QIP 2018/19 – Workplace Violence Prevention · QIP 2018/19 – Workplace Violence Prevention AIM MEASURE ... Change Ideas Accountability ProcessMeasures Goal for Change Ideas

QIP 2018/19– Workplace Violence Prevention AIM MEASURE Quality

dimension Objective Indicator Current performance

Targetfor 2018/19

Targetjustification Comments

Safe Reduce harm to staff

Number of workplace violence incidents (overall) reported by hospital workers within a 12 month period.

Note: workplace violence incidents are reported via the incident reporting system.

Note: Definitions for the terms “worker” and “workplace violence” will be those in the Occupational Health and Safety Act (OHSA, 2016).

773

(January – December 2017)

≤ 700

in calendar 2018

This reduction of approximately 10% is a stretch target given our specialized patient populations (including trauma,mental health, long-term care and alternate level of care patients with dementia and responsive behaviours) who can suffer from conditions that can lead to behaviours that put others at risk.

2017 has the highest number of reported incidents in the last three years.We attribute this primarily to three changes: • We launched a new Leaders Guide on

responding to and reporting violent incidents. This has increased awareness among leaders and staff of the value in reporting incidents as it enables better improvement strategies to be developed. The issue has also been reported in the media recently.

• An increase volume of patients overall. • An increase in the number of patients with

conditions that can lead to behaviours that put others at risk (e.g. trauma and dementia)

Sunnybrook’s main focus is to reduce the number of Lost Time Incidents (most severe incidents) related to a workplace violent incidents from 8 to 7 (Jan-Dec 2017). Ideally the goal is to have zero incidents Lost Time Incidents; however this may not be attainable due to factors outside of Sunnybrook’s control i.e.unpredictable patient behaviour and staff's ability to return to work.

As of January 9, 2018, Sunnybrook had 6,576.30 full-time equivalent (FTE) employees, 517 active acute care beds and 472 long-term care beds. Note that our incident data includes volunteers as we consider them a type of service provider and want to learn from any events in which they are involved.

February 22,2018

QIP 2018/19– Workplace Violence Prevention CHANGE

ChangeIdeas Accountability Process Measures Goal forChange Ideas Provide on-line Code White 1/ Workplace Violence Prevention training to all staff • Continue to monitor staff completion of the Code

White/ Violence Prevention training and increase compliance among Active Staff by keeping leaders informed of progress.

1 Code White is an emergency code for staff to notify others of an incident that requires immediate action,in particular to assist staff when interacting with person who is or who may become violent.

Occupational Health and Safety will report compliance rates and progress to the following to ensure accountability in reaching targets: • Managers monthly • Occupational Health and Safety

Committee monthly • Responsive Behaviour Working

Group quarterly.

Percentage of Active Staff that complete the Code White/ Workplace Violence Prevention training.

Denominator: Count of Active Staff as of April 1, 2018.

90% by March 31, 2019

Current performance (Sept 2017): 80%

Provide Non-violent Crisis Intervention education with a focus on high-risk areas • Ensure regularly scheduled course offerings as needed

April 2018 to March 2019. • Complete the roll-out and increase participation rate

from 61% to 90% in high risk areas 2 and expand to staff in lower risk areas.

• Continue to monitor staff attendance via the Learning Management System and share results with leaders.

2 High Risk Areas are the Emergency Department, Veterans Centre units (Dorothy Macham,LGSE,LGSW, LSSE, and LSSW) and acute care units C5, D5, F2 (Mental Health) and Nursing Resource Teams (CNRT/ACRNT).

The Emergency Preparedness Team will report progress quarterly to the Responsive Behaviour Working Group to ensure accountability in reaching targets.

Percentage of Active Staff assigned on a regular basis in high risk areas that attend a non-violent crisis intervention education session.

Denominator: Count of Active Staff as of April 1, 2018.

90% by March 31, 2019

Current performance (January – December 2017): 340/779 = 43%

• Emergency Department – 62%

• Veterans Centre – 71% • Acute care C5/D5 -

92% • Acute care F2 –100% • Nursing Resources

Team ACNRT – 51%

February 22,2018


ChangeIdeas Accountability Process Measures Goal forChange Ideas Monitor that the Framework for Responding to Reported Violent Incidents (3 step process) is being followed.

Step 1: Team huddle – Run by the team that responded immediately after any violent patient incident.

Step 2: Unit Debrief and Patient Safety Care Plan – the Debrief is to be conducted after any repetitive

incidents and/or actual/potential serious harm and – the Safety Care Plan is to be developed as necessary.

Step 3: Serious Incident Investigation/System Review -this is completed for actual or potential violent situations involving serious injury or if a weapon was used. It is led by Risk Management and Occupational Health and Safety.

All recommendations from Step 2 and 3 will be prepared by Occupational Health and Safety for the Joint Occupational Health and Safety Committee & the Violence Prevention Committee and will be shared with the Vice President, Human Resources and senior leadership to address any barriers in implementing the recommendations.

Step 3 System Reviews will be prepared by Risk Management for the Quality of Care Information Protection Act (QCIPA) - Quality of Care Committee to ensure that there is awareness of important trends at the senior management and Board level and to address any barriers in implementing the recommendations.

% of Patient Safety Care Plans developed when required

% of System Reviews completed

Baseline: 35% (Jan – Dec 2017)

Target: 80% of required Patient Safety Care Plans completed

100%

February 22,2018


ChangeIdeas Accountability Process Measures Goal forChange Ideas Continue to support practice changes to enhance violence prevention with staff.

A. On two units engaged in pilot violence prevention work in 2017/18: • Implement pilot Violence Assessment and

Documentation Tool for admitted patients in the Emergency Department to identify o Those who have a history of, or have

The Violence Prevention and Responsive Behaviour Working Group will report progress quarterly to the Violence Prevention Committee for the purpose of engagement and feedback.

The percentage admitted patients who have had a “staff assist” and/or “code white”* called during their Emergency Department stay and who have a completed “Violence Assessment and Documentation Tool” in the Emergency Department.

≥ 70 %

demonstrated behaviour that, puts others at risk and

o de-escalation care strategies that can be used to address the behaviour.

• For the identified patients, implement unit-based care planning processes to identify triggers/ contributors to the demonstrated behaviour and more intensive care interventions to continue prevent /mitigate it.

B. Apply the learnings from the Part A (above) to another priority high risk unit. Develop learnings by December 2018 and implement by March 2019.

Senior Friendly Lead and the Patient Care Managers will articulate learnings.

The percentage admitted patients who have had a “staff assist” and/or “code white”* called during their Emergency Department stay and who have a completed care plan on the inpatient unit.

*indication of violence or potential violence

≥ 60 %

February 22,2018


ChangeIdeas Accountability Process Measures Goal forChange Ideas Consult and collaborate with community partners to support practice changes to enhance violence prevention with staff. • At Toronto Academic Health Sciences Network-

Senior Friendly Community of Practice meetings, discuss opportunity to collaborate and develop common strategies.

• Explore risk identification and communication processes to inform the Sunnybrook electronic patient care record;

• Explore electronic documentation solutions for flagging behaviours that put others at risk

• Explore opportunities to develop common strategies to identify and communicate risk among community partners

• Share progress with Screening and unit-based Care Planning processes with Michael Garron Hospital.

Risk Management and Senior Friendly will oversee work with community partners.

All consultations initiated and at least 50% completed.

By March 31, 2019

February 22,2018

QIP 18/19 – Suicide Prevention

AIM MEASURE

Quality dimension

Objective Indicator Current performance

Targetfor 2018/19

Target justification

Comments

Safe Development and implementation of suicide-prevention interventions

Percentage of inpatients, Emergency Department patients (when indicated),and Veterans residents for whom suicide screening is completed

Screening includes completion of either:

• Columbia Suicide Severity Rating Score (CSSRS) or

• Documentation of equivalent suicide risk screen at one point during their care in hospital

Baseline data will be collected via sample chart audit in early

2018

Target will be set after baseline data collected

Ultimately we wish to reach 100%, but we recognize that both system and patient factors make a doubling in year 1 followed by further incrementalgains to be a more realistic target.

Our ultimate goal is to reduce suicide attempts and deaths among Sunnybrook patients.

Two key mediators for reaching this goal are screening (year 1 focus) and interventions (year 2 focus).In our year 1 work plan, we are also including work to prepare for year 2.

Year 2 Draft Plan: For Mental Health, Emergency

Department, Inpatients or Outpatients who screen positive for elevated suicide

risk, implementation of any of the

following interventions:

• Basic management steps and psychiatric referral where appropriate

• Completion of Coping Card • Access to focused psychotherapy

(i.e., Cognitive Behavioural Therapy, problem-solving app)

• Timely access to ketamine clinic services

• Timely access to Electroconvulsive therapy (ECT) clinic services

• Implementation of means restriction(s)

• Timely access to follow-up services for inpatients

CHANGE

Change Ideas Accountability Process Measures Goal for Change Ideas

1. Staff Training on Suicide Prevention Awareness and

Training Module “Preventing Suicide at Sunnybrook” • 12-minute Suicide Prevention e-learning training ison-

line and registration occurs through Sunnybrook’s Learning Management System (LMS)

• Implement broad communication strategies to improve leader and staff training rates

Provide monthly

reports showing completion rates to

department managers and quarterly to the

Suicide Prevention

working group.

Percentage of staff (full-time and part-time) that complete the New Suicide Prevention Strategies Awareness and Training.

Denominator: Count of permanent full-time and

part-time staff as of April 1,2017.

80% by end of year 1

(March 31, 2019)

2.Initiate DiscussionswithSunnycare team on the creation Brain Sciences and Discussions initiated and Initiate contact with of an electronicprocess fordocumentation ofscreening and Department of next steps documented Sunnycare team by Apr referrals forsuicideprevention interventions Psychiatry Leadership and monitored 1, 2018 and note and

monitor all follow-up actions.

3. Take the Quality Improvement Plan to the Department of Chief of Psychiatry will Present the plan in Implement suggested Psychiatry Patient and Family Advisory committee for review. present the plan at an

upcoming meeting. advance of March 31, 2018 changes to the plan

wherepossiblebyApril 30,2018.

CHANGE


4.Increase externalcapacityandaccesstocommunity services(psychotherapyandfollow-up) • A half-day educational event(s) on suicide screening and

prevention strategies will be organized for community

agencies, Local Health Integration Network and primary

health care teams. Workshops will also enhance

capacity for coordination with Sunnybrook services. Targeted invitations will be disseminated. Focus will be

on psychotherapy services and follow-up support post-discharge from Emergency Department or inpatients

Event organizers will track information on

number and type of attendees, and obtain

feedback on the event, including capacity for Sunnybrook patients accessing services

Number of agencies that attend event

> 10 agencies/ organizations/ teams per event

This is preparation for Year 2

CHANGE


5.Increase internalcapacityfor deliveryof suicide-prevention strategiesandtreatments

• Develop and disseminate information within Sunnybrook on key suicide prevention strategies for patients who screen positive for suicide risk

• This specifically includes: - Using Columbia Suicide Severity Rating Score

(CSSRS) to track change in suicidal thoughts - Use of the Sunnybrook Coping Card - Access to psychotherapy resources (Cognitive

Behavioural Therapy (CBT), problem-based app) - Establishment of new ketamine and

neuromodulation clinics - Access to Electroconvulsive therapy (ECT)services

(inpatient and ambulatory) - Restricting access to lethal suicide methods

• Work with hospital resources (Communications, Sunnycare) and programs (Department of Psychiatry, Brain Sciences) to build internal resources and enhance communication / access across the organization

Brain Sciences and Department of Psychiatry Leadership

Track usage of specific interventions/ strategies

Develop ketamine and neuromodulation clinics

Begin tracking Apr 1, 2018

Launch ketamine and neuromodulation clinics

This is preparation for Year 2

Hand Hygiene Quality Improvement Plan 18/19 AIM MEASURE Quality Current Targetfor Target Comments

dimension Objective Indicator performance 2018/19 justification Safe To improve hand hygiene

performance on medical and surgical inpatient units at Sunnybrook Health Sciences Centre using electronic monitoring (E-monitoring),in order to prevent hospital acquired infections.

Rate of hand hygiene performance (hand hygiene events divided by hand hygiene opportunities measured via e-monitoring).

Numerator (hand hygiene events):the number of times that healthcare providers (nurses, other health professionals, residents, physicians, Environmental Services Partners, and Patient Services Partners ) clean their hands

Denominator (hand hygiene opportunities): a validated number of expected number of hand hygiene opportunities based on multiple variables

47.9%

Q1 17/18

(462,205 hand hygiene events divided by 964,935 hand hygiene opportunities. This is an aggregate of five pilot medical/surgical units D2, D3, D5, B4, C5.)

≥ 60%

average performance across all pilot medical/ surgical units by Q4 2018/19

Few hospitals have used E-monitoring to measure improvement in hand hygiene compliance. Sunnybrook’s target is based on a published study in North Carolina which demonstrated a 25% absolute improvement in E-monitored hand hygiene compliance which was associated with a significant reduction in hospital acquired infections caused by methicillin-resistant Staph aureus (MRSA).

Hand hygiene compliance is a patient safety indicator of Health Quality Ontario. The traditional method of measuring hand hygiene is based on direct observation during spot audits, whereas this new indicator introduced at Sunnybrook* in 2017, measures hand hygiene compliance continuously on the unit using a built-in motion-activated censor measure against a validated number of expected hand hygiene opportunities for the unit based on multiple variables (e.g. patient acuity and unit census). It provides more accurate performance measurement than direct observation and has been validated both externally and internally.

*This is part of a multi-centre initiative with four other Ontario hospitals (Michael Garron Hospital, Sinai Health System, Lakeridge Health and St. Michael’s Hospital).

CHANGE Methods ChangeIdeas

Process Measures Goal forChange Ideas (AccountabilityandResponsibility)

Implement provision of weekly E-monitoring Feedback Reports (contain hand hygiene compliance for the prior week) to front-line staff.

Infection Prevention and Controlwillset up a system so that Feedback Reports will be automatically generated and pushed to all hand hygiene champions, Team Leaders, Advanced Practice Nurses and Patient Care Managers for the unit to share with all staff.

• % of unit leadership receiving E-monitoring Feedback Reports on a weekly basis

• 100% of unit leadership • >50% of the front-line

staff on the pilot study unit.

All units will set a 1-month and a 3-month goal for hand hygiene compliance. Goals will be set by the unit during Quality Improvement huddles and

• posted on Quality boards • included in Feedback Reports • shared with the unit Infection Prevention & Control

coordinator

Patient Care Managers and/or other unit leaders as assigned willensure goals are set.

1-month and 3-month goals will be tracked on monthly corporate E-monitoring reports

To set a monthly E-monitoring goal at least 10% above baseline at the start of each month.

To set a 3-month E-monitoring goal at least 10% above baseline every quarter.

Monitor that a minimum of two weekly Quality Improvement huddles will occur on units to review and discuss E-monitoring Feedback Reports and identify opportunities for iterative changes* that promote better hand hygiene compliance.

*Examples of iterative changes arising from huddles may include walk-arounds to identify specific physical locations where hand sanitizer location may be optimized to improve workflow, and reviewing hand hygiene data at specific times of day to correlate with patient care activities.

Quality Improvement Huddles are organized by unit managers with the support of Infection Prevention and Control. Huddles are attended by most clinical staff on the unit.

Discussion at bi-weekly Quality Improvement huddles will be recorded by Infection Prevention & Control

At least 1-2 new ideas or lessons are generated on each unit every month. These will be shared with other units as applicable to drive improvement.

CHANGE Methods ChangeIdeas

Process Measures Goal forChange Ideas (AccountabilityandResponsibility)

Empower patients and families to make hand hygiene an expectation of care by:

1) Providing point of care hand hygiene bottles for patients and families at the bedside

2) Formalizing empowerment of patients and families to assist with audit and feedback of healthcare provider hand hygiene

E-monitored point of care bottles will be installed at the bedside by the Patient Care Managers and Infection Prevention and Control Coordinator will monitor product use.

Infection Prevention & Controlwillwork with Patient Engagement Team, and patient/family representatives to design a process that formalizes patient/family involvement in providing audit and feedback to healthcare providers about their hand hygiene.

Absolute number of hand hygiene events using point of care bottles will be monitored and reported using the e-monitoring system.

To increase the number of hand hygiene events of point of care bottles on the intervention units. (Target will be set with Sunnybrook’s patient engagement team.)

Quality of Discharge Summary – Quality Improvement Plan 18/19 AIM MEASURE

Quality Current Target for Target Objective Indicator Comments dimension performance 2018/19 justification Effective Improve the quality

of Discharge Summaries to ensure effective communication of patient information when transitioning patients to the community.

Percentage of primary care physicians who responded “yes” to the question, ‘Was the content of the Discharge Summary relevant and concise?’

33%

October 2017

≥ 75%

Q4 2018/19

This is a challenging stretch goal because we want to make a lot of progress this year to get to the ultimate goal of 100%.

Survey was conducted in October 2017 and was responded to by nine family physicians from Sunnybrook’s Family Health Team and the North Toronto sub-LHIN (Local Health Integration Network) Primary Care Council. The survey will be repeated at the end of Q2 and in the fourth quarter of 2018/19 to re-measure the indicator.

There were two other questions on the survey. One asked about timeliness (1/9 said yes, 6 said sometimes) and one solicited ideas for improvement. The key themes that emerged were:

• Timeliness • Clarity of follow-up plan • Completeness

CHANGE Methods Goalfor ChangeChangeIdeas ProcessM easures (Accountability & Reporting) Ideas

1. Implement changes to resident training on Discharge Summaries in line with Toronto Central Local Health Integration Network (TCLHIN) recommendations a. Implement University Heath Network tool kit which specifies best practices for

Discharge Summaries b. Implement video education to support resident learning c. Corporate trainers to provide training to residents on units (units will be selected

based on current performance data) d. Create Discharge Summary quick reference guide (based on University Health

Network’s) to inform residents on Discharge Summary best practices including Sunnybrook’s focus on timeliness, completeness (required components) and clarity of follow up plan

e. Modify orientation (December 2017 and further for July 2018)

Office of Education to oversee implementation of changes to resident education. • Reports progress into Discharge

Summary Working Group • Corporate Training Services

(Director, Health Records) to conduct training and distribute quick reference guide and report feedback to Discharge Summary Working Group

Completion score on list of criteria.

Health Data Records to audit completion of the Discharge Summaries using TCLHIN standard template (criteria), as well as the criteria for follow-up plan that Sunnybrook develops.

20% improvement in result from baseline by March 31, 2019

Baseline will be collected by June 30, 2018 if possible.

CHANGE Methods Goalfor ChangeChangeIdeas ProcessM easures (Accountability & Reporting) Ideas

2. Modify Discharge Summary template to align with LHIN best practice template (also used by St. Michael’s Hospital and University Heath Network). a. Base modifications on learnings from

i. other hospitals that have implemented the template ii. ’high’performing physicians here at Sunnybrook iii. Quality audit – e.g. Length, sections left empty,quality of follow-up section

b. Implement modifications to template if required: - Consult with Sunnycare - Obtain Medical Advisory Committee approval - Obtain Forms Committee approval

Director, Health Records and Chair Medical Advisory Committee execute action plan • Reports progress into Discharge

Summary Working Group

Revised Discharge Summary approved by Medical Advisory Committee.

• Paper form completed by December 31, 2017.

• Electronic form completed by December 31, 2018

3. Continue to increase timeliness (rate of Discharge Summary completion within 48 Lead (Chair, Medical Advisory % Discharge Summaries Baseline: 75% hours) Committee) continues work of QIP completed within 48 hours Target: above 80% by a. Take new target completion rate of above 80% to Medical Advisory Committee

for approval b. Conduct focus groups with those not meeting targets to determine barriers and

how to improve rates using tools such as fishbone diagram. c. Seek and share insights and strategies to overcome barriers from high performers d. Continue physician education on Discharge Summary completion (e.g. through e-

learning) e. Implement a quality improvement process to make Discharge Summary process

efficient for providers (without impacting quality)

17/18 to increase completion rate. • Reports progress into Discharge


across the hospital as per policy requirements

March 31, 2019

4. Continue to improve fax success rate (the percentage of faxes to primary care that Health Data Records (Director) to lead % Discharge Summaries Baseline: 70% successfully go through (e.g. not rejected due to wrong number or primary care fax improvement in fax completion rate. successfully faxed to Target: 80% by March 31, turned our etc. a. Improve accuracy of documentation of patient’s family physician at time of

registration b. Implement fax registry maintenance (using University Heath Network’s process) c. Streamline discontinuation of faxing for primary care physicians who are on HRM

(Hospital Report Manager) Note 1: HRM coming fall 2017 and this will cover many Family Practitioners Note 2: College of Physicians and Surgeons of Ontario (CPSO) moving to email in 2018, so will need to develop a plan to incorporate this change once it is available

d. Implement Auto-fax e. Create a one page document to detail how Health Records department is trying

to get Discharge Summaries out to physicians with tips to increase success rates – send out to primary care physicians with Discharge Summaries

• Reports progress into Discharge Summary Working Group

Physicians included in the cc field within 24 hours of being sent to Health Records

2019

5. Engage with patients and families to solicit and implement improvement ideas. Health Records Department (Director) to lead • Reports progress into Discharge


Survey patients through MyChart about their satisfaction with the Discharge Summary.

20% improvement in result from baseline by March 31, 2019

Baseline to be collected early in fiscal 2018/19.

Quality Improvement Plan 18/19 – Repatriation with Markham-Stouffville Hospital

AIM MEASURE Quality


Targetfor 2018/19

Target justification

Timely To create a defined model for repatriation that is safe, timely, and provides an excellent experience for patients and families.

The proportion of patients repatriated to Markham-Stouffville Hospital (MSH) within 2.5 days of initiation of repatriation (Initiation of repatriation defined as when the Sunnybrook Repatriation Office is contacted by the Sunnybrook clinical team).

67% Q2 17/18

≥ 90% Quarterly

The target for improvement reflects that repatriation from Sunnybrook to Markham-Stouffville Hospital is already high performing as compared to repatriation from Sunnybrook to other hospitals, and emphasizes the 2.5 day target for repatriation process duration.

Page 1 of 3

CHANGE

ChangeIdeas Accountability Process Measures Goal forChange Ideas

1. Improve transfer of accountability (TOA) between Sunnybrook and Markham-Stouffville Hospital

The Transfer of Accountability Leads at Sunnybrook and Markham-Stouffville Hospital will jointly oversee the following:

The Transfer of Accountability Leads at Sunnybrook and Markham-Stouffville Hospital will jointly oversee a sample audit of compliance with optimized transfer of accountability

Compliance with transfer of accountability process

100% compliance

(Baseline not available as not currently tracked)

a. Optimize process for transfer of accountability for repatriation

The Flow Steering and Utilization Committee at Markham-Stouffville Hospital and The Shared Knowledge Working Group of the Sunnybrook Repatriation Taskforce will oversee the following:

b. Improve handover between sending and receiving physician i. Create guideline for Sunnybrook to determine correct

receiving service at Markham-Stouffville Hospital when initiating repatriation

ii. Increase understanding of repatriation principles and processes for Physicians at Sunnybrook and Markham-Stouffville Hospital. Create education package regarding repatriation for Resident orientation/education.

c. Clarify roles and responsibilities. Develop a standard repatriation guide for staff that outlines the repatriation process, roles and responsibilities, and key contact information.

process, and report progress quarterly to the Sunnybrook Repatriation Taskforce and to the Markham-Stouffville Hospital Flow Steering and Utilization Committee.

2. Improve communication regarding repatriation with patients and The Shared Knowledge Working Group Staff self-rated levelof 6.5 out of 10.0 family of the Sunnybrook Repatriation understanding of (From Sunnybrook

The Shared Knowledge Working Group of the Sunnybrook Repatriation Taskforce and the Flow Steering and Utilization Committee at Markham-Stouffville Hospital will jointly oversee the following:

Taskforce and the Flow Steering and Utilization Committee at Markham-Stouffville Hospital will oversee a staff survey to measure retention of

repatriation staff survey regarding repatriation, administered in

a. Educational outreach to ensure staff are using consistent and educational outreach. Survey results 2016) appropriate terminology when discussing repatriation with will be reported to the Sunnybrook n=85 staff patients and families Repatriation Taskforce and to the respondents

b. Co-design with patients and family members a comprehensive Markham-Stouffville Hospital Flow repatriation information package for patients and families. Steering and Utilization Committee. Target: 7.5 out of

10.0

Page 2 of 3

CHANGE


3. Understand patient and family experience of repatriation The Shared Knowledge Working Group Patient and family Target to be

The Shared Knowledge Working Group of the Sunnybrook Repatriation Taskforce will oversee the following:

of the Sunnybrook Repatriation Taskforce will oversee the measurement of patient and family

satisfaction with repatriation process

determined.

Create a plan for measuring patient and family experience of satisfaction with repatriation, and will Measure of repatriation and assess patient and family satisfaction with the report results quarterly to the satisfaction to be process of repatriation. Design quality improvement initiatives Sunnybrook Repatriation Taskforce defined in alignment based on patient and family feedback. and to the Markham-Stouffville

Hospital Flow Steering and Utilization Committee.

with Canadian Patient Experience Survey (CPES) and National Research Council (NRC) Health standard method for displaying survey results (‘top box scoring’).

Page 3 of 3

EmergencyD epartment Lengthof Stayf or Non-admittedP atients: Quality Improvement Plan18/ 19

Quality ive dimension Object Indicator Currentp erformance Targetfor2018/19 Targetjustification

Timely Reduce length of stay for non-admitted patients in the Emergency Department.

90th percentile Length of Stay for all Non-Admitted patients

9.0 hours Oct 17, 2017 YTD

≤ 7.7 hours by March 31 2019

Since the target was not met last year, we are keeping it the same. The target is an ambitious improvement of approximately 15% from our current performance.

Physician Initial Assessment 1A number of initiatives will be reviewed,tested (if necessary) and introduced when appropriate to improve flow so that new patients can be seen by an Emergency Department physician sooner after arrival to the EmergencyDepartment:

• Increased nurse time in the Ambulatory area• Adjusted start time for the Triage nurse(s)• Process for CCL (Clinical Care Lead) to work more closely with Bed

Flow staff • Flowing patients more proactively from triage into the department,

and from the department to the ward • Improving bed “sign-over” times (including porter and environmental

services processes) • Facilitating ambulatory patients waiting in the waiting room when

appropriate • Moving appropriate stretcher patients into a chair

1 This indicator measures the time interval between the earlier of triagedate/time or registration date/time and the date/time of physician initially assesses the patient in the emergency department.

Chief,Emergency Department,and associated team members will oversee the review and implementation of these initiatives.

Physician Initial Assessment 4.7 hours (Oct 17, 2017 Year to Date)

3.7 hours Average by Q4 2018/19

AIM MEASURE

Goal forChange Ideas Process Measures Accountability ChangeIdeas CHANGE


Consult Arrival 1. A. Report new consultation 2 time measures (from consultation request Director of Medical Affairs will provide Complete monthly reporting of 100% monthly reporting

date/time to patient discharge home date/time) for the eight most reports on a monthly basis new consultation time frequent consulting services to the Department Chiefs

Director of Medical Affairs will collect the measures of the eight most frequent consulting services

1. B. Solicit feedback from Department Chiefs feedback received from Department Chiefs.Together with the Chief of Emergency Department, the Director of Medical Affairs will consider the feedback received and

Convene meeting of relevant stakeholders to further discuss the suggestions made for

Present findings, recommendations for improvements and progress

2 In the Emergency Department,a consultation is when an emergency medicine explore the suggestions made for improving improving consult times and updatesto the Medical physician contacts another physician (specialist or otherwise) for advice or consult times with appropriate stakeholders. implement changes Advisory Committee at least intervention regarding patient care. twice during 2018/19. 2. A. Complete implementation of Phase 2 of HERMES 3 trial by April 30,

2018 with ability to:

i. Track the following psychiatry consult time metrics• Consultation request• Bedside arrival• Staff physician contacted• Decision made, and• Disposition/discharge

ii. Offer a new interactive interface between HERMES and the consultant;and

iii. Implement a new peak hours FAST TRACK protocol.

Chief of Emergency, in partnership with the

Department of Psychiatry, Psychiatry

Emergency Services Director, and chief residents are leading the pilot. Emergency

Department Information Technology Lead

will assist with data collection.

Chief of Emergency, Executive Vice

President/ Chief Medical Executive and

Director Medical Affairs will review and

report on results.

Report to the Medical Advisory

Committee on the outcome of the pilot and make

recommendations regarding roll-out and establishing

targets for other services.

Present outcomes from the

pilot to Medical Advisory

Committee by June 30, 2018.

Develop roll-out timeline andtargets for other services by

October 31, 2018.

2. B. Review and analyze the consultation data from Phase 2 andrecommend changes to improve consultation times by June 30, 2018.

3 HERMES is a pilot project using a new iPhone application measuring veryspecific time intervals in the consultation process. The data can then be used to

make improvements in time from consultation request to consultation.

3. Partner with Clinical Champions to implement improvement opportunities Chief of Emergency, Executive Vice Implement new process(es) in Other services,as appropriate, in other services. President/Chief Medical Executive, Director other services and report to to set Consult arrival time

Medical Affairs and Emergency Department Medical Advisory Committee targets by December 31, 2018. Information Technology Lead willpartner on results with Clinical Champions in consult services Implement new process(es) to roll-out improvements. and begin measurement by

January 31, 2019 (dependent on availability of quality data).

CHANGE


DiagnosticImagingComplete full establishment of the Emergency & Trauma Radiology Division (ETRD) with overnight reporting by hiring the last member of this ETRD staff radiologist team by January 2018.

Change led by Head of the Emergency & Trauma Radiology Division and Chief, Medical Imaging

Rollout and performance metrics will be conveyed at the Emergency Department Quality Improvement Plan meetings.

Percentage of finalized reports within 4 hours of exam completion between 10pm-8am

50% improvement on weekends compared to baseline (will be measured in first half of 2018).

Analyse the need to expand current on-site ultrasound technologist coverage (Monday - Friday 8:00 a.m. up to 12:00 a.m.) to Monday – Sunday 24 hours aday. Analyze if change would improve patient care and total length of stay for non-admitted Emergency Department patients. The key is to analyze number of ultrasound orders on off-hours (between midnight and 8 am and onweekends and statutory holidays).

Change led by Head of the Emergency & Trauma Radiology Division and Director, Medical Imaging.

Progress to be shared at Emergency Department Quality Improvement Plan meetings.

In July 2018, analyse 6 months of demand from January 2018.

Within three (3) months of completion of analysis, develop changes ideas andtimes lines to support new targets.

Present business case and seek approval from Senior Leadership Team to Change led by Director, Medical Imaging. Emergency Department CT 90% of CT turnaround times <increase CT (computerized tomography) technologist staffing to two staff perafter-hour shift as part of initiative to improve turn-around time of Endovascular Treatment (EVT) in stroke management.

Progress to be shared at Emergency Department Quality Improvement Plan meetings.

turnaround times in afterhours 4:00 hours in after-hours

Implement the Senior Leadership Team approved construction project of building a point-of-care radiology reading room in Emergency Department to improve radiologist support in an acute clinical setting.

Change led by Director, Medical Imaging

Progress to be shared at Emergency Department Quality Improvement Plan meetings. Corporate Planning and Development will assign a Project Manager to start this project.

Radiologists of various applicable sub-specialties, including Emergency & Trauma Radiology Division,interpreting and consulting in the this shared reporting room

Provide point of careradiological consult in Emergency Department. Completion date to be determined pending assignment of Project Manager.

Explore and analyse patient transportation support for safe, timely and efficient movement of patients from Emergency Department to Diagnostic Imagining locations allowing patients for their tests and treatment procedures

Change led by Director of Medical Imaging, Director of Environmental Services

Patients transports are wellsupported by porters on a timely basis

Increase alignment of Patient arrival times align with appointment times.

CHANGE


Ambulance offload time (90th percentile Transfer of Care time baseline 82 minutes, overall goal = 45 minutes)Phase 1/Input:

Improve the process for knowing when an Ambulance has arrived.

Develop kiosk for Ambulance paramedics self-check-in.• On arrival, the Ambulance paramedics would check-in using the kiosk and

their unique Trip Number. This would alert the triage nurses to the ambulance arrival and allow them to call the crew for triaging. Triaging is the first step for the patient to be identified by the Emergency Department system and allows them to be placed in appropriate areasbased on their severity.

• Steps for this change idea include:1. Train Ambulance personnel on Check-in Kiosk2. Implement Kiosk Trial Period – Nursing Education3. Rapid PDSA (Plan-Do-Study-Act) cycles to improve process

Timeframe: Ambulance Kiosk Live Date: Jan 1, 2018 Kiosk Trial Period: Jan – March, 2018

Time points measured: 1. Time from Ambulance Arrival to Kiosk Check-in2. Time from Kiosk Check-in to Patient Triage

Compliance measure: Percentage correctly inputting Trip Number

Ambulance Check-in Kiosk developed by the Emergency Department Information System Administrator. Overseen by Quality Improvement staff. Leaders for Change Idea steps are: 1. Toronto Paramedic Services Stakeholder2. Emergency Department Clinical Educator3. Quality Improvement staff

Step leaders above will report progress at every other monthly Emergency Department Quality Improvement Plan meeting.

Time from Ambulance Arrival to Patient Triage – 90th

percentile

Source: Patient Distribution System managed by theToronto Paramedic Services.

Time from Ambulance Arrival to Patient Triage (90th

percentile): - Baseline Q1 2017/18:25 minutes - Target Time (by June 2018):14 minutes (45% reduction)

Phase 2/Throughput: Transitional Zone to be Developed by the Percent of Ambulance patients Baseline Q1 2017/18: Chief of Emergency, Trauma/Emergency placed on offload delay*. 58.4%

Improve the flow of Emergency Department patients to increase stretcher availability. Maximizing the stretcher availability will improve the ability to transfer ambulance patients into the Emergency department as well as general flow.

A. Emergency Department Transitional Zone. Develop an area for ambulancepatients waiting to be transitioned into the Emergency Department,so that they will not be held on offload delay*. During offload delay, a patient will remain with the ambulance paramedics and this delays both the patient’s care and the time that the paramedics remain in the hospital. This area would also serve to help bed flow and would be for eligible patients already seen by a physician and awaiting tests.

*Offload delay is defined as when a patient must remain with the Ambulanceparamedic after being triaged because there is not yet an Emergency Department nurse available to complete the transfer.

Department Advanced Practice Nurse and Quality Improvement staff.

Report progress at every monthly Emergency Department Quality Improvement Plan meeting.

Source: Emergency Department Information System. Includes all patients that arrive by ambulance, excluding trauma, stroke or resuscitation patients.

Target: 29.2% (50% reduction)

CHANGE

ChangeIdeas Accountability Process Measures Goal forChange Ideas Phase 2/Throughput: (continued)

B. Develop Transitional Protocol for nurses to help guide moving patients tothe appropriate areas,including: • Ambulance patients to be moved to chair/waiting area• Ambulance patients to be moved to Transitional Zone• Emergency Department patients in a stretcher to be moved to a chair or

the Transitional Zone

Transitional Protocol to be developed by the Chief of Emergency, Trauma/Emergency Department Advanced Practice Nurse and Quality Improvement staff.

Report progress at every other monthly Emergency Department Quality Improvement Plan meeting.

Percent compliance = numerator: number of patients moved to Transitional Zone/Chairs denominator: eligible patients based on protocol criteria

Data source: audit

80% of eligible patients moved to Transitional Zone or to chairs

Phase 2/Throughput: (continued)

C. Registration Flow:Registration occurs after triage and is necessary for the patient to be placed inthe Emergency Department information system and obtain health record information. Perform flow mapping and time analysis of the current registration process. Implement PDSA (Plan-Do-Study-Act) cycles to improve the process.

Registration flow improvement led by the Emergency Department Administrative Coordinator and Quality Improvement staff.


Time from Triage completion to Registration completion -90th percentile

Triage completion to Registration completion time (90th percentile):- Baseline Q1 2017/18:26 minutes - Target Time:18.2 minutes (30% reduction)

Source: Emergency Department Information System.

Phase 2/Throughput: (continued)

D. Transfer of Care for Emergency Department Admitted Patients:For admitted patients, an Emergency Department nurse must give the unit ward nurse information through a process of Transfer of Care. The goal of this phase is to perform flow mapping and time analysis of the current transfer of care process. If admitted patients have a delay to being transferred to theward, this impacts the general Emergency Department flow as the stretcher that the admitted patient occupies is blocked for other use. Therefore there will be PDSA (Plan-Do-Study-Act) cycles implemented to improve the process and transfer of care time for admitted patients and increase the stretcher availability in the Emergency Department.

Transfer of Care for Emergency Department Admitted Patients developed by the Chief of Emergency, Trauma/Emergency DepartmentAdvanced Practice Nurse and Quality Improvement


Ward Ready to Discharge Time - 90th percentile.

Ward ready time is defined as the time that a bed is available on an inpatient unit. Discharge time is defined as the time a patient leaves the Emergency Department and is removed from the Emergency Department Information System.

Ward ready to discharge (90th

percentile): - Baseline (April – July 2017):2.1 hours - Target Time (by Dec 2018):1.2 hours (45% reduction)

Source: Emergency Department Information System.

CHANGE

Compassion Quality Improvement Plan 18/19

AIM MEASURE

Quality dimension Objective Indicator Current

performance Targetfor2018/19

Targetjustification

Patient-Centred

Improve the patient experience by

% positive response* in the overall Respect and Dignity Dimension (made up of nine questions) from the Canadian

67.9% ≥ 72% A minimum of 72% was selected because it is the 2016/17 Ontario Inpatient Academic

enablingcompassionate person centredcare.

Patient Experience Survey in the Women’s & Babies, Trauma, Cancer, Community, Cardiac, and Holland programs.

The Dimension is defined in four sectors: 1. Communication with Nurses - This measure is a

composite measure of three questions measuring the patients' responses to whether they were treated by nurses with courtesy and respect, were listened to, and explained things in an understandable way.

2. Communication with Doctors – Three questions thatdescribe how well doctors communicate with patients.

3. Emotional Support - One question that describes theemotional support provided for anxieties, fears or worries during their hospital stay.

4. Involvement with Decision-making – Two questionsthat describe how well patients and families are involved in decision-making.

* The questions are all on a four point scale (never,sometimes, usually, always), and the % positive score is only used for the ‘always’ response.

Q1 17/18 By Q4 2018/19 Hospital average. It will be a stretch target as it is a relative improvement of 6%. As well, our results from the previous six quarters hada fairly narrow range from 66.1% to 69.0%.]

The change initiatives are well aligned with Sunnybrook’s Person Centred Care Strategy which is currently monitoring 4 of the 9 questions included in the Respect and Dignity dimension.

Other organizational alignments include:• Newly launched quarterly “Quality Hub”

data reviews • Introduction of Quality Conversations

held at the local unit, to review data andcreate action plans

• Focus on the comments from patientsand families in the surveys,to help staff understand survey scores

• Recognition that compassion for staff isas important as compassion for patients and families

CHANGE

ChangeIdeas Methods (Accountability & Reporting) Process Measures Goal forChange Ideas

The goal of the Compassion work on the hospital’s quality strategic plan The accountability of this change idea will be held 1. All job postings to reflect 1. December 2018is to lead in valuing the humanity and vulnerability of our staff, patients by Director of Human Resources and person centred care language and families through implementing innovative initiatives promoting the Organizational Development and Leadership, 2. All Interview tools to be 2. December 2018humane aspects of healthcare. We will accomplish this by:

1. Advance a culture of compassion2. Support health care providers to deliver compassionate care3. Support staff and physician wellness.

Manager of Organizational Development and Director of Interprofessional Practice and will be monitored quarterly through the Person Centre Care Committee, which will include a report on

updated with person centred care questions and language

3. Performance appraisals toinclude person centred care language in communication

3. December 2018

ADVANCE A CULTURE OF COMPASSION the percentage completion for:

• Job descriptions competency

4. All Sunnybrook Leadership 4. March 2019Attract, recruit and retain a workforce committed to consistently • Interview guides Institute programs to includeapproaching patients, residents, and family in a person centred way that • Performance appraisals person centred care principles demonstrates compassion for the emotional experiences of receiving health care services. It is recognized that every Sunnybrook staff person

(2018 – 19) 5. Corporate orientation to 5. December 2018

makes a difference in patient and family experiences of high quality care. include person centred care learning module, with person

1. Revise job descriptions to recruit talent committed to this values- centred language and storiesbased approach to care throughout the orientation

2. Revise behavioural-based interview guides to enable applicants to program. describe their strengths in this area

3. Update performance appraisals with accompanying conversationguides to enable managers to review and discuss behaviours and accountabilities to continuously improve integration of compassion in daily care

STAFF ENGAGEMENT Engagement is described as a positive attitude held by employees towards the organization and its values. It is a two way relationship and organizations must work to develop and nurture engagement. One of the strongest drivers of engagement is a sense of feeling valued and involved. Engagement is heightened by compassion and commitment increases when staff have an opportunity to both experience and express compassion. As an organization, we wish to increase our understanding of our staff’s level of engagement by measuring drivers of engagement,including compassion.

Add questions measuring drivers of engagement to the current Staff & Physician Engagement Survey. Results from the Staff and Physician Engagement Survey inform the Wellness Strategy. Additionally each leader is provided with their own results, and is required to develop a shared team action plan based on the review of the results.

The Director of Human Resources will lead the second cycle of the Staff and Physician Engagement Survey,which will be updated to include new questions regarding what, helps staff to feel valued and involved. The Director of Human Resources will lead subsequent monitoring of completed team action plans.

Implementation of the updatedStaff & Physician Engagement Survey by December 2018.

Team Action Plans developed

The new “Drivers of Engagement” questions will be used to create a baseline tobe monitored over time.

100 % of Team Action Plans completed by March 2019.

CHANGE


NEW COMPASSION AWARD

Develop and implement a new annual team Compassion RecognitionAward which will be open to everyone. Specific criteria that recognize compassion for patients, families and staff will be developed. The new award will be aligned to the Schwartz Centre Rounds and will becelebrated at the new Human Resources Day in 2019.

Co-leads of the Schwartz Centre Steering Committee will provide leadership for this change idea through the Schwartz Centre Steering Committee.

Launch of the Compassion Recognition Award

Launch and recognition of 4-6Compassion Recognition Awards at the New Human Resources Day, 2019.

MEASURE IMPACT OF SCHWARTZ ROUNDS*

Implement measurement tool to evaluate the impact of Schwartz CentreRounds on participants’ overall wellness. The enhanced evaluation willmeasure the impact of participating in the rounds over time. An Ethics approved multi-methods study will explore the impact on the individual and organization as it relates to compassion, meaning of work and burnout.

*Schwartz Centre Rounds provide staff with an interprofessional forumand space to reflect and discuss the social, emotional and ethical impactof working in the health care system.

Oversight of the study will be provided by the Schwartz Centre Steering Committee, with co-principal investigators to be determined.

Completion of literature review by April 2018 to determine the quantitative and qualitative study measures to be evaluated.

Ethics-approved study will beimplemented and completed by March 2019.

COMPASSIONATE PERSON CENTRED CARE

Utilize unit-based discussions to enable interprofessional teams to collectively review and act on patient-reported data, with a goal to improve patients’ experiences of compassionate care.

Quality and Patient Safety Specialist will provide leadership for quarterly distribution of patient survey data to Operations Directors who will then share locally with each team.

Professional Leader of Nursing will provide

Unit Based Person Centred Care Action Plans will be developed for each patient care area.

≥ 80% of Nursing Council representatives will complete unit based Person CentredCare Action Plans for each patient care area that outline activities aimed to improvethe patient’s experience of

Teams will be supported to develop and implement local improvements ideas. Unit-based improvement activity is informed by numerous sourcesincluding: 1. iLead data2. Themes found in comments from Canadian Patient Experience

Survey 3. Data from quarterly “Conversations with Patients” audits4. Improvement ideas from a new question to be added to

“Conversations with Patients.”

leadership with Nursing Council for“Conversations with Patients” and will work with the team Business Analyst to distribute unit based results.

Person Centred Care lead will provide leadership in collaboration with Quality and Patient Safety Team to support local teams to use Comment Framework for Survey comments to review themes.

compassionate care.

CHANGE


PATIENTS AS EDUCATORS: ADVANCING COMPASSIONATE CARE

Create a website with written and video content to share the individual experience of five Sunnybrook patients who experience bipolar illness. This website will be designed to help enhance the compassion of medical

Vice President of Education will provide leadership and reporting will occur through the Sunnybrook Education Advisory Committee(SEAC).

% of student learners that state that the website enhanced theirempathy and compassion towards people with mental illness.

80%

students and residents at the University of Toronto towards people with mental illness. The website will also be shared with patients, family members and the general public in order to help viewers better understand these patients’ experiences and to reduce stigma.

A health reporter will interview five Sunnybrook patients about their lifeexperience with bipolar illness and a film company will create a video for the website. We will measure views of the website and patient andfamily and student learner satisfaction.

% of patients who viewed the website and state that they want to want to share it within theircare network (family members/clinicians).

80%

STAFF AND PHYSICIAN WELLNESS AND RESILIENCE

Implement and evaluate programs to foster compassion and overall wellness:

1. Mindfully Working with Stress Program for Health Professionals and Physicians (2018 – 2019)

2. Building Mental & Emotional Wellness Workshop (2018) 3. Emotional Wellbeing & Mental Health Keynote (2018) 4. Narrative Medicine in Palliative Care 5. Lavender Alert Pilot in General Internal Medicine 6. Improving Wellness through Improvisation

Director of Human Resources and Organizational Development and Leadership, Manager of Organizational Development and Director of InterprofessionalPractice willprovide oversight for implementation and evaluation of programs, monitoring collective impact.

The following measures will be collected for each program:

• Number of participants in existing health wellness and resilience program(s)

• Number of participants in newhealth wellness and resilience programs

• Post-Evaluation Surveys with common evaluation questions specific to wellness and meaning of work

Increase staff participation by 5% in existing health wellness and resilience program(s) by March 2019.

Greater than 500 staff will participate in new healthwellness and resilience programs March 2019.

Common improvement metric for each program to be developed by March 2019. .

QIP 18/19 – Quality of Discharge and Transition Planning AIM MEASURE Quality

Dimension Objective Indicator Current

performance Targetfor 2017/2018

Targetjustification

Patient Centred

To more effectively

provide patients with the

information they need and

want to prepare for transition home by

increasing the quality of discharge planning.

Percentage of respondents who responded positively to the following question: Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital? (The Canadian Patient Experience Survey (CPES) question #37)

54.4%

Q1-Q2 2017/18

≥59.8%

By Q4 2018/19

The target is set at the national average and is a stretch target as it represents a 10% relative improvement.In the longer term, we will aspire to exceed the Ontario Academic inpatient average of 62.0%.

CHANGE

Planned improvement initiatives Accountability Process Measures Goal forchangeideas

IDENTIFYING ESTIMATED DATES OF DISCHARGE Co-leads of the % Compliance with entering Baseline: 41%;Aug – Oct 2016 An Estimated Dates of Discharge is important as it gives the patient, their Discharge and Transition Estimated Discharge Dates into (3 months) family and the health care team a time line during which they can strive to provide the information patients need prior to discharge.

On a monthly basis, disseminate the Estimated Discharge Date (EDD) Dashboard (contains compliance and accuracy data) to the following teams to

Planning Committee and Flow Department monitor compliance and accuracy results and success of improvement

Bed Management System within 24 hours of admission. Note: Bed Management System automatically updates Sunnycare.

Goal: 75%

enable improvement strategies to be developed and implemented where strategies. % Accuracy of Estimated Baseline: 49%; Aug –Oct 2016 appropriate: Discharge Date entered by 7:30 (3 months) • Clinicalteams (including resident physicians) • Discharge and Transition Planning Committee • Occupancy Executive Committee • Interprofessional Quality Committee (biannually)

a.m. for patients who discharged on that same day.

Goal: 75%

CHANGE


IMPLEMENTING AND SUSTAINING DISCHARGE BEST PRACTICES Teams will report Self- Based on Self-Assessment,teams Question #19 we have

Improve patient experience with preparing for discharge and the transition Assessment results and identify areas to improve the consistently exceeded the

home. progress to the Discharge and Transition

discharge process. National Research Corporation average (78.1%) and have set

Implement and sustain Discharge Best Practices and Tools to support discharge Planning Committee monthly.

Canadian Patient Experience Survey questions:

the improvement target as greater than 79.1%.

planning process and patient education. Discharge Best Practices and Tools include: 1. Standardized questions in Discharge Planning Rounds *

2. Discharge Poster *

3. Discharge Video

4. Patient Engagement Whiteboards *

Discharge and Transition Planning Committee will provide oversight for impact of interventions on patient experience of discharge. Committee

#19: During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

For Question #20, the improvement target is greater than 79.3% which is the Ontario Academic inpatient average. We have consistently exceeded the National Research

5. Unit Discharge Pamphlet * will monitor three #20: During this hospital stay, did Corporation average of 71.5 6. PODS (Patient Oriented Discharge Summary) NEW questions on the you get information in writing and in two quarters exceeded * = Sustain Canadian Patient

Experience Survey about what symptoms or health problems to look out for after you

the Academic Hospital average. We look forward to leading in

Clinical Teams will be provided with a Self-Assessment Tool to evaluate how related to discharge; left the hospital? best practices and scores

well the Discharge tools are integrated into practice and to identify

opportunities for improvement.

(#19, #20, & #37 (overall indicator)).

related to this question.

In addition, comments related to discharge will be reviewed quarterly and mitigating strategies will be developed as required.

CHANGE


IMPLEMENTING PATIENT ORIENTED DISCHARGE SUMMARIES

Develop, implement and evaluate PODS (Patient Oriented Discharge Summary1 ) on three units. Implementation of PODS will include simulation based education for staff on the core competencies of Health Literacy 2 and Teach Back 3 . Staff education programming and evaluation will be completed in collaboration with Michael Garron Hospital to further advance system partnership and collaboration.

Post discharge calls to patients and families willbe used to evaluate the effectiveness of PODS.

1 A written summary provided to patients typically with five key pieces of information they need to know in order to effectively manage their health after a hospital discharge:

• Signs and symptoms to watch out for • Medication instructions • Appointments • Routine and lifestyle changes • Telephone numbers and information to have available

2 Health Literacy is the degree to which patients have the capacity to obtain, process, and understand health information needed to make appropriate health decisions.

3 The teach-back method, also called the "show-me" method, is a communication confirmation method used by healthcare providers to confirm whether a patient (and/or their care takers) understands what is being explained to them. If a patient understands, they are able to "teach-back" the information accurately.

PODS Working Group will lead the implementation of PODS and evaluate effectiveness and feasibility.

The Working Group will report progress to the Discharge and Transition Planning Committee monthly.

Staff education will be completed in partnership with Patient and Family Education and progress will be reported to both the Discharge and Transition Planning Committee and the Sunnybrook Education Advisory Committee (SEAC).

Post Discharge Calls will be completed by designated unit leads.

On three Pilot Units:

• Compliance of using PODS with patients who are discharged

• Completion of both Health Literacy and Teach Back education

• Healthcare provider satisfaction – Focus Group

• Patient and family experience – Post Discharge Telephone Calls

• 80% compliance

• 80% completion

• Positive satisfaction verbalized by healthcare providers

• Positive experience verbalized by patients/ families

CHANGE


DEVELOP EFFICIENT STRATEGIES TO SHARE INFORMATION AMONG HOSPITALS, PRIMARY CARE AND PATIENTS.

Pilot “Notification and Warm Handovers” between the Sunnybrook Family Health Team and Sunnybrook Internal Medicine teams at/near admission and prior to discharge.

This initiative will encompass:

This change initiative will be led by co-leads of the Discharge and Transition Planning Committee in Collaboration with the Executive Director, Family Health Team.

Baseline data collection is required to set improvement targets.

Surveys will be used to determine health care provider satisfaction with current information availability/content/ timeliness at

Baseline data is collected by

March 31 2018.

Surveys completed with

General Internal Medicine and

Family Practice by Sept 2018 with a goal of 10%

• Identifying the information needs of primary care, internal medicine and complex patients.

• Involving the Family Health Team nurse navigator to facilitate information sharing, “Warm Handovers”,and completion of Patient Orientated Discharge Summaries

• Identifying best practices to communicate with primary care • Using feedback from the Family Health Team Nurse Navigator on

various communication strategies.

Background: Primary care is an essential partner for optimal and efficient care throughout each patient's health journey. While the Sunnybrook Family Heath Team patient admissions only comprise 1% of the total admissions, the Family Health Team serves many patients with complex health conditions and would be a good pilot model for developing communication strategies that can work for these patients and other patients in the future.

Information received by primary care providers from hospitals is often considered inadequate, inaccessible and/or untimely. Primary Care providers are often unaware their patients have been admitted. Internal Medicine physicians in the hospital can also feel there is a lack of accessible information about the patient's care prior to admission.

baseline and at the end of the pilot.

Telephone follow-up calls will be used to evaluate patient satisfaction/experience,pre- and post-improvement implementation

improvement in satisfaction

with communication/ information transfer.

Patient satisfaction/experience

surveys (20 minimum) completed by Nov 2018 with a

goal of 70% satisfaction overall.

Quality Improvement Plan 2018/19: The Quiet Campaign– EmbracingN oise Reductionand Sl eepEnhance ment Strategies across Sunnybrook

AIM MEASURE Quality

dimension Objective Indicator Current

performance Targetfor2018/19

Targetjustification Comments

Patient Reduce noise % of patients who 34.6 % A 10% relative This increase is a stretch target as Initialpatient Centred levels on patient

care units.

A three year multi-year plan is proposed toachieve this with the first year focused on developing a greater understanding of unit specific noise challenges and piloting strategies in selected areas.

respond positively to the Canadian Patient ExperienceSurvey question “During this hospital stay, how often was the area around your room quiet at night?”.

Numerator: Number of positive responses within selected units

Denominator: Total Number of responses within selected units

Hospital average(2016/2017)

Individualunit levels vary.

increase from baseline on the selected pilot units by March2019.

Pilot units have been identified in collaboration with program and unit leadership.

Sunnybrook is already close to theaverage rate for Teaching Hospitals of 35.5% (Year-to-date October 2017/2018).

Patient verbatim feedback collected through several methods 1 indicates noise needs to be addressed as patients find sleep difficult while in the hospital and report that noise is a significant source of distress. Multiple studies also connect noise to physical and psychological distress, and highlight its negative impact on sleep, recovery, delirium, and hospital stay. A stretch target was developed to address this.

1 Sources include Patient Care Manager post-discharge follow-up phone calls, Canadian Patient Experience Survey verbatim comments, and hospital engagement interviews with patients.

engagement feedback indicates that noise sources at Sunnybrook are primarily from the patient’s surrounding environmental (doors closing, busy units, overhead paging and construction), and people (staff, patient andvisitors).

This Quality Improvement Plan is designed to be multiyear with the learnings from year one leveraged to reduce noise across sites over years two and three.

CHANGE Change Ideas Accountability Process Measures Goal for Change Ideas

Conduct assessments of noise levels and factors contributing to noise on selected units. Observations as well as patient and staff surveys and interviews will be included in the assessments.

Based on assessments, develop a broader understanding of the challenges that lead to noise on the units and identify unit specific strategies that can be implemented to reduce noise.

The Corporate Nursing Council Noise Working Group, with support from the Professional Leader for Nursing, will facilitate the unit assessment process and development of recommendations to reduce noise.

Noise assessment results and recommendations will be shared with:

• Corporate Nursing Council • Professional Council of Nursing • Health Professional Leadership Council • Professional Practice Council • Unit leadership

Reports will be submitted quarterly on progress.

Number of units that complete an assessment of unit specific noise factors and develop strategies to reduce noise as of June 30, 2018.

Identified strategies will be implemented in year two and three.

Six to eight units

Implement sustainable strategies to reduce noise levels on a minimum of three selected pilot units.

Patient Care Managers, Advanced Practice Nurses /Clinical Educators, and Health Professional Innovation Fellows on units will be responsible for planning, implementing and evaluating the pilots on their units. Updates and results will be shared quarterly to:

• Health Professional Leadership Committee

• Patient Care Managers Committee • Professional Practical Council • Corporate Nursing Council

• Total number of staff to participate in awareness training regarding noise issues and noise reduction strategies on the selected pilot units.

• Number of recommend strategies to reduce noise on selected pilot units implemented.

• Noise reduction strategies will be evaluated via patient survey.

• 80% percent of staff on the pilot units will participate in awareness training by October 2018.

• 75% of recommended strategies to reduce noise will be implemented on pilot units by October 2018.

• 20 patients and/or families (total) will be engaged to provide feedback through the survey on unit specific strategies and their impact.

CHANGE Change Ideas Accountability Process Measures Goal for Change Ideas

Implement a One Month Quiet Education Campaign across all Sunnybrook Campuses and Programs to raise awareness of the impact of noise on patients and share data and strategies.

The Quiet Campaign will be developed and implemented collaboratively by:

• Health Professional Leadership Team • Professional Council of Nurses • Nursing council • Patient Partners • Communications

Status reports will be shared with each committee and the Professional Practice Council quarterly.

• The number of “views”/“clicks” on the Quiet Campaign Intranet Site

• The number of Patient Care Area teams at Sunnybrook who sign up to participate in the Quiet Challenge.

By February 2019 there will be increased awareness of the impact of noise on our patients demonstrated by:

• >1000 views of the Sunnybrook quiet Campaign Intranet Site

• 15 Patient Care Area teams will sign up to participate in the Quiet Challenge

Implement a Three Month Team Quiet The Quiet Challenge will be facilitated and Percentage of inpatient 60% of inpatient teams will Challenge that follows the Quiet Campaign. implemented collaboratively by:

• Health Professional Leadership Team teams that complete the Quiet Challenge

complete the Quiet Challenge by June 2019.

A toolkit with strategies to support noise • Professional Council of Nurses demonstrated by their reduction will be available on the intranet • Nursing Council submission of a creative and teams will be able to select the most • Patient Partners report. appropriate strategies for implementation. • Communications

Status reports will be shared with each committee and the Professional Practice Council quarterly.

CHANGE ChangeIdeas Accountability & Reporting

(HQO’s Methods column) Process Measures Goal forChange Ideas

Increase revenue from patients selecting Preferred The Implementation & Integration 1) Increased number of patient Increase fiscal year 18/19 Accommodations Committee will receive regular reports interviews for preferences net revenue by $724,000. • Improve work-flow processes to enable more patients developed by the Sustainability Project 2) Increased placement of patients in

to be interviewed for their preferences and increase the Office to monitor these measures. preferred accommodations likelihood of successfully placing patients in their Senior Leadership Team will also preferred rooms despite high occupancy. receive detailed monthly reports on

the progress of these initiatives. Identify increased revenue opportunities from retail services The Implementation & Integration 1) Increase in retail pharmacy and gift Increase fiscal year 18/19

• Expand retail opportunities by scaling existing services, Committee will receive regular reports shop revenues from existing net revenue by $1,300,000. delivering new services, and assessing unsustainable developed by the Sustainability Project offerings offerings. Office to monitor these measures. 2) Increase in overallrevenue from

• Ensure staff, visitors and patient preferences are taken Senior Leadership Team will also new retail offerings

into account by conducting initialsurveys on receive detailed monthly reports on 3) Surveys of staff, visitors and patient preferences and assessing satisfaction once new retail the progress of these initiatives. preferences and satisfaction. initiatives are implemented.

Ensure that the data submitted to the Ministry of Health The Utilization Committee will receive 1) Develop a process to identify charts Audit 1,000 charts that that is used for funding purposes more accurately quarterly reports developed by Health for review trigger Data Quality flags.

represents the services provided to patients. Data Records and Decision Support to 2) Develop and deliver education • Implement a comprehensive Data Quality Program to monitor the outcomes of process material to physicians to support

ensure that reported activity aligns with services measures and the change idea. improved documentation

provided and enhances Sunnybrook’s funding position. 3) Recode and re-submit charts identified by the audit process

Quality Improvement Plan1 8/19 – Total Margin AIM MEASURE

Quality dimension Objective Indicator Current

performance Targetfor 2018/19

Targetjustification

Efficient Improve

organizational financial health

Total Margin (consolidated): Percent, 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.

2.48%

Q2 2017/18

≥ 0% Maintaining a balanced budget (expenses do not exceed revenues) is a greater and

different challenge each year and continues to be a top priority for the

hospital.

Alternate Level of Care: Quality Improvement Plan 18/19

AIM MEASURE Quality


Targetfor 2018/19

Targetjustification

Efficient Ensure patients are receiving care in the most appropriate location to meet their care needs.

Alternate Level of Care 1 Rate Overall (%) for Acute & Post-Acute patients located at all Sunnybrook sites (Bayview, Holland & St. John’s Rehabilitation).

1 Alternate level of care (ALC) refers to a patient who is occupying a bed in a hospital but does not require the intensity of resources or services provided in this setting (source: Health Quality Ontario: qualitycompass.hqontario.ca/ portal/plans-hospital/Alternate-Level-of-Care?extra=pdf)

9.20%

Q1 2017/18

≤ 8.74%

By Q4 2018/19

This is a 5% relative improvement which will be challenging as Sunnybrook can only control its internal processes and not the availability of community resources or patient complexity and need.

CHANGE ChangeIdeas Accountability & Reporting Process Measures Goal

1. Consistent use of best practices • Complete Alternate Level of Care Self-

Assessment Tool developed by the Toronto Central Local Health Integration Network

• Incorporate patient and family feedback where possible

• Address gaps as required

Leads: Sunnybrook Program Operations Directors (Musculoskeletal Program, Brain Sciences & Community programs, and Trauma, Emergency & Critical Care Program) and Manager, Alternate Level of Care team, Toronto Central Local Health Integration Network

• Report progress regularly into Alternate Level of Care Task Force

# gaps identified and addressed

Target: ≥ 90% controllable gaps addressed by June 30, 2018

2. Maximize the number of rehabilitation facilities Program Operations Directors and Patient Care Number of Baseline: 2.0 (Q3 selected by patients to enable them to receive rehabilitation in as timely a manner as possible

Mangers will roll-out Tool-Kit Rehabilitation referrals per patient

2017/18)

• Ensure Sunnybrook’s new Tool Kit processes • Progress reviewed regularly by Program Target: ≥ 2.1 (a 5% are implemented so that referrals to multiple Operations Directors and Patient Care relative increase) by Q4 rehabilitation facilities are maximized (when appropriate) and that a first bed available policy is utilized whenever possible

Mangers and by Alternate Level of Care Task Force

2018/19

CHANGE ChangeIdeas Accountability & Reporting Process Measures Goal

3. Maximize the number of Long-Term Care homes • Leads on counseling and initiation of Percentage of Baseline: 64% (Sept. 18, selected by patients to enable them to be in a home setting in as timely a manner as possible

escalation: Professional Leader for Social Work & Client Services Manager, Hospitals,

patients who have selected 4 or more

2017)

• Ensure patients have received communication Toronto Central Local Health Integration Long-Term Care Target: 80% by Q4, and/or counseling related to the benefits of making five Long-Term Care home choices.

• Follow tool kit processes to ensure choices are maximized (include all team members to support patient and family as required).

Network • Leads on escalation communication and

associated counselling when required: Patient Care Managers and Program Operations Directors

• Report progress regularly into Alternate Level of Care Task Force

homes 2018/19

4. Maximize referrals to new transitional care beds and programs (e.g. at Pine Villa,St. Hilda’s and Hillcrest). • Implement processes to support assessment

and referral of patients who meet eligibility criteria.

• Professional Leader for Social Work, Operations Directors and Patient Care Mangers will ensure staff are aware of and maximizing the number of appropriate referrals to transitional care beds and programs.

# patients referred per month to transitional care beds and programs

≥2 / month

ImprovingqualityofcareforPregnantWomenwithPhysicalDisabilities:QualityImprovementPlan18/19“DevelopPackageofCare”

AIM MEASURE Quality

dimension Objective Indicator Currentperformance

Targetfor2018/19 Targetjustification

Equity Improvethequalityofcaretowomenwithphysicaldisabilitiesinpregnancy

Develop“PackageofCare”1forAccessibleCarePregnancyClinic.1This“PackageofCare”willspecifykeybestpracticesthatapregnantwomanwithaphysicaldisabilityshouldreceiveprenatally.

“PackageofCare”isunderconsideration

“PackageofCare”developedbyMarch31,2019

Althoughwealreadyhaveastrongsenseofwhatthekeybestprenatalpracticesareforapregnantwomanwithaphysicaldisability,muchconsultationandengagementstillneedstooccurbeforewecandevelopabestpractices“PackageofCare”.Ultimately,wewillalsomeasureitssuccessfulimplementation.

CHANGE

ChangeIdeas Accountability,Responsibility,Reporting ProcessMeasures GoalforChangeIdeas

1. Collaborateonthedevelopmentofthe“PackageofCare”fortheAccessibleCarePregnancyClinic.ThiswillinvolveclinicalstakeholderssuchasotherstaffandphysiciansintheWomen’sandBabiesprogramandfamilyphysicians.Examplesofbestpracticesmightinclude:• ultrasoundappointmentsthataccommodateextratimeif

needed• anesthesiaconsultifneeded• explorationofneedforcommunityresources/nurturing

attendantifneeded

AccessibleCarePregnancyClinicteamwilloverseethecollaboration

Collaborationcompleted. CollaborationcompletedbyAugust31,2018.

2. Holdafocusgroupand/orconductasurveywithcurrentand/orformerpatientsandfamiliesregardingthedraft“PackageofCare”inordertoco-createthefinal“PackageofCare”.

AccessibleCarePregnancyClinicteamwillworkwithManagerofEngagementandHealthEquitytoplanandconducttheengagement.

Reviewdraft“PackageofCare”withpatientsandfamilies.

Patient&familyfeedbackisincorporatedinto“PackageofCare”wherepossiblebyOctober31,2018.

3. IncreaseawarenessoftheAccessibleCarePregnancyClinicandits“PackageofCare”toreferringphysiciansintheGreaterTorontoAreavia• Webpage• Letters• Outreachtogroupsthatrepresenttheinterestsofwomen

withphysicaldisabilities,forexample,theSpinaBifidaandHydrocephalusAssociationofOntario.

AccessibleCarePregnancyClinicteamwill• workwithCommunicationsandStakeholder

RelationsandtheDigitalandVisualCommunicationsteamtoenhancewebpage

• sendoutletters• reachouttogroupsthatrepresentthe

interestsofwomenwithphysicaldisabilities.

Numberofclinics/groupsthatrepresenttheinterestsofwomenwithphysicaldisabilitiescontactedandinformedaboutthedevelopmentofthe“PackageofCare”.

Atleast10lettersoroutreacheffortscompletedbyMarch31,2019.WebpageenhancedbyMarch31,2019.

Documents

QIP 2018/19 – Workplace Violence Prevention · QIP 2018/19 – Workplace Violence Prevention AIM MEASURE ... Change Ideas Accountability ProcessMeasures Goal for Change Ideas