2014/15 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

Transcription

1 2014/15 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario April 2014

2 Overview of Our Organization s Quality Improvement Plan The Royal s Quality Improvement Plan (QIP) is driven by our corporate vision: Mental health care transformed through partnerships, innovation & discovery. It is guided by the strategic directions from our Strategic Plan including: CARE DISCOVERY PARTNERSHIPS ENGAGEMENT SUSTAINABILITY To lead a culture of recovery, quality and patient safety To become a leading academic centre To provide leadership in integrating our mental health system To become an employer of choice To ensure organizational efficiency, effectiveness and financial strength We recognize that our clinical care is our primary role and improvement to the client experience drives the quality improvement initiatives across our organization. The 2014/15 QIP was developed by reviewing the indicators from the Royal s 2013/14 QIP and identifying progress towards the established targets. The Royal s Peer hospital Scorecard was used to ensure common comparable indicators remained. The Royal s peer organizations include Ontario Shores, Waypoint, and the Centre for Addiction and Mental Health (CAMH). Finally, the 2014/2015 selected QIP indicators incorporate opportunities for improvement that were identified through The Royal s Client Experience Survey, the Family Satisfaction Survey, Staff/Physician Survey, and aggregated (critical) incident data. Focus There are three primary goals providing the foundation to our Quality Improvement Plan: 1. To enhance care; 2. To enhance the patient and family experience; and 3. To improve patient-centred clinical outcomes. The Royal will be implementing new processes to strengthen the quality infrastructure and to oversee and support the corporate quality improvement objectives. The following section describes the objectives and the planned initiatives that will ensure The Royal is able to successfully reach our QIP targets. These objectives are classified according to the dimensions set by Health Quality Ontario. SAFETY Medication Reconciliation at Admission Medication Reconciliation at Discharge Physical Restraints Chemical Restraints Objective 1 is to increase the proportion of inpatients receiving medication reconciliations on admission to 100%. Planned improvement initiatives include: improving the tracking mechanism for medication reconciliation; reevaluating the process for medication reconciliation and the impact on the electronic process; and evaluating the Royal s IT platform for medication management.

3 Objective 2 is to maintain the proportion of inpatients receiving medication reconciliations at discharge from the Geriatric Program to 75%. The medication reconciliation at discharge process is dependent upon the medication reconciliation at admissions process. As such, the reevaluation of the IT platform will determine the progress of this indicator. Objective 3 is to decrease the number of patients whose RAI-MH admission assessment reported use of physical (includes mechanical, physical, and chair prevents rising) restraints, in the last 3 days (excludes confinement to room, unit, or seclusion). The improvement initiatives will be to reinforce and review training in The Royal s clinical programs in order to improve data reliability and data quality. Also, in order to engage staff, clinical programs will be provided with quarterly data through a measurement and feedback system. Lastly, Code White practices and the existing training program will be reevaluated in order to identify areas for improvement related to restraint use following a Code White. Objective 4 is to decrease the number of patients whose RAI-MH admission assessment reported use of chemical restraint, in the last 3 days. Improvement initiatives include reevaluating the current education program. Programs will also be provided with a measurement and feedback system that will assist in informing and engaging frontline staff. EFFECTIVENESS Total Margin (consolidated) Employee Survey Physician Survey Objective 5 is to improve organizational financial health by keeping our total margin greater than or equal to zero. Planned improvement initiatives include: reducing the number of hours employees are off due to illness; managing vacancy rates; and managing nurse overtime and agency use. Objective 6 is to improve employee satisfaction with team/unit experience. Planned improvement initiatives include: developing program-based initiatives; and increasing the number of on-time performance appraisals done per program. Objective 7 is to improve physician satisfaction with team/unit experience. Planned improvement initiatives include: carrying out a change management strategy related to the implementation of the Electronic Medical Record (EMR) project; and implementing a voice recognition system into the EMR system. ACCESS Average Wait Time Mood Objective 8 is to reduce wait times for our Mood Outpatient services with a comprehensive examination of the overall Mood Outpatient Program; and implementing of Phase 2 of the Central Intake triage process. PATIENT- CENTRED Survey: Overall, how would you rate the care you are receiving? Objective 9 is to improve patient satisfaction. Improvement initiatives include: increasing data reliability; establishing clear expectations related to the roles of the patient and the care providers; and improving compliance of the interprofessional care plan in the Forensic Program.

4 INTEGRATED ALC Days Objective 10 is to reduce unnecessary time spent in a specialized mental health care facility. Improvement initiatives include formalizing the ALC workgroup to a Committee; and implementing LOCUS, a level of care utilization system. Alignment The Royal s QIP has been developed with a foundation grounded in the Excellent Care for All Act. Specifically, improving the quality of care through the incorporation of data provided by client, family, employee and physician surveys, as well as aggregated (critical) incident data. The comprehensive plan is also aligned with several planning processes including: 1. The Hospital Service Accountability Agreement (H-SAA) regarding the required reporting on Total Margin; 2. The Royal s Strategic Plan with regard to each QIP indicator; 3. Accreditation Canada s Required Organizational Practices and Service Standards related to medication reconciliation; 4. The Champlain LHIN s Hospital clinical Services Distribution Plan Guiding Principles for enhanced accessibility; and 5. The Mental Health Addiction Quality Initiative Comparison Scorecard (with peer organization comparators) regarding client and family experience, employee and physician satisfaction with team, restraint use, medication reconciliation, and ALC days. This initiative provides a forum to share improvement ideas with peer mental health organizations. The following chart provides an overview of indicator alignment at The Royal. Quality Dimension Objective (overview label) HQO Priorities Indicator selection informed by: Strategic Plan/ Peers Accreditation Canada ROPs ROHCG Priority Priority Safety Med Rec on Admission X X X X I Med Rec at Discharge X X X I Physical Restraints X I Chemical Restraints X M Effectiveness Total Margin X X M Employee Satisfaction X X I Physician Satisfaction X X I Access Wait times in Mood Outpatient X X I Patient-Centred Inpatient Satisfaction (Overall, how would you rate the care you are receiving?) X X X I Integrated ALC days X X M

5 Integration & Continuity of Care Transitions of care in a specialized mental health care facility are complex and characterized by confusion, frustration, and uncertainty for patients and their families. As such, The Royal has encompassed many areas of the care process into key initiatives in the 2014/15 QIP. Particularly, in conjunction with Accreditation Canada, The Royal envisions an aggressive approach to implementing medication reconciliation across all inpatient areas. Also, a comprehensive analysis of the Mood Outpatient Program will examine ways to increase access for patients seeking care. This is a complex program that continues from last year to streamline service delivery and find increasingly effective ways of allowing access to patients when they are most vulnerable. Finally, to close the loop, The Royal will implement LOCUS, a level of care utilization program that will assist in supporting patients to transition to the community thereby opening beds for new inpatients. Challenges, Risk & Mitigation Strategies The improvement priorities identified in the QIP are recognized as necessary initiatives in ensuring patient safety, accessibility, and satisfaction. In an effort to maintain or reduce wait times in The Royal Mood Outpatient program, a comprehensive analysis will be conducted to restructure the program itself. In conjunction with the implementation of Phase 2 of the Central Intake triage process, there could be a temporary increase in wait times. Mitigation strategies will be grounded in Lean Six Sigma methodologies for process improvement. Challenges relating to Information Management Systems will affect different aspects of our improvement initiatives. Particularly, delays in implementing the Performance Management System could impact the number of performance appraisals required to meet our target. Secondly, the timely roll out of the Electronic Medical Record (EMR) project will impact initiatives set out to improve physician satisfaction with team/unit experience. Weekly meetings have been set up with physicians to address EMR progress in order to ensure timely communication of the EMR roll out. Thirdly, the implementation of LOCUS, the level of care utilization system will directly impact access to care. This is an information management system project which could also prove to have significant delays. A Committee will be formalized to ensure integration of this system into The Royal s current practices in a timely manner. Also, The Royal is examining methods to automate the patient satisfaction survey. This is a new initiative that will require senior leadership endorsement. A needs assessment will be performed to identify mitigation strategies consistent with findings. Finally, the medication reconciliation strategy is largely based on the Information Technology platform that will be selected to move this initiative forward. The Royal is currently awaiting updates from the developer of the system. Mitigation strategies will be determined once the platform has been finalized. Information Management Systems The Electronic Medical Records Suite for inpatient, outpatient and outreach settings is scheduled to be rolled out on November 4, Evaluation of the system will be performed following system roll out. Engagement of Clinical Staff & Broader Leadership Studies show that engaged staff is correlated to better patient care. The Royal is committed to improving employee satisfaction with its primary initiative grounded in employee engagement. The value placed on employee engagement is evidenced by its inclusion in The Royal s Strategic Plan as well as the QIP for the past 2 years. Primary initiatives have included a Leadership Development program,

6 Conflict Resolution programs, as well as unit-based quality initiatives for staff engagement. These programs are expected to continue this fiscal year. The Royal is also developing a strategy to engage frontline. This is a new initiative that aims at Strategic Plan deployment using Hoshin Kanri as the theoretical foundation for engagement. The Royal also engages clinical staff through the Quality of Care Review Committee. This committee aims at identifying methods to improve care related to patient incidents. The approach is geared at empowering clinicians in the quality improvement goals of the organization. Accountability Management The Royal has a performance-based compensation plan in place for the Senior Management Team which includes: the Chief Executive Officer; Chief of Staff and Psychiatrist-in-Chief; Executive Vice President and Chief Financial Officer; Vice President, Professional Practice and Chief Nursing Executive; Vice President, Communications; Vice President, Patient Care Services. The Royal has allocated 25% of the performance-based pay to the Quality Improvement Plan, with allocation to all 10 initiatives developed under the quality dimensions of the QIP set out by Health Quality Ontario including: Access, Effectiveness, Integrated, Patient-Centred, and Safety. Specifically, 25% is allocated to each of the indicators as outlined below: Quality Dimension Outcome Measure Allocation Access Average wait time for Mood Outpatient Services maintained at 6 months Total Margin at greater or equal to 0% Increase the percentage of employees reporting a positive satisfaction rating Effectiveness from 55.7% to 58.8% Increase the percentage of physicians reporting a positive satisfaction rating from 66.7% to 68.7% Integrated Reduce the number of inpatient days designated as ALC from 6.32 to 7.9 Patient-centred Increase the overall percentage of patients who are satisfied with their overall care from 78% to 79% Formal medication reconciliation on admission for inpatients is maintained at 100% Formal medication reconciliation on Safety discharge for the Geriatric program is maintained at 75% Reduce the percentage of physical restraints used from 10.1% to 6% The percentage of chemical restraints used is maintained at 12%. Health System Funding Reform Not applicable at this time.