Quality Improvement Plan Workplan

Quality Improvement Plan Workplan Quality dimension

Q

Performance Indicator

Performance Goals

Value at Goal Setting

Fiscal Year 2016-17 Value

Effective

QBP Readmission Rate, all cause to CKHA for Chronic Obstructive Pulmonary Disease

70.0%

56.7%

48.9%

Staff Engagement

>

74.0%

62.9%

53.1%

Safe

Medication Reconciliation completed on Discharge

>

40.0%

19.9%

31.3%

Safe

Workplace Violence Prevention

PatientCentred Patientcentred Effective

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Collecting Baseline

Quality Improvement Plan Workplan Quality dimension Effective


Performance Goals

QBP Readmission Rate, all cause to CKHA for Chronic Obstructive Pulmonary Disease Data Source Rate / COPD QBP Cohort from IDS / January 2016- December 2016

Definition: Non-risk-adjusted 30-day all-cause readmission rate for patients with Chronic Obstructive Pulmonary Disease (COPD) (QBP cohort)among patients admitted to any acute care facility reported in IDS.

Significance: COPD patients have a high rate of readmissions in Ontario.

Performance Goal: Target set at 10% of current performance as we already perform above our LHIN peers on this indicator.

Planned Improvement initiatives


63.0%



56.9%

55.0%

(Change Ideas)

1)Conduct nurse leader rounding on patients in the ED as per a standard process with established expectations. 2)QI event planned 2018-19 Q1 to review work flow, assignment and scheduling to improve quality, patient safety, efficiency and patient/family experience in ED. Methods • Establish nurse leader expectations and standards for rounding as well as tracking requirements. • Kaizen event organized for May to review ED processes.

Process measures • % of required patients seen by nurse leader • CKHA Patient Experience Advisors participating in planning the event (Program Council), the event itself and report-out to ensure collaboration and co-design with patient/family to improve patient/family experience in ED.

Target for process measure • 100% of required patients seen by nurse leader • Membership of two Patient Experience Advisors on ED Program Council. Participation of at least one Patient Experience Advisor in the Kaizen event. Attendance of at least one Patient Experience Advisor at event report-out. Comments

Quality Improvement Plan Workplan Quality dimension Patientcentred


Performance Goals

Patient Experience "How would you rate this hospital?" Data Source % / Discharged Med/Surg patients who receive and respond to NRCC survey from NRC Picker / Q1 FY 2017-18

Definition: From NRC Canada: "Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?" - For inpatient Med/Surg (add together % of those who responded with score 9 or 10)

Significance: Measuring patient experience and satisfaction with the care they have received is an important indicator for measuring the quality in health care. Patient satisfaction affects clinical outcomes. It affects the timely, efficient, and patient-centered delivery of quality health care. Patient satisfaction is a very effective indicator to measure the success of hospitals and the staff who deliver care. This indicator is the voice of our patients and provides us with rich information on what we are doing well and what we need to improve on. Performance Goal: 70% represents the top quartile performance of Ontario Inpatient Community Hospitals

> Planned Improvement initiatives

70.0%



56.7%

48.9%

(Change Ideas)

1)Patients will be asked daily what their goals are and this will be communicated on the navigator board. 2)Patient feedback (ie CPES results) is communicated to all staff on a quarterly basis 3)Managers of Medicine and Surgery will perform Patient Rounding based on Studor methodology

Methods • Random audits weekly by department manager to identify if goals are recorded on white board. Monitor scores on CPES questions #2, #30 and #31 for improvement. These questions all relate to communication and information sharing. • Program-based Quality and Performance Boards will be updated quarterly and results shared in daily staff huddles. • Managers will submit monthly report to Program Directors regarding Rounding statistics. They will identify percentage of rounding completed compared to number required (80pts/month) Process measures • %CPES questions #2, #30, #31 that are answered "usually" and "always" - % navigator boards with goals identified. • # of times Quality and Performance Boards are updated quarterly with CPES results • Number of patient rounds completed by manager.

Target for process measure • 2018-19 Q3: 100% of navigator boards audited will have patient goals identified. • Results will be posted quarterly 100% of the time beginning 2018-19 Q2 • 100% of 80 patients/month received patient rounding by manager. Comments

Quality Improvement Plan Workplan Quality dimension Effective


Performance Goals

Staff Engagement Data Source % / Worker from NRC Picker / 2017-18 Q3

Definition: Staff engagement is a gauge of overall work experience. The engagement score is the summary score of 5 key questions: 1. Inspires best job performance 2. Values are similar to the organization`s values 3. Proud to say I work here 4. Satisfaction in current role 5. Look forward to going to work Significance: Engaged employees are committed to their employer, satisfied with their work and willing to give extra effort to achieve the organization’s goals. Research suggests that organizations with top quartile engagement scores achieve a 17% improvement in productivity and over 40% less absenteeism. The science tells us that engaged employees achieve better outcomes for their organizations. An engaged workforce bring their energy, ideas and best effort to their work. An engaged CKHA will achieve better quality outcomes for patients. Performance Goal: 74% represents the average of all community hospital average performance and the average performance of top quartile performers.


74.0%



62.9%

53.1%

(Change Ideas)

1)Individual units/departments will develop and implement individual unit/department plans to address opportunities for improvement identified in survey results 2)Implement the LEADS in a Caring Environment health leadership capabilities Framework (LEADS) 3)Organizational commitment to a psychologically safe workplace.

Methods • Staff engagement sessions will be facilitated by Unit Managers and Directors to review survey results and develop action plans to address opportunities. • Develop an implementation plan for the LEADS framework at CKHA. • Use the methodology of the "National Standard of Canada for Psychological Health and Safety in the Workplace" to develop psychologically safe workplace policies

Process measures • Number of actions plans completed by unit/departments • Completed, comprehensive implementation program developed and approved by Senior Leadership Team. • development of a gap analysis based on the recommendations in the standard and an action plan to address gaps.

Target for process measure • 100% of units/departments surveyed will have developed action plans within 30 days post survey results received • Implementation plan completed May 2018. Initial education beginning June 2018. • CKHA will have an action plan, including implementation timelines and evaluation metrics developed by Q1 of 2018/19 Comments • Unit/Department staff will be engaged in the development • Implementation will begin with general introductory sessions with the overall goal of creating a CKHA LEADS-based leadership development program.

Quality Improvement Plan Workplan Quality dimension Safe


Performance Goals

Medication Reconciliation completed on Discharge Data Source Rate per total number of discharged patients / Discharged patients from Hospital collected data / October – December (Q3) 2017

Definition: Medication reconciliation at discharge: Total number of discharged patients for whom a Best Possible Medication Discharge Plan was created as a proportion the total number of patients discharged.

Significance: Medication Reconciliation can prevent harmful medication errors or adverse drug events when used effectively it can intercept these errors before they lead to an adverse event. Because this practice is so important to the safety of our patients we are striving for a completion target of 100%. Our change ideas associated within this indicator are designed to support our team to get from where we are to 100%. Misses and errors will be viewed as a collaborative learning opportunity rather than a failure. Performance Goal: Based on current performance and gap analysis to identify areas for improved data collection.


40.0%



19.9%

31.3%

(Change Ideas)

1)Review CKHA Discharge Med Rec Plan in full. Ensure plan is inclusive of stats collection organizationwide. 2)Engaging others in the discharge med rec process, ie Elston's, community pharmacy, FHT, HACC.

Methods • Via mapping and gap analysis, review stats collection/measurement process to ensure all work is being captured. • Through interview, mapping, surveying investigate opportunities to engage stakeholders to ensure med rec for all patients being discharged from CKHA.

Process measures • 2018-19 Q1: Formal review and gap analysis of med rec and med rec measurement across CKHA. 2018-19 Q2: Roll-out of plan to address identified gaps in med rec and measurement of same. • 2018-19 Q2: Formally connect with partners to gain an understanding of capacity and willingness to share discharge med rec workload.

Target for process measure • By Sept 2018: Discharge Med Rec process in place for all units discharging patients from CKHA, including a method for measurement. • Completion of working meeting/mapping session with potential partners.

Comments

Quality Improvement Plan Workplan Quality dimension Safe


Performance Goals

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Workplace Violence Prevention Data Source Count / Worker from Local data collection / January - December 2017




Collecting Baseline

(Change Ideas)

1)Every workplace violence incident reported will be investigated by department manager using standardized templates that include cause and effect analysis as well as action plan templates to document and monitor identified improvements. 2)Organizational commitment to a psychologically safe workplace.

Definition:

Methods

Number of workplace violence incidents reported by hospital workers (as by defined by OHSA) within a 12 month period. Workplace violence is defined as: 1. The exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical / psychological harm/illness/injury to the worker 2. An attempt to exercise physical force against a worker, in a workplace, that could cause physical injury to the worker 3. A statement or behaviour that is reasonable for a worker to interpret as a threat to exercise physical force against the worker, in a workplace, that could cause physical/psychological harm/illness/injury to the worker Significance:

• Use of standardized templates for Workplace Violence Incidents • Use the methodology of the "National Standard of Canada for Psychological Health and Safety in the Workplace" to develop psychologically safe workplace policies

Workplace violence prevention is a high priority in Ontario’s healthcare sector and for the leadership at CKHA. We all have the right to work in a supportive environment where workplace violence is not tolerated. Performance Goal: CKHA is collecting baseline data for 2018-19

Process measures • Number of incidents investigated within 5 business days • Development of a gap analysis based on the recommendations in the standard and an action plan to address gaps. Target for process measure • 100% of workplace violence incidents will be investigated within 5 days of occurrence. • CKHA will have a action plan, including implementation timelines and evaluation metrics developed by Q1 of 2018-19 Comments CKHA FTE = 967