Improvement Targets and Initiatives

Transcription

1 Improvement s and Initiatives PART B MARKHAM STOUFFVILLE HOSPITAL - Quality Improvement Plan (QIP) Please do not edit or modify provided text in Columns A, B & C AIM MEASURE CHANGE Quality dimension Objective Measure/Indicator Current perf. for ideas () Safety Reduce hospital acquired infection rates Clostridium Difficile (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 0.74 < 0.60 Markham We will continue to focus on reducing the number of patients with newly diagnosed, hospital acquired clostridium difficile (C. Difficile) across the Organization. We will achieve this through ongoing corporate wide focused efforts to achieve compliance with best practice guidelines for hand hygiene, environmental cleaning and a dedicated focus on antibiotic stewardship. Number of CDI cases. strategies See also hand hygiene Markham : < 44 cases per year Uxbridge : < 6 cases per year 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 87.4% > 90% yearly Achieve at or above 1 1) Attain hand hygiene compliance rate for Moment 1 (before initial contact) of 90% across both sites. We will achieve this through the involvement of hand hygiene champions, monthly auditing and follow-up with staff, a focused education program, and a standard monitoring process. We will Identify and develop strategies to address hospital specific barriers through use of a survey of staff related to knowledge and barriers to compliance. 2) Reinforce hand hygiene audit processes including minimum number of audits/month and accountability for reporting and monitoring of audit results. % of units that achieve 80% compliance with Moment 1 90% Ventilator Acquired Pneumonia (VAP) rate per 1,000 ventilator days: the total number of newly diagnosed VAP cases in the ICU after at least 48 hours of mechanical ventilation, divided by the number of ventilator days in that reporting period, multiplied by 1,000 - Average for Jan- Dec. 2012, consistent with publicly reportable patient safety data 0% 0% Maintain better than 3 Renew education on VAP bundles with all ICU staff to ensure ongoing compliance Markham Stouffville Hospital QIP - Page 1

2 Quality dimension Objective Measure/Indicator Current perf. for ideas () Rate of central line blood stream infections per 1,000 central line days: total number of newly diagnosed CLI cases in the ICU after at least 48 hours of being placed on a central line, divided by 0% the number of central line days in that reporting period, multiplied by 1,000 - Average for Jan- Dec. 2012, consistent with publicly reportable patient safety data 0% Maintain better than 3 We will maintain Central Line Infections (CLI) at a rate of 0% through the continued application and monitoring of Safer Health Care Now (SHCN) best practice guidelines. Reduce incidence of new pressure ulcers Pressure Ulcers: Percent of complex continuing care residents with new pressure ulcer in the last three months (stage 2 or higher) - Q2, FY 2012/13, CCRS Avoid patient falls Falls: Percent of complex continuing care residents who fell in the last 30 days - Q2, FY 2012/13, CCRS Reduce use of physical restraints Physical Restraints: The number of patients who are physically restrained at least once in the 3 days prior to the initial assessment divided by all cases with a full admission assessment - Q4 FY 2009/10 - Q3 2010/11 OMHRS Reduce rates of deaths and complications associated with surgical care Rate of in-hospital mortality following major surgery: The rate of in-hospital deaths due to all causes occurring within five days of major surgery - FY 2011/12, CIHI CHRP ereporting tool Surgical Safety Checklist: number of times all three phases of the surgical safety checklist was performed ( briefing, time out and debriefing ) divided by the total number of surgeries performed, multiplied by Jan-Dec. 2012, consistent with publicly reportable patient safety data Jan-Dec 2012 Theoretical Best Benchmark 3 We will achieve a rate of completion of all 3 phases of the surgical safety checklist of by monitoring compliance with checklist. 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) - Increase proportion of patients Medication reconciliation at admission: The total number of patients receiving medication reconciliation with medications reconciled as a proportion of the total number of patients admitted to the upon admission hospital - Hospital-collected data, most recent quarter available (e.g., Q2 2012/13, Q3 2012/13) Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the Emergency Department (ED), Medicine/Telemetry (3E), Inpatient Mental Health (1Wf) and the Surgical Assessment Clinic (SAC) Jan 2013 Average: 73% > 90% by Dec 2013 Accreditation Standards 2 Enhance compliance with med rec on admission on 3E, ED, 1Wf and SAC through education and publishing/discussion of audit results Reduce inpatient Falls Rate of inpatient falls per 1000 patient days Fiscal YTD (Dec) 2012: 4.9 < target 2 Continued focus on inpatient falls prevention, risk assessment and implementation of patient specific interventions and follow-up Markham Stouffville Hospital QIP - Page 2

3 Quality dimension Objective Measure/Indicator Current perf. for ideas () Effectiveness Reduce unnecessary deaths in hospitals Hospital Standardized Mortality Ratio (HSMR): number of observed deaths/number of expected deaths x FY 2011/12, as of December 2012, Canadian Institute for Health Information (CIHI) Fiscal Year 2011/12 (as publicly reported in Dec 2012): 79 with a Confidence interval (CI) of with a Confidence interval of Reduce hospital acquired positive culture Urinary Tract Infections (UTIs) through comprehensive initiative entitled Holy Moly My Patient has a Foley, which includes 1) implementation of best practice standards regarding insertion of Foley catheters. 2) Developing criteria for removal of indwelling Urinary Tract catheters 3) Implementation of postcatheter care plans 4) Continued education and discussion at bullet rounds 5) Improved processes related to proper documentation of hospital acquired UTIs. % of IP indwelling urinary tract catheters in place that do not meet insertion criteria (as a % of patients with catheters audited) % IP indwelling urinary tract catheters removed within 48 hours of insertion in keeping with criteria < 30% by Jan based on monthly audits > 60% by Jan 2014 Continue with implementation of Antibiotic Stewardship best practices including daily rounding and ongoing education and awareness Defined Daily Dose (DDD) [Antibiotics usage per 100 patient days measured by defined daily dose based on pharmacy drug dispensing information] Total Antibiotic usage/expenditure <45 % < $3.31/patient day Susceptibility of pseudomonas to Ciprofloxacin > 80% Maintain achievements related to Sepsis best practices Sepsis Mortality Rate < 20% Improve organizational financial health Total Margin (consolidated): Percent by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year. Q3 2012/13, OHA's Ontario Healthcare Reporting Standards (OHRS) FYTD Q3: Provincial mandate 2 We will put in place enhanced process controls and early warning systems to facilitate improved budget management both departmentally and corporate-wide Financial reports reviewed and discussed monthly at Senior Management meeting. Financial reports reviewed and discussed quarterly by Leadership Team at LPC meetings Continue efforts to reduce sick time hours through a focus on Return to Work, and implementation of a renewed staff Wellness Program sick time hrs as a % of total worked hours < 3% Markham Stouffville Hospital QIP - Page 3

4 Quality dimension Objective Measure/Indicator Current perf. for ideas () 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 /12 Q4-2012/13 Q3: 47.4 hours - Markham < 40.3 hours target 2011-/12 Q4-2012/13 Q3: 20.6 hours - Uxbridge < 20 hours target 1 2 1) Streamline and standardize patient flow related roles, develop standard work for patient flow, bed flow meetings and Daily Access and Reporting Tool (DART) 2) Incorporate an assessment tool into the discharge process to identify patients at higher risk for readmission and to work with our community partners and primary care physicians to have appropriate supports in place post-discharge. 90th Percentile Wait from decision to admit to Emergency Department (ED) discharge - Markham % medical cases discharged on weekend as a % of all medical discharges per week - Markham # scheduled surgeries canceled related to no inpatient bed available to support post-op admission due to increased in-patients (INEs) in the Emergency Department excluding ICU and paediatric beds. < 35 hrs > 20% < 4 cases in one year Patient-centred Improve patient satisfaction From NRC Picker / HCAPHS: "Would you recommend this hospital to your friends and family?" (add together percent of those who responded "Definitely Yes" or Yes, definitely ) Oct Sep 2012: 74.4% YTD > 75% Exceed community of 71% 2 Ongoing unit/department focused attention on purposeful rounding on all inpatient units and anticipated improvement of patients who answer that the time to call bell is reasonable. % pts who feel that the time to call bell is reasonable based on NRC survey results > 60% based on NRC survey results From NRC Picker:" Overall How would you rate the care and services you received at the Hospital." Oct Sep 2012: 91.6% YTD > 95% Exceed community 1 1) Continue to do Just In # inpatient JIT surveys completed per week 10 /week Time (JIT) patient experience surveys on inpatient units to provide real time patient % pts completing JIT IIP survey who indicate that they > 75% satisfaction info and assess had discharge plans discussed with them impact of focus on patient flow and discharge planning. 2) survey 10 acute JIT IP Survey response to "would you recommend this > 75% medical/surgical/ maternal hospital to your friends and family?" - Definitely Yes child inpatients per week 3) Identify and address factors related to why JIT IP Survey response to "Overall, how would you rate > 95% patients would or would not the care you received at the Hospital?" recommend our hospital to others". Develop JIT Survey for ED and Diagnostic Imaging patients # ED and DI JIT Surveys combined completed/week starting in Sept /week - starting in Sept 2013 Markham Stouffville Hospital QIP - Page 4

5 Quality dimension Objective Measure/Indicator Current perf. for ideas () In-house survey (if available): provide the percent response to a summary question such as the "Willingness of patients to recommend the hospital to friends or family" (Please list the question and the range of possible responses when you return the QIP) Integrated Reduce unnecessary time spent in acute care Percentage Alternate Level of Care (ALC) days: Total number of inpatient days designated as ALC, divided by the total number of inpatient days. Q3 2011/12 Q2 2012/13, Discharge Abstract Database (DAD), Canadian Institute for Health Information (CIHI) 2012/13 YTD Q3 Corporate: 11% < 11% Maintain or exceed current performance 1 1) Promote No Place Like Home Philosophy and culture 2)Work with CCAC to identify patients appropriate for CCAC's Home First Program 3) Enhance communication and coordination with two on-site Family Health Teams (FHTs) for highly complex admitted patients 4) Develop profile of MSH's most complex /high cost patients and potential to provide more coordinated care ALC Days as a % of Total acute patient days - Markham ALC Days as a % of Total acute patient days - Uxbridge ALC - Average Length of Stay (ALOS) - Markham ALC ALOS - Uxbridge < 10% < 17% < 20 days < 20 days # pts discharged on Home First - Markham > 6 per month # pts discharged on Home First - Uxbridge > 4 per month Reduce unnecessary hospital readmission Readmission within 30 days for selected CMGs to any facility: The number of patients with select CMGs readmitted to any facility for non-elective inpatient care within 30 days of discharge, compared to the number of expected non-elective readmissions - Q2 2011/12 Q1 2012/13, DAD, CIHI Consider selecting process indicators such as: Percentage of discharged patients for whom a comprehensive discharge summary was completed. Refer to the QIP Guidance Document for Ontario Hospitals more information on this. Markham Stouffville Hospital QIP - Page 5