2015/16 Quality Improvement Plan for Ontario Hospitals "Improvement ...

2015/16 Quality Improvement Plan for Ontario Hospitals "Improvement Targets and Initiatives" Chatham-Kent Health Alliance 80 Grand Avenue West P.O. Box 2030

AIM Quality dimension Access

Effectiveness

Integrated

Measure Objective Measure/Indicator Reduce wait times in ED Wait times: 90th percentile ED length the ED of stay for Admitted patients.

Improve organizational financial health

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. Reduce unnecessary Percentage ALC days: Total number of time spent in acute acute inpatient days designated as ALC, care divided by the total number of acute inpatient days. *100

Change Unit / Population Hours / ED patients

% / N/a

% / All acute patients

Reduce unnecessary Readmission to CKHA Within 30 days for % / All acute hospital readmission selected Case Mix Groups (CMGs) for any patients cause: The rate of non-elective readmissions to CKHA within 30 days of discharge following an admission for select CMGs. The selected CMGs Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Stroke.

Patient-centred

Improve patient satisfaction

From NRC Canada: "Overall, how would % / All patients you rate the care and services you received at the hospital (inpatient care)?" (add together % of those who responded "Excellent, Very Good and Good").

From NRC Canada: "Overall, how would % / ED patients you rate the care and services you received at the ED?" (add together % of those who responded "Excellent, Very Good and Good").

Safety

Source / Period Organization Id CCO iPort Access 1223* / Jan 1, 2014 Dec 31, 2014

OHRS, MOH / Q3 995* FY 2014/15 (cumulative from April 1, 2014 to December 31, 2014) Ministry of 995* Health Portal / Oct 1, 2013 Sept 30, 2014

Hospital collected data / April 2013-Aril 2014

995*

NRC Picker / 995* October 2013 September 2014

NRC Picker / 995* October 2013 September 2014

Current performance 10.55

1.61

8.2

6.4

95.6

90

Target 11.8

0

8.5

6.2

96

92

Target justification Maintain status in top 10%in Ontario P4R Hospitals

Planned improvement initiatives (Change Ideas) 1)Increase ED nursing staff and physicians awareness of all ED wait times

Methods Daily (Monday-Friday) Ed staff huddles with ED Manager or Director to review the posted daily DART report, Weekly ED indicator report and Monthly QIP tracking document

2)Decrease ED length of stay for Admitted patients to ICU by decreasing turnaround time for lab results; specifically troponin, lactate, INR by implementing point of care testing in the ED

Data will be collected on all "turn around time" results for Troponin, Lactate, Percentage of times targets are met. INR

3)Establish a working group to review current "turn around times" for Diagnostic Imaging Tests for the ED patients and investigate process improvements to decrease "turn around times" and set targets

Working group of key stakeholders will be established May, 2015. Will meet bi-monthly until goals have been reached

Specific Process improvements will be identified. Targets will be set for "turn Meeting will occurr bi-monthly around times". Method for auditing compliance with "turn around time" for audits will be established

Intending to acheive a balanced operating budget. Will be challenging with planned investment on Quality Improvement Health Information Systems project.

1)Engage Decision Support staff and managers in reviewing budget performance

Decision support staff will initiate quarterly meetings with managers to review financial performance

percentage of managers met with quarterly

100% of managers will meet with decision support quarterly

2)Reduction in patient transportation costs (related to patient transfers to another facility for admission or diagnostic/ treatment purposes)

Decision support will compare patient transfer costs for 2015/2016 to 2014/2015 costs on a quarterly basis

Difference between 2014/15 costs and 2015/16 costs for transportation

Reduction in transportation costs by 105 over previous year costs

Maintain status of lowest ALC rate in the LHIN

1)Integrate the data obtained from Medworxx regarding "readiness for discharge" in discharge planning process by having Medworxx "readiness for discharge" data be used in daily bed rounds and unit specific "bullet rounds" for Inpatient Medicine and Surgical units

Patient Flow Manager to develop working group of key stakeholders (Unit Managers,Unit Clinical Leaders,Patient Flow Co-ordinators, Discharge Planners) to develop plan to incorporate use of Medworxx "readiness for discharge" results into daily rounds

Working group will be developed and meeting by May 30, 2015 and a plan for integration of "Medworrx" data into daily rounds will be developed by June 30th, 2015

Implementation plan and roll-out plan developed by June, 30th, 2015

2)Conduct formal weekly hospital-wide Complex Discharge Reviews ensuring Social Worker, Unit Clinical Leader and Community Care Access Centre case all key stakeholders are in attendance with the goal of facilitating discharge co-ordinator meet weekly with Manager and Director of Patient Flow, to the most appropriate level of care for the patient. Manager of Flow and Unit Managers to hold Complex Discharge Reviews

Percent of CDR patients who are discharged or transferred to the right place of care

Achieve and maintain an Alternative Level of Care rate equal to or less than 8.5%

1)Conduct interviews(in person or by telephone)with patients readmitted to our facility within 30 days of discharge. Purpose of interview is to identify opportunities to improve quality of discharge process and prevent readmissions in future.

Professional Practice Nurse will review the daily readmission within 30 days report (Monday-Friday) and arrange and conduct interview with patient and/or family asking specific questions targeted at identifying opportunities to prevent readmissions.

Percentage of patients readmitted to CKHA within 30 days of discharge (any diagnosis)

Achieve a rate of 50% of readmitted patients receive interview

2)Roll-out and educate nursing staff on newly developed discharge process and discharge instructions for the following case mix groups; Stroke, Congestive Heart Failure,and Chronic Obstructive Pulmonary Disease.

Nursing staff and allied health staff on Inpatient Medicine, Rehabilitation and We will measure the percentage of nursing staff and allied health staff on Stroke Unit will be educated by Professional Practice Team on new discharge Medicine, Rehabilitation and Stroke unit who receive education process, tools and discharge instructions by May 30, 2015

100% of staff in these areas receive the education

3)Patient's with a diagnosis of congestive heart failure,chronic obstructive pulmonary disease and stroke will have documentation on chart that they received appropriate discharge instructions

10 charts per month of patients for selected case mix groups will be audited for evidence that patient received appropriate discharge instructions

100%

This has been a challenge for our organization to reach targets in past QIP,new strategies underway to identify root cause of readmissions; this is a new initiative

The patient population for this indicator are In-PatientAcute ( Medicine, Progressive Care and Surgery)

Improve by 2.2% over current performance

Process measures Percentage compliance of posting of reports by ED Manager and percentage compliance by Manager or Director with daily (Monday- Friday) ED team huddles.

Percentage of charts audited that contained evidence of appropriate discharge instructions

Goal for change ideas 100% compliance

Target set for 80% for initial Audits will be performed monthly implementation of point of care for first three months then testing which is targeted for May reassessed 30, 2015

1)Clinical Managers of Inpatient Medicine, Inpatient Surgery and Progressive Managers will monthly monitor progress of unit specific initiatives to ensure Percent of times quarterly meetings between Managers and Directors occur. Care develop unit specific initiatives to improve patient satisfaction based on targeted milestones are met. Managers will review their targeted NRC Picker Percentage of initiatives that are achieving targeted milestones. unit specific NRC Picker results results quarterly with Director and review status of planned initiatives.

Improvement in overall NRC Picker scores beginning Q2

2)Each acute care unit develop a plan to share NRC Picker results related to unit specific initiatives as well as corporate performace scores monthly (scorecard, huddles, performance boards)

Each unit decides on a method and tracks it on our QIP monitoring template

Improved NRC Picker scores to achieve corporate targets

1)Improve ED NRC Picker scores related to physical comfort

Education of all ED nursing staff regarding assessment and documentation of Audit 10 charts per week for evidence of documentation that physical patient comfort and interventions to improve comfort. comfort was assessed, interventions provided where applicable and physical comfort reassessed routinely.

2)Develop and implement a ED waiting area "rounding" program. (Triage Nurse would have set routine rounding schedule to provide ongoing and consistent communication to patients and families in ED waiting area

Working group to be developed to create standard "rounding" operating procedures. Develop a method of auditing compliance with rounding procedures

Process and audit tool to be developed by of September 2015

Extent to which process is completed, reviewed, and communicated and discussed with frontline staff

Improve in NRCPicker scores related to physical comfort in the ED Improvement in "Overall, how would you rate the care and services you received at the ED" Marked improvement in NRC Picker QIP indicator for ED by end of Q3

Increase proportion of patients receiving medication reconciliation upon discharge

Med Rec at Discharge: The total number of % / Medicine & adult acute care discharges with Rehab medications reconciled as a proportion of the total number of adult care discharges

In-house survey / 995* 15/16

CB

50

current performance uncertain due to 1)Develop an interdisciplinary team to review the current medication prior method of data collection. Will reconcilliation process (this team will make improvements related to aim for greater than current compliance, sustainability/spread and quality of process) performance estimates

Director of Pharmacy and Professional Practice Lead will develop an interdisciplinary Med Rec coordination team. Team will meet monthly

Interdisciplinary team meets monthly

Reduce hospital acquired infection rates

CDI rate per 1,000 patient days: Number of Rate per 1,000 patients newly diagnosed with hospitalpatient days / All acquired CDI, divided by the number of patients patient days in that month, multiplied by 1,000 - Average for Jan-Dec. 2014, consistent with HQO's Patient Safety public reporting website.

Publicly 995* Reported, MOH / Jan 1, 2014 - Dec 31, 2014

0.29

0.26

Improve by 10.34 % over current performance

Annual review of hospital antibiotic biogram with Department of Medicine and Nurse Practitioners led by Pharmacy and Infection Provention and Control practitioner

Presentation/review of hospital antibiogram will occur at every Medical Reach CDI QIP target rate Department meeting and session will be scheduled for all Nurse Practitioners

1)Promote use of the hospital antibiotic biogram to optimize antimicrobial use

Comments

100% occurrence of monthly meetings with demonstrated action items to improve compliance, quality of sustainability/spread of Med Rec

2)Review current hand hygeine initiatives/campaign to explore opportunities Develop a hand hygeine working group that includes membership of frontline Working group developed by May 30, 2015. Assessment of current state Reach QIP targets for CDI rates for improvemet or alternative initiatives/campaign staff, patient expereince advisors and infection control practitioners. Evaluate complete by September 2015. Future state plan complete January, 2016. Kickcurrent state of hand hygeine awareness/initiatives/ compliance and develop off renewed campaign January 2015 plan for future state.

Although these have been conducted for a year they need continued focused resources to maintain gains achieved and renewed attendance by all key Chatham-Kent Health Alliance has developed a daily report which provides us the data on any patient readmitted to our facility within 30 days for any diagnosis.

Medicine department initiatives focused on patient and family involvement in care Surgery initiatives focused on Physical Comfort

Increase proportion of patients receiving Med Rec at Admission and Transfer)

The total number of acute care admissions % / Hospital with medication reconciled as a proportion Medicine,Psych, collected data / of the total number of adult acute care ICU, PCU, Surgery 15/16 admissions and transfers

995*

CB

70

Target set at 70% for 15/16. 14/15 performance was measured by "spot" audits done quarterly and focused on 7 days of data. 15/16 will be measuring percentage of Medication Reconciliation completed on all patients in the specified populations

1)Develop an interdisciplinary team to review the current medication reconcilliation process (this team will make improvements related to compliance, sustainability/spread and quality of process)

Director of Pharmacy and Professional Practice Lead will develop an interdisciplinary Med Rec coordination team. Team will meet monthly

Interdisciplinary team meets monthly

2)Explore strategies to automate/simplify the data collection process

Develop team to explore strategies. Progress will be tracked by assessing the Team will be developed fall, 2015. Meetings begin Winter 2015. Full following milestones; 1) team developed 2) team begins meeting 3) Process implementation dependant on implementation of Quality Improvement developed 4) Implemented (process development and implementation will be Health Information System being implemented dependant on functionality and implementation of Quality Improvement Health Information System being implemented at Chatham-Kent Health Alliance

100% occurrence of monthly meetings with demonstrated action items to improve compliance, quality of sustainability/spread of Med Rec Target date for implementation of automated data collection process Q4 2016/17 (tentative)

Significant investments are being made in the Quality Improvement Health Information Systems project and will allow for improved methods of data collection.