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 The Royal Ottawa Place LTC April 2014 The Royal Ottawa Health Care Group 1

2 Overview of Our Organization s Quality Improvement Plan Overview 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. ACCESS Falls Restraints Objective 1 is to reduce the percentage of residents who had a recent fall (in the last 30 days) to 9%. The planned improvement initiative is to reevaluate the current Falls Prevention program. The Royal Ottawa Health Care Group 2

3 Objective 2 is to reduce the percentage of residents who were physically restrained (daily). The improvement initiatives will be to monitor data for consistent measurement of restraints and to improve documentation through an auditing process. Effectiveness Incontinence Objective 3 is to reduce the percentage of residents with worsening bladder control during a 90-day period. The improvement initiative will be to implement HQO s Resident First protocol, Restoring and Promoting Continence. Integrated ED visits Objective 4 is to reduce the number of emergency department visits due to an ambulatory care sensitive condition. The improvement initiative will be to implement HQO s Resident First protocol, ED Utilization. This is a new initiative that will require the development of a data collection system. Resident-Centred Patient satisfaction Objective 5 is to improve patient satisfaction. The Client Experience Survey question Overall, how would you rate the care you are receiving? will be used to measure this indicator. The improvement initiative will be to evaluate the existing protocols on Responsive Behaviour. This protocol is a newly implemented initiative that assists in decreasing the number of incidents of verbal aggressive behavior. This project was identified as an area for improvement based on the previous resident satisfaction survey. 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. Quality Dimension Indicator Name HQO Priorities Indicator selection informed by: Accreditation Canada ROPs ROHCG Priority Access Falls X X Restraints X X Effectiveness Incontinence X Integrated ED visits X Patient-Centred Resident Satisfaction (Overall, how would you rate the care you are receiving?) X X The Royal Ottawa Health Care Group 3

4 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. Many of these initiatives will impact The Royal s Long Term Care facility. Challenges, Risk & Mitigation Strategies The improvement priorities identified in The Royal s LTC QIP are recognized as necessary initiatives in ensuring patient safety and satisfaction. These initiatives will have mitigation strategies grounded in Lean Six Sigma methodologies for process improvement. That is, frameworks and methodologies will be used for implementing new best practice guidelines pertaining to incontinence and ED visit indicators. Furthermore, reevaluation of existing initiatives will be consistent with program evaluation methods and grounded in data analysis for effective and efficient changes. Information Management Systems The Royal s LTC facility uses the Point Click Care system. Data is generated regularly to assist in monitoring indicators for review at interdisciplinary meetings for the development of action plans as required. 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, 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. The Royal Ottawa Health Care Group 4

5 Accountability Management The QIP for The Royal s LTC facility will report initiatives to the internal interdisciplinary meetings and will also report quarterly to The Royal s Senior Management Team. Sign-off I have reviewed and approved our organization s Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. Rob Notman John Helmkay George Weber Board Chair Quality Committee Chair CEO The Royal Ottawa Health Care Group 5