2014/15 Quality Improvement Plan for Ontario Hospitals

Transcription

1 2014/15 Quality Improvement Plan for Ontario Hospitals 75 Springs St., Almonte, ON. KOA 1A0 April 2014

2 Overview of Our Organization s Quality Improvement Plan 1. Overview of our quality improvement plan for (the Hospital) is a small, rural hospital located in Almonte, Ontario, 40 kilometers west of downtown Ottawa. It serves a catchment population of over 30,000 people. The Hospital offers a wide range of acute and continuing care services including an Emergency Department. There are 21 Medical/Surgical beds, five level-one Obstetrical beds, 26 Complex Continuing Care beds and two Operating Rooms. In addition, the Hospital operates the Fairview Manor, a 112 bed Long Term Care Home located on the hospital campus, as well as the Lanark County Paramedic Service. The Hospital campus also includes the Ottawa Valley Family Health Team; the Leads, Grenville & Lanark District Health Unit and Lanark County Mental Health. Together, these facilities provide our hospital patients and long term care home residents with integrated, coordinated healthcare to support their seamless movement from one care setting to another. The Hospital s Quality Improvement Plan (QIP) is driven by the corporate mission to provide a continuum of integrated acute care, complex continuing care and long term care to our communities, focusing on quality care and personal attention, accountability and fiscal responsibility. The QIP is a tool to affirm and map the commitment of the Board of Directors and all staff in the continuous pursuit of positive clinical outcomes, positive patient experiences and positive staff work life. The QIP was developed with consideration to the requirements of the Excellent Care for All Act, Data from patient, family and staff surveys, critical incident reviews and the patient relations process were reviewed and assisted with prioritizing initiatives in the plan. The plan has been aligned with other in-hospital planning processes and Accreditation Canada initiatives. prides itself on its history of working collaboratively across the range of continuum of care providers in order to support patients as effectively as possible. Overall, the plan is aligned with the priorities of the Champlain LHIN and the Ministry of Health and Long-Term Care including Ontario s Action Plan for Health Care, The hospital plans to strengthen services by focusing on five of the dimensions that define quality within the Excellent Care for All Act, 2010: Safe, Effective, Accessible, Patient-Centred, and Integrated. This will be accomplished within our priorities of improving access and eliminating harm with strategies that are cost-effective. Priority Objectives Providing the Foundation for our Quality Improvement Plan:

3 The following information describes the objectives and the planned initiatives that will ensure we are able to successfully reach our QIP targets. These objectives are classified according to the dimensions set by Health Quality Ontario (Access, Effectiveness, Integrated, Patient-Centred and Safety). a. Length of Stay: Increases in patient volumes on the Medical /Surgical Unit in 2013 created a need to ensure patient care is being delivered within evidence-based, national expected length of stay day timelines. This approach is important to ensure care and services remain available to those who need them. The theoretical best variance between actual and expected length of stay is zero days. Current performance is 2 days and the target has been set for 1.75 days. As such, the focus for is a decrease in the average actual length of stay variance rate by 12.5%. b. Total Margin (consolidated): Improving the Hospital s financial health poses a significant challenge given that there is no expected increase in provincial funding for This coupled with collective agreement increases in salaries and other inflationary pressures limits the organization s ability to improve fiscal stability. As such, the Hospital will continue to review the efficiency of operations as well as identify opportunities for revenue generation. The Hospital will achieve a consolidated operating income position of balanced or better. c. Employee Engagement: The Hospital is committed to improving the work life of staff. A new Employee Engagement Survey was launched in February 2013 as a means of learning directly from staff what priority issues require improvement. During a team representing employees across all 3 divisions (, Fairview Manor and Lanark County Paramedic Service) worked to identify meaningful opportunities for improvement, informed by the results of the 2013 survey. This year ( ) the Hospital will focus on implementing actions to support strengthening employees access to information and communications. The impact will be measured in the results of the 2015 Employee Engagement Survey. d. Supported Discharges for Alternative Level of Care (ALC) Designated Patients: Long wait lists for access to long term care beds, a perceived lack of community-based home

4 support and a caring/dedicated small rural hospital staff (who often have a personal connection to patients) can result in delayed discharges of patients designated as ALC. Our improvement initiatives identified opportunities to strengthen the coordination of care for our patients between providers and environments, with a particular focus on the elderly with complex conditions. Prioritized improvement initiatives are evidenced-informed, taken from Health Quality Ontario s Best Path: Transitions of Care, 2013 publication. These initiatives focus on establishing smooth transitions for patients, whose care needs have already been met in hospital, successfully and in a timely way to a more appropriate setting for ongoing care and support. The Champlain Local Health Integration Network (LHIN) has set the target for percentage ALC days at 9%. Current performance is 21.9%. Therefore, the focus for is a decrease in the ALC rate by 59%. Of note, this indicator must be interpreted with caution for small rural hospitals due to low patient volumes resulting in significant variation in ALC rates. e. Readmission: Unplanned readmissions to hospital have been identified as common, costly and potentially avoidable. By assessing and identifying readmission risks prior to discharging patients from hospital and putting strategies in place to address these risks, evidence suggests these approaches will likely prevent some of these readmissions. Our improvement initiatives focus on the use of an evidence-informed assessment tool that quantifies the risk of readmission using both clinical and non-clinical characteristics to help health care providers identify people who might benefit from more intensive or specific post-discharge care. The Hospital s current readmission rate for selected case mix groups (CMGs) is 13.13%. The target has been set at 11.8%. The focus for is a decrease in the readmission rate by 10%. f. Patient Satisfaction: Staff recognize the importance of offering services in a way that is sensitive to an individual's needs and preferences and our proud to share that Maternity care at (AGH) is ranked #1 in Ontario by patients asked the question, Would you recommend this hospital to your family and friends? AGH is also in the 90 th percentile of rated hospitals when the same question was asked about acute inpatient care and emergency department care. Being in the 90 th percentile means AGH scored higher than 90 percent of the other hospitals ranked in that category. Building on the Hospital s success, there remains a commitment to ensure the best experience for patients in care. Therefore, a targeted improvement initiative was developed in accordance with the Registered Nurses Association of Ontario (RNAO) Best Practice Guideline: Establishing Therapeutic Relationships, The initiative involves implementing a model of care that promotes and supports the establishment of therapeutic relationships (between the nurse and patient) on the Medical/Surgical Unit.

5 The Hospital s current overall rate, for those inpatients who responded Yes, definitely to the question Would you recommend this hospital to your friends and family? is 90.6%, representing the 90 th percentile. This is a multi-year initiative. This year, our focus is to strengthen nurses engagement with patients related to their expressed anxieties and fears. As such, we do not know if improvement in our change initiatives will result in an improvement in our overall patient satisfaction performance measure. Therefore, we have not established an improvement target for our overall Patient Satisfaction rate for g. Formal Medication Reconciliation on Admission: Medication reconciliation (MedRec) is a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully assessed and documented. Health care providers follow a formal process to work together with patients, families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care. MedRec has been a multi-year quality improvement focus for. Over the past 2 years, the organization has successfully achieved improvement targets using improvement initiatives focused on completing MedRecs at each point of transition. This year, our improvement initiatives are focused on improving the quality of the completed MedRecs using an evidencebased quality audit tool. The organization has set improvement targets for each quarter, recognizing that process refinements need to be completed and implemented prior to achieving significant improvement results. The theoretical best compliance rate is 100%. The current (October 2013) national average Quality Score is 67%. Current performance is 52.8% and the overall target has been set for 63%. As such, the focus for is an increase in the overall compliance rate by 10%. 2. Integration and Continuity of Care understands that a strong focus on integration across all areas of the patient journey, beyond the care delivered in the hospital, will help to ensure patients receive high quality, accessible and coordinated care. This year s QIP includes several evidence-informed initiatives from Health Quality Ontario s Best Path: Transitions of Care, 2013 publication targeted to strengthen transitions in care by strengthening discharge planning, including identifying patients at high risk for readmission and putting actions into place that will support the patient post discharge from hospital. Initiatives also include strengthening information sharing appropriately with providers across the continuum of care. A Smooth Transitions of Care Team has been created with representatives of the, the Ottawa Valley Family Health Team, the Mills Community Support Corporation and the Community Care Access Centre (CCAC) to work in collaboration to support a seamless continuum of care for the community. 3. Challenges, Risks and Mitigation Strategies The improvement priorities identified in our QIP are recognized as necessary initiatives to ensure that care and services are accessible, effective, integrated, patient-centred, and safe. Risk Management at is founded on the philosophy that leadership sets the tone and directs efforts

6 across the organization to foster a culture that values learning, continuous improvement, innovation, and commitment to high quality, patient-centred care. Our staff is instrumental in improving quality of care and services despite fiscal and human resource challenges. Limited availability of human resources to assist with testing for compliance is a relevant risk for all initiatives. In response, checklists will be developed to increase the efficiency of compliance testing and testing will be conducted quarterly rather than monthly. Given that there remains no increase in provincial funding for , coupled with collective agreement increases in salaries and other inflationary pressures is a risk to the organization s ability to provide resources to support implementation of the Quality Improvement Plan. Lastly, the Hospital is preparing for an on-site Accreditation Canada survey in October (2014) placing additional workload requirements on all staff. In response, teams are working collaboratively and sharing strengths. 4. Information Management Systems The Hospital is in the process of acquiring its first electronic medical record (EMR). In the meantime, best efforts are exerted to manually extract information from a paper-based system. 5. Engagement of Clinical Staff & Broader Leadership The Hospital engages clinical staff and broader leadership in establishing shared quality improvement goals and commitments for the organization in the following way: Broad representation on internal committees including (but not limited to): the Quality Improvement & Risk Management (QIRM) committee, Infection Prevention & Control Committee, Joint Occupational Health & Safety Committee, Ethics Committee, Privacy Committee, Obstetrics Committee, Pharmacy & Therapeutics Committee, and Leadership Team. Implementation of patient order sets Late Career Nursing Initiative funded quality improvement projects Ongoing quality improvement efforts to remain compliant with Accreditation Canada standards Policy development and review in response to legislative, regulatory and professional practice requirements 6. Health System Funding Reform (HSFR) To date, small hospitals have not been subject to the Health-Based Allocation Model (HBAM). The Ministry of Health and Long-Term Care (MOHLTC) Quality-Based Procedures (QBPs) did not include procedures done at this hospital. It is unclear, at the time of writing, how QBPs will be implemented in in the small hospital context. 7. Accountability Management In accordance with legislative requirements, the following positions are subject to performance-based compensation: President and Chief Executive Officer Chief of Staff Vice President and Chief Financial Officer Vice President, Patient and Resident Services and Chief Nursing Executive Vice President, Corporate Support Services

7 All of the members of the Senior Team ( the Team ) are responsible for the operations of Almonte General Hospital and Fairview Manor. In addition, all members except the Chief of Staff support the operations of the Lanark County Paramedic Service. The performance-based compensation plan ( the Plan ) reflects our corporate values of Accountability for fulfilling our obligations, Respect for the contribution that each member makes to the organization and the Teamwork that is necessary for the organization to succeed. As such, a Plan has been created that contains congruent, not conflicting, goals for each member of the Team, and which rewards the Team for working together towards achievement of the goals. The culture of the organization would not support a Plan which contained incentives for contrary behavior by different members of the team who were each striving to achieve their own objectives. Selection of the goals for compensation was based on this principle and the three that were chosen are those to which every member of the Team makes a contribution. The amount of compensation at risk in 2014/15 is 2.5%. As there was no pay for performance plan in place at the time of the Government s freeze on Executive Compensation, the at-risk compensation is deducted from the salary of each Senior Team member and repaid if the goals are achieved. One goal has been chosen from each of the Safety, Effectiveness and Access quality dimensions. The three goals chosen improving the quality of medication reconciliation on admission to the Medical/Surgical unit; maintaining a balanced operating budget position; and reducing the variation between actual and expected acute length of stay reflect the organization s commitment to safe, high quality care, fiscal accountability and responsible use of patient care resources. In addition, data for each of these three measures is readily available for the purpose of monitoring performance throughout the year and the Senior Team has the ability to directly influence the outcome. Achievement of the goals is measured on a 5 point scale, with 3 being acceptable performance. If the Team achieves an average score of 3 or greater across the goals, each member will be paid 100% of the at-risk compensation. If the Team achieves an average score of 2, each member will be paid 50% and at an average score of 1, the Team will receive none of the at-risk compensation.

8 2014/15 Senior Management Team Performance Goals and Structure Safety Effectiveness Access Improve the average Medication Reconciliation Quality Score at admission on the Medical/Surgical unit from 52.8% to 63% Current performance is 52.8% QIP target for 2014/15 is 63% National benchmark is 67% Achieve balanced Financial position on hospital operations QIP target for 2014/15 is 0 Reduce the difference between actual and expected acute length of stay on the Medical/Surgical unit Current performance is 2 days QIP target for 2014/15 is 1.75 days 5 is 67% 4 is 65-66% 3 is 63-64% 2 is 53-62% 1 is 52% 5 is greater than 1.5% surplus 4 is 0.6 % to 1.5% surplus 3 is 0.5% deficit to 0.5% surplus 2 is 0.6% to 1.5% deficit 1 is deficit of 1.5% or greater 5 is 1.4 days 4 is 1.5 to 1.74 days 3 is 1.75 to 2 days 2 is 2.1 to 2.6 days 1 is 2.7 days

9 2014/15 Quality Improvement Plans for Ontario Hospitals Improvement Targets and Initiatives, 75 Spring Street, Almonte, ON KOA 1AO AIM MEASURE CHANGE Quality dimension Objective Measure / Indicator Unit / Population Source / Period Current Performance Target Performance Target justification Priority level Planned improvement initiatives (Change Ideas) Methods Process Measures Goal for change ideas (2013/14) Comments ACCESS Improve patient flow Length of Stay Variance: The difference between the actual and expected length of stay for acute inpatients on the Medical/Surgical Unit. days/ Medical Surgical Unit inpatients DAD, CIHI/ Q1 Q days 1.75 days The theoretical best variance between actual and expected length of stay is zero days. This is a multiyear QI initiative This year, our focus is on awareness and quality of documentation. Improve Standardize the quality of physician documentation to improve the accuracy of the Actual Length of Stay calculated rate on the Medical/Surgical Unit. Develop and implement a policy and procedure to set clear expectations regarding physician documentation required to accurately reflect all factors that contribute to actual length of stay. Develop and implement a process to ensure the expected length of stay is placed on patient charts within 24 hours of admission. Audit for compliance quarterly. Approval of the policy by the Medical Advisory Committee by December 31, Percent of patients charts on the Medical/Surgical Unit with documented expected length of stay / per quarter. Policy approved by December 31, % compliance by Improve organizational financial health Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the impact of facility amortization in a given year % / N/a OHRS, MOH / Q % 0% Hospital Service Accountability Agreement (HSAA) requirement Maintain Continue to identify opportunities for revenue generation. Continue to review efficiency of operations. EFFECTIVENESS Strengthen employee engagement Employee Engagement: Overall rating from the 2013 Talent Map Employee Engagement Survey % / Survey employee respondents Talent Map Employee Engagement Survey / February 11 to March 8, % 77% Our baseline performance is 25% above the Benchmark. This is a multi year QI initiative. This year, our focus is to implement the employee endorsed change initiatives. Next year, we will focus on re evaluating and setting our 'big dot' baseline measure and target. Maintain Provide employees with access to resources to support their ongoing learning/professional growth and development. Begin to establish the infrastructure required to support employee's use of computer technology Develop and implement a web based Learning Management System (LMS) that supports employees ease in access to on line education and training modules. Establish corporate network accounts for all full time and part time employees. Set up an on site computer training lab for employees Implementation of the Learning Management System by June 30, Set up of accounts by Set up of a computer training lab by 100% implementation by June 30, % completion by 100% completion by The Employee Engagement Survey is conducted every 2 years in accordance with the Excellent Care for All Act, 2010 requirement (next survey: 2015).

10 AIM MEASURE CHANGE Quality dimension Objective Measure / Indicator Unit / Population Source / Period Current Performance Target Performance Target justification Priority level Planned improvement initiatives (Change Ideas) Methods Process Measures Goal for change ideas (2013/14) Comments Implement individualized Care & Discharge Plans (ICDPs) on the Medical/Surgical Unit. Conduct ICDPs within 24 hours of a "decision to admit" to hospital; revise as required based on therapeutic progress, consultations, and new information. Audit for compliance quarterly The percentage of ICDPs completed and present on patient charts within 24 hours of a "decision to admit" to hospital / per quarter. 80% compliance by December 31, INTEGRATED Reduce unnecessary time spent in acute care Percentage ALC days: Total number of acute inpatient days designated as ALC, divided by the total number of acute inpatient days. % / All acute inpatients Ministry of Health Portal / Q to Q % 9% Hospital Service Accountability Agreement (HSAA) requirement Improve Implement Team Rounds and use of whiteboards to inform the ICDPs. Develop and approve a standardized process for sharing a copy of a written Discharge Plan with the patient and their caregiver(s) at the time of discharge from hospital. Hold Team Rounds weekly Implementation of team rounds on the Medical/Surgical Unit, and use of white boards on the using the whiteboard to Medical Surgical Unit / by June inform the ICDPs. Audit for 30, compliance quarterly. Develop a patient discharge plan template using easy to understand text with input from nurses, physicians and patients. Present the new discharge plan template to the Medical Advisory Committee for approval by Approval of the process by the Medical Advisory Committee by 100% implementation by June 30, Process approved by Reduce unnecessary hospital readmission Readmission to any facility within 30 days for selected case mix groups (CMGs) for any cause. The rate of nonelective readmissions to any facility within 30 days of discharge following an admission for select CMG's. % / All acute patients DAD, CIHI / Q to Q % 11.8% 10% improvement Improve Develop and approve a process for sharing a copy of a written Discharge Plan with the patient's primary care team and other appropriate community providers within 24 hours of discharge. Implement the LACE Index Scoring tool to identify individuals who are at risk of readmission post discharge and arrange appropriate follow up support. Develop a provider specific discharge plan template with input from nurses and physicians. Present the new discharge plan template to the Medical Advisory Committee for approval by Implement the LACE Index Scoring tool on the Medical/Surgical Unit by September 30, Audit for compliance quarterly. Approval of the process by the Medical Advisory Committee by The percentage of LACE Index Scoring tools completed and present on patient charts on the Medical Surgical Unit / per quarter. Process approved by 80% compliance by

11 AIM MEASURE CHANGE Quality dimension Objective Measure / Indicator Unit / Population Source / Period Current Performance Target Performance Target justification Priority level Planned improvement initiatives (Change Ideas) Methods Process Measures Goal for change ideas (2013/14) Comments Develop and implement a process, with input from Before leaving hospital, nurses and physicians, for patients deemed at high booking follow up risk of readmission are appointments within 48 expected to have a booked hours with primary care appointment to see their team, for patients deemed primary care team within high risk for readmission. 48 hours. Audit for compliance quarterly. Percentage of high risk patient's charts with evidence of booked follow up appointments / per quarter. 60% compliance by PATIENT CENTRED Improve patient satisfaction Patient Satisfaction: From NRC Picker: "Would you recommend this hospital (inpatient care) to your friends and family? (add together % of those who responded "Yes, Definitely". % / All inpatients NRC Picker / Oct 2012 to Sept % 90.6% Current performance is in the 90th percentile. This is a multi year QI initiative. This year, our focus is to strengthen nurses' engagement with patients related to their anxieties and fears. As such, we do not know if this will move our 'big dot' measure. Maintain Implement a nursing model of care that promotes and supports the establishment of therapeutic relationships (nurse: patient) on the Medical/Surgical Unit. Review literature to identify current best practice nursing model(s). Select and implement a nursing model on the Medical/Surgical Unit by Percentage of "yes completely" responses to the Medical Surgical Unit NRC Picker Survey question "If you had any anxieties or fears about your condition or treatment, did a nurse discuss this with you?" / per quarter. Increase from 60% (2013 Q1) to 70% by SAFETY Improve the quality of medication reconciliation upon admission Medication Reconciliation Quality Score at admission: The average Medication Reconciliation (MedRec) Quality Score at admission (Medical/Surgical Unit). % / All Medical Surgical Unit inpatients Safer Healthcare Now Metrics / Oct % 63% The National Benchmark is 67% 10% increase over baseline is what is feasible this year. Improve Strengthen nurses knowledge of best practices associated with obtaining a Best Possible Medication History Develop an on line education and evaluation tool based on best practices, including the Sunnybrook Hospital model Educate nurses (Medical/Surgical unit and Emergency Department) using the new education and evaluation tool Completion of the on line tool by September Percent of Medical/Surgical unit and Emergency Department nurses who successfully complete the education and evaluation tool 100% completion by September 30, % by December 31, % by March 31, 2015

12 Accountability 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.