Niagara Health System. April 1, Niagara Health System Ontario Street St. Catharines, ON

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1 Niagara Health System April 1, 2011 Niagara Health System 1

2 Part A: Overview of Our Hospital s Quality Improvement Plan 1. Overview of our quality improvement plan for The Niagara Health System is committed to our Vision and Mission to be Leaders in Healthcare and to Provide Equitable and Timely Access to patient-centered and safe medical care for all Niagara residents. The Niagara Health System (NHS) will also continue to work with our community and Local Health Integration Network (LHIN) partners to address unnecessary hospital admissions and time spent in hospital with a focus to enhancing patient-centered care. These initiatives will contribute to a positive patient experience for our patients and visitors when they receive care and services at the Niagara Health System. We are accountable for and committed to providing care and services to our patients whereby: 1. Patient care is provided in the safest environments possible that reduce the likelihood of errors or harm. 2. The care we provide is evidence-based and exemplifies the most effective use of knowledge and resources. 3. Access to care is both timely and efficient to support patients in maintaining their optimal health. 4. Patients are partners with us in their care through effective communication and respect for individual choices. 2. What we will be focusing on and how these objectives will be achieved Over the course of the next year NHS will focus on improving the overall quality of care and services delivered at all seven hospital sites. By March 31 st, 2012 NHS will achieve the following aims and measures. SAFETY Our aim is to improve the overall safety of care we deliver to our patients. Our success in achieving this aim will result in: A reduction in the number of patient falls from 12.14% to 10.94% EFFECTIVENESS Our aim is to provide patient care reflective of current evidence-based practice and the appropriate use of available resources. Our success in achieving this aim will result in: A reduction in our Hospital Standardized Mortality Ratio (HSMR) from 100 to 95. Continued financial improvement which will see our Total Margin being maintained at -0.80%. ACCESS Our aim is to ensure patients in the communities we serve have timely access to the appropriate care and services required to maintain their optimal health status. Our success in achieving this aim will result in: A reduction in the amount of time patients who are admitted to hospital wait in the Emergency Department before moving to their inpatient bed from 45.3 hours to less than 39.9 hours. Niagara Health System 2

3 PATIENT-CENTRED Our aim is to provide care and services to all patients and families that reflect our respect for individual choices and patients as partners in their care. Our success in achieving this aim will result in: 75.3% of our inpatients stating that they received all services needed. 56.2% of our ED patients stating that they received all services needed. 3. How the plan aligns with the other planning processes Quality of care and patient safety have always been key strategic priorities for the NHS. The Quality Improvement Plan (QIP) aligns with many strategic initiatives that we are engaged in that are actively aimed at improving the quality of care and experience for patients. These other strategies include maintaining compliance with patient safety standards as defined by Accreditation Canada, Safer Healthcare Now and ensuring compliance with agreements in place with the Ministry of Health and Long- Term Care and the Local Health Integration Network (LHIN) in key areas. The NHS has invested in the Lean process and process improvement initiatives that are aimed at attaining innovative improvements in care delivery that result in patient client centred care and collaborative practice to improve patient and staff satisfaction, quality, safety and cost reduction. These initiatives involve our external partners as key stakeholders in the process. The NHS actively engages in ongoing quality improvement initiatives and in the public reporting of our performance in key areas. To learn more about specific projects underway and to see how we are doing we encourage you to visit the Quality and Performance section of our website at: 4. Challenges, risks and mitigation strategies Inherent in all quality improvement plans is the risk of not successfully implementing the required changes and thus not achieving our quality improvement goals. The NHS QIP is an ambitious plan targeted at improving specific areas of care and service that we believe will enhance our ability to deliver high quality, safe and reliable care to all patients. In order to support these efforts and mitigate the potential risks, several actions are underway to support the successful achievement of our plan. The organization has many competing priorities, such as Hospital Improvement Plan (HIP) implementation, Lean strategies and specifically for the St. Catharines sites preparing to move into the new facility. Therefore, implementation of all plans will require intensive monitoring and support to ensure progress and goals are attained. Additional risks relate to the availability and support of external partners in the improvement journey. The Alternate Level of Care (ALC) days are a function of many different factors, and the NHS is working actively with many of our external partners to ensure patients receive the right care in the right place and at the right time. However, a higher than average elderly population coupled with a shortage of Long Term Care (LTC) beds in Niagara is a particular challenge for the NHS, and places additional risk on meeting targets. This is an ongoing challenge and dialogue continues with our partners to proceed to mitigate against this risk. Unforeseen risks may also occur that could potentially jeopardize the attainment of goals such as health emergencies or disasters (e.g. H1N1 pandemic influenza, etc.). While the NHS plans for such public health emergencies, it is clear that this type of public health crisis would take priority over internal goals and priorities. Niagara Health System 3

4 Part B: Our Improvement Targets and Initiatives Please see the document entitled Improvement Targets and Initiatives. Niagara Health System 4

5 Part C: The Link to Performance-based Compensation of Our Executives Purpose of Performance-based compensation: 1. To drive performance and improve quality care 2. To establish clear performance expectations 3. To create clarity about expected outcomes 4. To ensure consistency in application of the performance incentive 5. To drive transparency in the performance incentive process 6. To drive accountability of the team to deliver on the Quality Improvement Plan 7. To enable team work and a shared purpose Manner in and extent to which compensation of our executives is tied to achievement of targets Our executives' compensation is linked to performance in the following way: The performance based component of executive compensation consists of the attainment of selected objectives in the Quality Improvement Plan (QIP); as well as the attainment of selected group and individual objectives. 60% of the performance-based component will be linked to the following 5 Quality Improvement Plan (QIP) Targets: Complex Continuing Care Falls under the Safety Dimension of Quality Hospital Standardized Mortality Rate (HSMR) under the Effectiveness Dimension of Quality Total Margin under the Effectiveness Dimension of Quality Emergency Room (ER) wait times under the Access Dimension of Quality Improve Patient Satisfaction under the Patient Centered Dimension of Quality. 5% of base pay has been reduced for the: o President and Chief Executive Officer; o Chief of Staff o Executive Vice President and Chief Operating Officer o Executive Vice President and Chief Nursing Executive o Vice President Medical 3% of base pay has been reduced for the other members of the Executive Team which includes: o Vice President Patient Services o Vice President Human Resources o Chief Financial Officer o Chief Communications Officer o Chief Capital Planning Officer. The above percentages of salary will be withheld until fiscal year end, with payout to be determined upon evaluation of year end performance. Niagara Health System 5

6 PCP Components QIP Goal 2011/12 Target Weighting Organizational Results Avoid Falls Reduce falls by 10% 12% Reduce Unnecessary deaths a) 25% reduction in Sepsis mortality b) Implement Early Warning System c) Implement VTE Order Set Reduce Wait Times in ED Reduce ED Wait Time by 10% (45.1 hr hr.) 12% 10% 1% 1% Improve Organizational Financial Health Reduce Sick time, Overtime and NEER costs by $1 million Improve Patient Satisfaction a) Improve IP Acute Patient Satisfaction by 10% (68.5% 75.3%) b) Improve ED Patient Satisfaction by 10% (51.2% 56.2%) 12% 6% 6% 60% Group Results Quality Domain Specific Objective 15% Quality Domain Specific Objective 15% 30% Individual Results Enhance Knowledge Specific Objective 10% Total 100% Niagara Health System 6

7 Part D: Accountability Sign-off I have reviewed and approved our hospital's Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan: 1. Was developed with consideration of data from the patient relations process, patient and employee/provider surveys, aggregated critical incident data, and patient safety indicators; 2. Contains annual performance improvement targets, and justification for these targets; 3. Describes the manner in and extent to which, executive compensation is tied to achievement of QIP targets; and 4. Was reviewed as part of the planning submission process and is aligned with the organization's operational planning. Ms. Betty Lou Souter Board Chair Mr. Paul Leon Quality Committee Chair Ms. Sue Matthews Interim Chief Executive Officer Niagara Health System 7