2015/16 Quality Improvement Plan for Ontario Hospitals "Improvement Targets and Initiatives"

Transcription

1 Patient-centred Improve In-house survey % / Complex In-house survey / 932* % satisfaction 1)Conduct a review of A comprehensive literature review of drivers of Literature review completed. satisfaction question: "How continuing care is the stretch drivers of CCC in complex continuing care. would you rate the residents goal for the satisfaction settings to quality of care at this 16. enable targeted hospital?". % of all interventions for improving CCC ins able to. participate in the survey rating quality of care as "Good" or "Very Good" (top 2 ratings) in To either validate or modify our CCC surveys in order to provide actionable items that will positively impact overall satisfaction with quality of care. 2)To either validate or modify our CCC satisfaction surveys based on completed literature review. Revise surveys as needed. Completion of survey revisions. To have an evidence-based inhouse CCC 3)Develop survey methods, sample sizes and frequencies which reflect CCC program throughput. Review program data to determine sample sizes, frequencies and survey methods. Completion of data review and overall survey methodology. To have a satisfaction survey methodology that meets the needs of the CCC 4)Conduct CCC As determined in previous steps, conduct CCC Completion of survey. To have data that is reflective of the current CCC population and will enable the development of meaningful action plans to improve 5)Develop and implement CCC improvement plans based on their survey results. Review survey results, develop and implement satisfaction plans in collaboration with the unit-based quality teams. Action plans developed and implemented. To make measurable improvements in CCC 6)To report CCC satisfaction results to the Quality Measurement and Mission Effectiveness committee of the Board. Results of the CCC survey will be tracked and reported on the quarterly Dashboard, and reviewed at the Quality Measurement and Mission Effectiveness Committee of the Board. QMME minutes indicating review of Dashboard, including CCC results. oversight of satisfaction trends at the Board level.

2 In-house survey % / Rehab In-house survey / 932* % satisfaction 1)Conduct a review of A comprehensive literature review of drivers of Literature review completed question: "How is the stretch drivers of satisfaction in geriatric. would you rate the goal for the satisfaction in our geriatric quality of care at this 16. in hospital?". % of all setting to enable targeted Geriatric interventions for improving. ins able to participate in the survey rating quality of care as "Good" or "Very Good" (top 2 ratings) in To either validate or modify our geriatric survey in order to provide actionable items that will positively impact with quality of care. 2)To either validate or modify our geriatric satisfaction surveys based on completed literature review. Revise surveys as needed. Completion of survey revisions. To have an evidence-based inhouse geriatric survey. 3)Develop survey methods, sample sizes and frequencies which reflect geriatric program throughput. Review program data to determine sample sizes, frequencies and survey methods Completion of data review and overall survey methodology. To have a satisfaction survey methodology that meets the needs of the geriatric 4)Conduct satisfaction surveys in the geriatric As determined in previous steps, conduct satisfaction survey in the geriatric Completion of survey. To have data that is reflective of the current geriatric population and will enable the development of meaningful action plans to improve 5)Develop and implement geriatric improvement plans based on their survey results. Review survey results, develop and implement satisfaction plans in collaboration with the unit-based quality team. Action plans developed and implemented. To make measurable improvements in in the geriatric

3 6)To report geriatric Results of the geriatric QMME minutes indicating review of Dashboard, survey will be tracked and reported on the quarterly including geriatric satisfaction results to the Dashboard, and reviewed at the Quality Measurement results. Quality Measurement and and Mission Effectiveness Committee of the Board. Mission Effectiveness committee of the Board. oversight of satisfaction trends at the Board level. In-house survey question: "How would you rate the quality of care at this hospital?". % of all Stroke s able to participate in the survey rating quality of care as "Good" or "Very Good" (top 2 ratings) in % / Rehab In-house survey / * % satisfaction is the stretch goal for the )Conduct a review of drivers of Stroke satisfaction in our to enable targeted interventions for improving A comprehensive literature review of drivers of satisfaction in Stroke. Literature review completed. To either validate or modify our Stroke surveys in order to provide actionable items that will positively impact with quality of care. 2)To either validate or modify our Stroke satisfaction surveys based on completed literature review. Revise surveys as needed. Completion of survey revisions. To have an evidence-based inhouse Stroke survey. 3)Develop survey methods, sample sizes and frequencies which reflect the Stroke program throughput. Review program data to determine sample sizes, frequencies and survey methods. Completion of data review and overall survey methodology. To have a Stroke survey methodology that meets the needs of the 4)Conduct Stroke As determined in previous steps, conduct Stoke survey. Completion of survey. To have data that is reflective of the current Stoke population and will enable the development of meaningful action plans to improve

4 5)Develop and implement Review survey results, develop and implement Action plans developed and implemented. Stroke plans in collaboration with the unit-based satisfaction improvement quality team. plans based on survey results. To make measurable improvements in Stoke 6)To report Stroke satisfaction results to the Quality Measurement and Mission Effectiveness committee of the Board. Results of the Stoke survey will be tracked and reported on the quarterly Dashboard, and reviewed at the Quality Measurement and Mission Effectiveness Committee of the Board. QMME minutes indicating review of Dashboard, including Stroke results. oversight of satisfaction trends at the Board level. Safety Increase proportion Medication % / All s Hospital collected 932* As this is a of s receiving medication reconciliation upon admission reconciliation at admission: The total number of s with medications reconciled as a proportion of the total number of s admitted to the hospital. data / most recent quarter available priority target for HQO, and because we need to improve to reach our target, this is a priority for Bruyere Continuing Care. The target is for all hospital programs at Bruyere (CCC, Palliative, Rehabilitation). We aim to reconcile all medications within 24 hours of admission. 1)To include timely medication reconciliation documentation within the new electronic record. This new method eliminates additional documentation for the pharmacist, thereby making a one-step medication reconciliations process. Provide staff education related to how medication reconciliation is documented in the new electronic record. Number of staff who have received education related to how medication reconciliation is documented in the new electronic record. medication reconciliation is documented in a timely manner in the new electronic record. Reduce hospital acquired infection rates Hand Hygiene % / Health Compliance before providers in the initial / entire facility environment contact: the number of times that hand hygiene was performed before initial / environment contact divided by the number of observed hand hygiene Publicly reported MOH / Calendar year * With the planned introduction of mobile workstations, new protocols for hand hygiene compliance and related education for staff will be required part way through the year. Therefore 1)Reports will continue to The Quality, Patient Safety and Risk Management be sent to all units regarding department will send out hand hygiene posters with the hand hygiene compliance the most recent moment 1 compliance rates for each for follow-up with staff by unit and for the entire organization to each clinical Clinical Managers. The manager for mounting in their Quality Matters board. Quality Matters boards that are mounted on every Bruyère unit will be updated monthly with Hand Hygiene compliance results % of units receiving updated hand hygiene reports every month in Unit-based hand hygiene reports will be distributed on 100% of units on a monthly basis

5 y for 2015/16 the 2)Tracking of learners taking During Orientation, each clinical staff member will target will be the hand hygiene e-learning complete the hand hygiene e-learning module. If they 90% compliance. module on the Learning cannot complete it then, they are required to complete Management System. it within 3 months yg indications for before initial / environment contact multiplied by consistent with publicly reportable safety data 3)Information to be Messages to be drafted and sent to webmaster for published throughout publication on InfoNet, digital TVs, and for permanent Bruyère via bi-monthly residence on the Infection Prevention and Control messaging on the InfoNet, website and wellness boards. and the Infection Prevention and Control website. % of new hires (clinical) who have completed the e- learning hand hygiene module within 3 months of hiring in # hand hygiene reports published on InfoNet and elsewhere throughout Bruyere in % of all new clinical staff will have completed the e-learning hand hygiene module Increased information specific to hand hygiene compliance and expectations will be disseminated throughout Bruyère; Unitbased information about hand hygiene compliance will be provided on a monthly basis Avoid Patient falls Number of falls per 1000 days. Rate per 1,000 / All s Hospital collected data / Most recent calendar year 932* The baseline for the falls indicator is the 2014 calendar year with a targeted reduction of falls by 10% (to 3.90 falls/1000 days) for )To implement evidencebased falls prevention initiatives to address the most frequent contributing factors related to falls across each of the hospital programs. Conduct a review of falls incident reports for each of the hospital programs to identify the most common contributing factors. Completion of the falls incident review, identification of most common contributing factors, and action plans to address them. To reduce the number of falls by 10% in each of the hospital programs. Using the current rates as baseline, 10% reductions over the next 2 years will bring our rates in line with the province rates and our stretch goal of <3.4 falls per 1000 days. 2) that hourly rounding is taking place across each of the hospital programs. Audits of hourly rounding Completion of the hourly rounding audit, and results To proactively address s needs with an aim to reduce unsafe behaviours through hourly rounding by nursing staff.

6 3)Identify best practices in Conduct a falls best practice review with a focus on Completion of the best practice review falls prevention for hospital specific non-acute populations ins in a non-acute setting. To identify best practices in falls prevention that are applicable to our setting and population.