Providence Manor s Quality Improvement Plan 2013-2014 Providence Manor s Residents First Quality Improvement Team Presents Our QI Journey Leading provider in Aging, Mental Health and Rehabilitative Care
PART ONE: Getting Started 11/12/2014 Providence Manor s Quality Improvement Journey 2
Developing a Collaborative Team www.residentsfirst.ca So you are going to develop a QIP? Now you need to create a team. It is recommended that the team have no more than 10 interdisciplinary members, and should include the professions and roles that touch the process. This means any of the staff members who are stakeholders in your QI initiatives. Identify QI facilitators Education, this is a new language 11/12/2014 Providence Manor s Quality Improvement Journey 3
Who Is On Your Team? 11/12/2014 Providence Manor s Quality Improvement Journey 4
Providence Manor s Team Facilitator- (in consultation with Shelagh) resource for QI lead and content experts, develop time lines, organizes meetings communicates agenda and minutes, reports QIP to SLT, Accreditation lead Leads- administrative link, approval power, communicate results to administration, ensures QI is sustained Content Experts - assembles team, develops QI, ensures plan is implemented communicates results to the team Champions, members of the content experts team, (do not attend all meetings) Corresponding Members - resources for and members of the QI team (decision support, ethics, quality and risk management) Groups Represented - RAI, Maintenance, Human Resources, Activities, Volunteers, Food and nutrition services, Occupational Health and Safety, Nursing, Administration, Spiritual Health Your Team and Your QIP must fit Your Organization 11/12/2014 Providence Manor s Quality Improvement Journey 5
Terms of Reference right from the act! Revised January 20, 2014 Approved February 19, 2013 Providence Manor Residents First Quality Team Terms of Reference Purpose: A forum to provide direction and leadership in the development and implementation of a quality improvement and utilization review system for ongoing reporting/review of quality improvement initiatives related to resident experience, accommodation, care services, programs and goods provided to residents of Providence Manor. 2007 c 8 s 84 11/12/2014 Providence Manor s Quality Improvement Journey 6
TEAM WORK! Coming together is a beginning. Staying together is progress. Working together is success. 11/12/2014 Providence Manor s Quality Improvement Journey 7
How do we keep on track? Monthly planning meeting with Administrator Monthly RFQI team meeting Regular QI presentations with a standardized power point template Clear agenda- Why & What Who & How Follow-up Action Plan Date reminders sent by Facilitator Working Plan Time Line 11/12/2014 Providence Manor s Quality Improvement Journey 8
PART TWO: The QIP 11/12/2014 Providence Manor s Quality Improvement Journey 9
Criteria For QI Objectives Does it Improve quality of life for our residents, does it matter to them? Can we measure our current performance? Is our Improvement measurable? Remember Soon is not a date and lots is not a number! & All improvement means change but all change does not mean improvement! 11/12/2014 Providence Manor s Quality Improvement Journey 10
How Did We Develop Our QIP? 1. RFQI TEAM Decide on Objectives Falls, Pressure ulcers, Restraints, Bladder Control, ED visits, Receiving and Utilizing Feed Back(the dinning experience), Pain management, aggressive responsive behaviours, staff safety 2. Choose the Lead and Content expert for each Objective 3. Lead & Content Expert develop a Team- they decide on Measure indicators, measure current performance, set targets,& target justification, plan improvement initiatives, process measures & goals 4. Verify data before submission 11/12/2014 Providence Manor s Quality Improvement Journey 11
Our Team Developed QIP Draft template QIP development working plan QIP data verification sign off QIP presentation PowerPoint template QIP posters 11/12/2014 Providence Manor s Quality Improvement Journey 12
What Did We Submit To HQO? Our 2014/15 Quality Improvement Plan Quality Improvement Plan (QIP) Narrative Supporting Tools From HQO Indicator technical specifications QIP Guidance Document QIP narrative for Health care organizations Frequently asked questions 2015/2016 The Navigator (coming soon) 11/12/2014 Providence Manor s Quality Improvement Journey 13
Decide: What Data To Use For Targets And Process Measures? MDS-RAI - CIHI (Canadian Institute for Health Information) CCRS ereports (Community Care reporting System) Resident Satisfaction Survey Internal Benchmarking Safety-Net Reports (staff and Resident) Annual Pressure Ulcer Prevalence Survey SELHIN Nurse Led Outreach Team Quarterly Reports Target Justification- provincial %, past Satisfaction survey results, internal benchmarking 11/12/2014 Providence Manor s Quality Improvement Journey 14
Spreading Our Results Presentations at Residents First QI Team meetings Attend resident and family council meetings SLT, PAC, Patient Quality Safety Committee Posters Family newsletter Intranet e-currents Post on QI bulletin board Posted on OANHSS member community as a guide (http://community.oanhss.org/) 11/12/2014 Providence Manor s Quality Improvement Journey 15
What Did We Learn? Clearly define the roles within the team Clearly define QI terms and all new language (different levels of understanding) Measure twice, submit once! (verify your date) Communicate your plan to all staff Celebrate your teams hard work and accomplishments 11/12/2014 Providence Manor s Quality Improvement Journey 16
Questions? Contact: Lynne Hendry, RN GNCc Quality Improvement Facilitator hendryl@providencecare.ca 11/12/2014 Providence Manor s Quality Improvement Journey 17