be improved and documented in Cerner Clinical leaders will have access to a monthly report by program of their medication reconciliation rates. Information to be shared at program meetings and quality circles Partner with the clinical program leadership teams and Program Chiefs and through a collaborative approach identify action plan. 90% BPMH completion rate 66% BPMH completion rate Monthly report available in the Business Intelligence Tool (BI). 4. Review the new Required Organization Practice (ROP) for medication reconciliation at admission Each test for compliance will be reviewed against our current practices and where there are opportunities to improve action plans will be developed.. Increase proportion of patients receiving medication reconciliation upon discharge Medication reconciliation at discharge: the total number of patients with medications reconciled as a proportion of the total number of patients discharged to the hospital - Hospitalcollected data, most recent quarter available (e.g., Q2 2012/13, Q3 2012/13) 56.60% 65% There is no benchmark for this indicator. Peer hospitals have set a target of 75%. In 2013/14 NYGH is looking to close the gap from current performance to the 75% peer target by 35% Increase the Surgical Program medication reconciliation % In partnership with Clinical Informatics and Cerner explore options to revising the Depart Summary that is used on discharge and includes prescription writing 100% complete including a decision on next steps by

4 2. Improve the medication documentation on discharge Pharmacy will review with the clinical programs the process for documentation on discharge, identifying opportunities for improvement including data integrity. 3. Communicate medication reconciliation at discharge results to the clinical programs. 4. Review the new Required Organization Practice (ROP) for medication reconciliation at transitions of care. Clinical program leaders will have access to a monthly report by program of their medication reconciliation rates. Information to be shared at program meetings and quality circles Each test for compliance will be reviewed against our current practices and where there are opportunities to improve action plans will be developed. Monthly report available in the Business Intelligence Tool (BI). Effectiveness Reduce unnecessary deaths in hospitals HSMR: number of observed deaths/number of expected deaths x FY 2011/12, as of December 2012, CIHI With the recalculation of HSMR, NYGH continues to perform well. Sustainability of results will be the focus in 2013/14 and therefore the target is maintained at the 2012/13 target and YTD performance. 3 1) Maintain the current performance through the ongoing review of patient charts using the Global Trigger Tool Monthly HSMR reviews presented and discussed at Program committees. When a monthly HSMR rate exceeds the target the results of the review will be presented and discussed at the Quality of Care Committee. 100% of monthly reviews completed and presented Access Reduce wait times in the ED ER Wait times: 90th Percentile ER length of stay for Admitted patients. Q4 2011/12 Q3 2012/13, iport 27.4 hours hours NYGH has exceeded its QIP target of 34 hours for 2012/13 and year over year results are a 28% improvement. In 2013/14 a 10% reduction from our HSAA target of is identified 1 1. In Year 2 the Access to Care (A2C) Steering Committee will prioritize, implement and evaluate patient flow initiatives focusing on reducing LOS. Implement Phase 3 of the Escalation Protocol which is focused on deploying patient population specific escalation protocols. Clinical areas to identify 1-2 CMGs where there are opportunities to reduce the LOS and therefore improve conservable days. Plans to developed and implemented throughout 2013/ % complete including achieving a target of 87% of the time the EAA is 15 patients or less by 1.5% improvement in conservable days with a target of 27.60%. Hospital occupancy rate 97% Upgrade the Teletracking System to provide more timely information on which decisions can be made. Status of discharges, cleaning of beds, tracking of availability of beds will be more transparent and easier to monitor. June 30, Increase inpatient room capacity for patients requiring isolation Review all inpatient areas identifying where former patient rooms have been allocated to non-clinical functions. Develop and implement plans to relocate these functions. Increase in private room capacity by 10 beds by end of Q4.

5 3. Improve discharge planning by implementing an electronic utilization review tool Transition from our current process to an automated tool in Medicine, Surgery and Cancer Care. An interprofessional team will lead the initiative 100% complete ny 4. Year 2 of the Enhanced Recovery After Surgery (ERAS) Project which uses an innovative knowledge translation strategy to implement a range of interventions that improve patient care, reduce hospital stay, and increase communication and collaboration among team members. Measure the outcomes of the ERAS project focusing on the metrics that decrease postoperative complications, reduce LOS and accelerate functional recovery. 80% of targets are ERAS is an ARTIC achieved by the end Project through of Q4. CAHO 5. Integration with Primary Care is a NYGH strategic initiative. Through our Connecting Care strategy we are working closely with our Family Health Team (FHT) and Department of Family and Community Medicine to improve the discharge process including timely discharge summaries and hand off processes between internal and external providers. Complete one pilot project on a "warm hand-over" process with an identified team of hospitalists. Pilot project complete by March 31, 2014 Complete the implementation of FHT and DCFM notification process and assess how the physicians are using information technology to support this. 90% of active and credentialed primary care providers will be receiving notification by. 6. Engage physicians and physician leaders in patient access and flow initiatives A2C physician lead will develop a project plan that will identify assess and flow initiatives that engage physicians and support an improvement in both the ED and inpatient LOS Plan developed by June 30,2013 with 100% implementation by

6 Improve Patient Satisfaction From NRC Picker: "In the Emergency Department overall, how would you rate the care and services you received at the hospital?" (add together percent of those who responded "Excellent, Very Good and Good") 79.50% 85% for results beginning with October 2013 surveys which will be reported in early 2014 An increase in patient satisfaction is incremental and improves over years. The target is set at slightly below a 50% improvement from the provincial benchmark of 91% as by Health Quality Ontario, though is at the provincial average for 2010/ Understand the experience that patients and families have when they enter our Emergency Department (ED) Staff and physicians to observe in the Waiting Area and provide their feedback and recommendations on their observations to the Emergency Services Program (ESP) July 31, Learn from hospitals that have achieved the benchmark for the "how would you rate the care you received" question. Identify 3-4 GTA hospitals who are achieving the highest Peer 3 results. Plan site visits by an June 30, 2013 interprofessional and support staff team. Report back to the ED Program Committee. 3. Seek feedback from Volunteer Services and Registration staff Schedule and hold focus groups with the 2 services. June 30, Increase the role of Volunteer Services in the ED Waiting Area 5. Improve communication in the Waiting Area, Triage and Registration Develop and implement a summer student volunteer program Through an interprofessional and support staff approach develop and implement communication expectations for the 3 areas. August 31, 2103 August 31, Integrate patient experience into ED staff orientation Using the Transforming Our Culture project develop 100% of toolkit and implement a formal process including a toolkit for complete by April new staff. Staff will spend 1.5 days listening, learning 30, During and sharing with our patients. Evaluate the outcomes of 2013/14, 100% of the project by conducting a post project self-assessment new nursing staff at completion, 3 months and 6 months. will participate. 7. Through formal Gemba Walks learn from our patients and families about their experience in our ED. On a monthly basis a minimum of four (4) 30 minute Gemba Walks will be completed by the ED leadership team. Beginning July 2013 and ongoing a minimum of 4 Gemba Walks per month.

7 Integrated Reduce unnecessary time spent in acute care Percentage ALC days: Total number of inpatient days designated as ALC, divided by the total number of inpatient days. Q3 2011/12 Q2 2012/13, DAD, CIHI 15.80% 14.50% ALC days are representative of system issues and therefore only a portion of improvements are within our control. A modest reduction in current performance is set due to the external factors In Year 2 the Access to Care (A2C) Steering Committee will identify and prioritize patient flow initiatives that will support a reduction in ALC % and days. 2. Improve discharge planning by implementing an electronic utilization review tool 3. Increase and further engage Family Physician in planning transitions of care with patients and families and the NYGH team. Implement of Phase 2 of There's No Place Like Home focusing on rehabilitation facilities and CCAC Transition from our current process to an automated tool in Medicine, Surgery and Cancer Care. An interprofessional team will lead the initiative Family physicians will participate in patient/family discharge planning conferences through the option of Skype or an alternate teleconference modalities,.. 4. Work with external facilities to develop partnerships to streamline transitions from acute care to alternate levels of care Partner with St. John's Rehabilitation Hospital on the development of a Stroke Pathway. Pathway complete and implemented by. NYGH is a partner in the Regional Stroke Program