Excellent Care for All Act, (ECFAA) MSH Quality Improvement Plans (QIP): Report for QIP The following template has been provided to assist with completion of reporting on the progress of your organization s QIP. Please review the information provided in the first row of the template which outlines the requirements for each reporting parameter. QIP Priority Indicator ED Wait times: 90th percentile ED length of stay (LOS) for Admitted patients. Markham Site Hours ED patients Q4 2011/12 Q3 CCO iport Access 47.40 40.30 36.02 (Q4 Q3 ) MSH has implemented several initiatives over the past 9 months that have resulted in significant improvement in patient flow throughout the hospital, and our ED admitted patient LOS. We implemented a Clinical Operations Manager role responsible for ensuring patient flow activities continue and are sustained throughout the evenings and on weekends. We opened an 11 bed Admissions Assessment Unit, (AAU), for patients needing short term admission for assessment and diagnosis and an expected LOS of less than 72 hours which frees up our inpatient units beds for the more complex higher acuity patients with longer expected LOS. We restructured and standardized our bed management meetings and increased the number of meetings to twice daily. The meetings focus on identifying and discussing impending discharges, flow, discharge barriers, and specific actions required to improve flow. The flow within the new Markham site ED department is continually being reviewed using LEAN methodology to optimize movement and MSH 2014/15 QIP Final April 2014 Page 1 of 9
QIP Priority Indicator ensure all processes are efficient as possible. Patient Flow and ED LOS for admitted patients will continue to be a focus of MSH in 2014/15 with an emphasis on improving organizational-wide awareness of bed situation and flow issues on a continual basis. Our bed flow management reports will be communicated 4 times daily and we will institute a bed allocator role with responsibility for constant monitoring, updating and communication of our bed situation. We will review our gridlock and surge capacity plans to bring clarity regarding the actions to be taken hospital-wide at each stage of gridlock. ED Wait times: 90th percentile ED length of stay for Admitted patients Uxbridge Site Hours ED patients Q4 2011/12 Q3 CCO iport Access 20.60 20.00 27.05 (Q4 Q3 ) Stronger collaboration and improved processes between the Markham Site and the Uxbridge site has greatly improved the ability to provide the best quality of care to our patients and reduce the ED LOS. Inclusion of Uxbridge in the 2x daily bed meetings has improved the ability to transfer patients between sites and to place patients in the right bed with the right care required. OTN has improved the capability for consults and assessments of patients on site. A dedicated hospitalist at the Uxbridge site with access to appropriate specialist consultation at the Markham Site has improved the overall quality of care for our Uxbridge patients. The recent implementation of a new Medicine Telemetry system at the Uxbridge site will help reduce the need for transfer of stable MSH 2014/15 QIP Final April 2014 Page 2 of 9
QIP Priority Indicator cardiac patients and reduce the length of time that these patients are in Uxbridge ED waiting for a bed. In 2014/15 we will further reduce our ED LOS by streamlining and standardizing roles and responsibilities and developing standard work for patient flow. The Daily Analysis and Reporting Tool, (DART), and bed status reports - tools used for communication of bed flow and bed utilization hospital wide will be revamped and the frequency and scope of distribution increased. Bullet rounds and Improved discharge planning and with a focus on increasing discharges before 1100 and on the weekend will enhance bed utilization and the flow from ED to inpatient beds. Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year - Corporate % Q3 OHRS, MOH 1.06 0.00 2.18 FY Q3) MSH has moved to a budget allocation methodology based on cost per weighted case to better align our budget monitoring with Health System Funding Reform, (HSFR), Health Based Allocation Methodology, HBAM) and Quality Based Procedures, (QBPs) and to facilitate peer to peer comparisons. In Quarterly budget meetings were instituted for key departments at which the Senior Team and the Departmental leadership meet to review and discuss the status of their budget and strategies to reduce shortfalls, increase revenues and identify potential issues/risks that may affect their ability to meet their budget targets. These meetings provide the Senior Team with a better understanding of MSH 2014/15 QIP Final April 2014 Page 3 of 9
QIP Priority Indicator organization-wide issues, trends and opportunities. Our financial status is discussed monthly by the Leadership team with facilitated discussions held on key issues impacting our bottom line including sick time/attendance management, wait times in all clinical areas, WSIB/Return to Work, patient volumes, revenues and opportunities to maximize Post Construction Operating Plan, (PCOP) funding. We have decreased medical/surgical costs through changes to our Just in Time, (JIT) ordering and inventory processes. HSMR: Number of observed deaths/number of expected deaths x 100 - Corporate Ratio (No unit) All patients 2011/12 DAD, CIHI 79.00 79.00 78.00 (FY ) The Hospital continues to monitor and assess trends related to hospital deaths. All unexpected deaths are reviewed by the relevant clinical area using a structured review tool. A mortality report is produced weekly and each clinical unit is expected to review and assess each death against specific criteria to identify those that require a formal interdisciplinary morbidity and mortality review. Our documentation and coding practices are closely monitored to ensure adherence to regulatory guidelines and best practices. There is ongoing feedback and discussion between Health Information coders and our physicians. The hospital s antibiotic stewardship program is now fully implemented and integrated into daily practice. The Holy Moly, My patient has a Foley campaign and associated policy regarding insertion and removal of indwelling catheters has been very successful with MSH 2014/15 QIP Final April 2014 Page 4 of 9
QIP Priority Indicator an impressive reduction of the number of inappropriate indwelling catheter insertions year to date. Percentage ALC days: Total number of acute inpatient days designated as ALC, divided by the total number of acute inpatient days. Corporate % All acute patients Q3 Q2 Ministry of Health Portal From NRC Picker / HCAPHS: "Would you recommend this hospital to your friends and family?" (add together percent of those who responded "Definitely Yes" or "Yes, definitely") (core-overall) % - Corporate Oct 2011 Sept 2012 11.00 11.00 10.10 (FY YTD Q3) 74.40 75.00 73.20 (Oct 2012 - Sept 2013) There has been a sustained support for the philosophy that home is the best place for a patient to await placement and make decisions regarding the future. Our reduction in ALC days has been enabled through ongoing commitment and collaboration between the hospital staff and physicians and Community Care Access Centre s (CCAC) staff. Discussions with patients regarding home as their discharge destination commence on admission and their transition home is enabled through CCAC s Home First and Home at Last Program as well as the hospital s GEM program. ALC related performance indicators are jointly reviewed and discussed monthly by the MSH-CLHIN CCAC Steering committee. Our focus in has been to review and analyze both our NRC Picker patient satisfaction results as well our internal Just In Time Patient Satisfaction survey results to identify those questions and responses that correlate most highly with whether or not a patient would recommend the hospital to others and their overall rating of care and services. Our root cause analysis identified patient communication regarding discharge planning and timeliness to call bell responses as key MSH 2014/15 QIP Final April 2014 Page 5 of 9
QIP Priority Indicator contributors to both patient sat indicators. We have begun to implement patient rounding to address our call bell response rate. In 2014/15 we will standardize and set clear expectations for patient rounding for front line staff, managers, directors and our executive team. In 2014/15 we will also implement standard work related to the use of Quality Boards; Shift handover at the bedside as well as Discharge Planning. In addition we will implement a formal Service Excellence/Customer Service Plan. From NRC Picker: "Overall, how would you rate the care and services you received at the hospital?" (add together percent of those who responded "Excellent, Very Good and Good") (core-overall) - Corporate % Oct 2011- Sept 2012 91.60 95.00 92.80 (Oct 2012 Sept 2013) Same comments as above for NRC Picker "Would you recommend" Medication reconciliation at admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the Emergency Department(ED), Medicine/Telemetry Inpatient Mental Health and the Surgical Assessment Clinic (SAC) Average/percentage (%) 73.00 90.00 95.00 FY YTD Q3) We have achieved our targets for medication reconciliation (med rec) on admission within the specific areas identified in our QIP. This was enabled through the dedication of resources to completion of the med recs. In 2014/15 we will extend medication reconciliation on admission to all our IP units and will improve the quality of the medication reconciliations through completion of qualitative audits and associated follow-up sessions/reviews with those who are completing the MSH 2014/15 QIP Final April 2014 Page 6 of 9
QIP Priority Indicator med recs. CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospital-acquired CDI, divided by the number of patient days in that month, multiplied by 1,000 - Average for Jan-Dec. 2013, consistent with publicly reportable patient safety data - Markham Site Rate per 1,000 patient days All patients 2012 Publicly Reported, MOH 0.74 0.60 0.46 (2013) MSH has maintained a CDI level below the provincial benchmark and our MSH QIP target. This is the result of our excellent Antibiotic Stewardship program and our corporate-wide focus on Hand Hygiene. We also implemented changes to our cleaning protocols including delineation of a threshold level of CDI cases that would trigger an enhanced cleaning protocol hospital-wide. We will continue to monitor our CDI numbers internally and publicly post our CDI rates as required on our hospital website. Hand hygiene compliance before patient contact: The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by 100 - consistent with publicly reportable patient safety data - Corporate % Health providers in the entire facility 2012 Publicly Reported, MOH 87.40 90.00 90.4 FY YTD Jan) Hand Hygiene has been a major change initiative at MSH this fiscal year. Senior Management, Managers and Directors have taken on accountability for this metric and for ensuring that good HH is an expectation of all staff/physicians and volunteers. Our Hand Hygiene Committee and our Infection Prevention and Control committee provide ongoing support and expertise. A revamped educational campaign was launched with new materials and approaches including encouragement of departmental challenges and recognition for 100% compliance. We improved our audit tool and process which better enables in the moment coaching and follow-up by Managers with individuals. Audit results are displayed on each MSH 2014/15 QIP Final April 2014 Page 7 of 9
QIP Priority Indicator unit's/department s Quality Board and there is an expectation that HH is routinely discussed e.g. at staff meetings, daily huddles, quality board safety huddles. VAP rate per 1,000 ventilator days: the total number of newly diagnosed VAP cases in the ICU after at least 48 hours of mechanical ventilation, divided by the number of ventilator days in that reporting period, multiplied by 1,000 - consistent with publicly reportable patient safety data. Rate per 1,000 ventilator days ICU patients 2012 Publicly Reported, MOH 0.00 0.00 0.00 (2013) MSH's VAP rate has remained consistently low due to continued adherence to the VAP bundle. The ICU will continue to monitor the VAP rate and will escalate the reporting as required. We will not retain VAP on our MSH's 2014/15 QIP. We will continue to publicly post our VAP rates on our hospital website. Rate of central line blood stream infections per 1,000 central line days: total number of newly diagnosed CLI cases in the ICU after at least 48 hours of being placed on a central line, divided by the number of central line days in that reporting period, multiplied by 1,000 - consistent with publicly reportable patient safety data. Rate per 1,000 central line days ICU patients 2012 Publicly Reported, MOH 0.00 0.00 0.00 (2013) MSH's CLI rate has remained consistently low due to continued adherence to the CLI compliance bundle. We will continue to monitor CLI internally and escalate the reporting if required. We will not retain CLI on our 2014/15 QIP. We will continue to publicly post our CLI rates on our hospital website. Surgical Safety Checklist: number of times all 100.00 100.00 MSH has maintained a compliance rate of 100% for MSH 2014/15 QIP Final April 2014 Page 8 of 9
QIP Priority Indicator three phases of the surgical safety checklist was performed ( briefing, time out and debriefing ) divided by the total number of surgeries performed, multiplied by 100 - consistent with publicly reportable patient safety data. All Surgical Procedures Percentage 100.00 (FY YTD Q3) all three phases of the surgical checklist in both our operating rooms as well as our Obstetrical OR. This process is well managed and monitored at the unit level and any issues would be escalated as appropriate. Surgical Safety Checklist is required to be publicly reported on a monthly basis through the hospital's website. We will not retain Surgical Safety Checklist compliance on our 2014/15 QIP. Rate of inpatient falls per 1000 patient days - Corporate 4.90 4.30 3.50 FY YTD Jan) In we continued to implement initiatives focused on falls prevention, risk assessment and patient specific interventions and follow-up. Our Falls policy has become engrained as part of standard daily work and every patient is assessed for their risk of falling and patient s at high risk are clearly identified. Each patient fall is reviewed and a post-falls protocol implemented. As falls continue to be one of the higher risk areas for injury/harm to our patients, we will maintain Falls rate on our 2014/15 QIP with a focus on achieving a decrease in the number of falls related serious safety events. MSH has purchased and put into use a number of patient beds that have falls prevention strategies built into the bed's technology. These beds can alert staff to patients in immediate risk of a fall. We expect to increase the number of these Smart beds within the hospital in 2014/15. MSH 2014/15 QIP Final April 2014 Page 9 of 9