Quality Improvement in a Hospital

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Quality Improvement Plan

Guidance Document

January, 2011


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Acknowledgements................................................................................................................. 3

A. Purpose ............................................................................................................................... 4

Purpose o this Guidance Document .....................................................................................4

Purpose o the Excellent Care or All Acts Quality Improvement Plan .....................................4

B. Background......................................................................................................................... 5

Denition o Quality ................................................................................................................ 5

Process Guidance ................................................................................................................. 5

Roles & Responsibilities or the Quality Improvement Plan ..................................................... 6

Development and Submission Process: .................................................................................8

Reporting to the OHQC: ........................................................................................................ 9

Public Posting: ...................................................................................................................... 9

C. Content Guidance............................................................................................................... 9

Part A: Overview o Our Hospitals Quality Improvement Plan ................................................. 9Part B: Quality Improvement Plan

Our Improvement Targets and Initiatives ................................................................................ 9

1. Columns ..................................................................................................................... 9

2. Rows ........................................................................................................................ 11

Part C: The Link to Perormance-based Compensation o Our Executives ...........................12

Part D: Accountability Sign-o ............................................................................................. 13

Appendix A: Quality Improvement 101 ................................................................................ 14

Appendix B: Indicator defnitions and technical inormation............................................ 17

Appendix C: Examples o other indicators to include in the QIP...................................... 20

Appendix D: Guidance on designing Overview o Our Hospitals

Quality Improvement Plan (Part A) ..................................................................................... 23

Appendix E: Guidance on perormance based compensation.......................................... 25

Appendix F: Example o completed row in QIP .................................................................. 30

Table o Contents


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Acknowledgements

This guide, and all o the support elements associated with the Quality Improvement Plan, have been developedin collaboration with hospitals, LHINs, the Ontario Health Quality Council, the Ontario Hospital Association, and

the Ministry o Health and Long-Term Care. The Quality Improvement Plan Task Group would like to recognize the

guidance and contribution o the ECFAA Implementation Working Group, as well as all o the hospitals involved in

the eld testing process.

Quality Improvement Plan Task Group:

Kelly Gillis, South West Local Health Integration Network

Sudha Kutty, Ontario Hospital Association

Nizar Ladak, Ontario Health Quality Council

Cyrelle Muskat, Ontario Hospital Association

Margo Orchard, Ministry o Health and Long-Term Care

Jillian Paul, Ministry o Health and Long-Term Care

ECFAA Implementation Working Group:

Tai Huynh, Director, Excellent Care or All Strategy, MOHLTC (Chair)

Anthony Dale, Vice President, Policy and Public Aairs, OHA

Elizabeth Carlton, Director, Policy & Legislative/Legal Aairs, OHA

Laura Kokocinski, CEO, North West Local Health Integration Network

Kim Baker, CEO, Central Local Health Integration Network

Ben Chan, CEO, Ontario Health Quality Council

Nizar Ladak, Chie Operating Ocer, Ontario Health Quality Council

Ray Hunt, Chie Executive Ocer, Espanola Regional Hospital and Health Centre

Sharon Pierson, Director, Quality, Patient Saety and Clinical Resource Management, Hamilton Health Sciences

Carolyn Baker, President and CEO, St. Josephs Health Centre

Jillian Paul, Project Lead, Excellent Care or All Strategy, MOHLTC

Margo Orchard, Senior Consultant, Excellent Care or All Strategy, MOHLTC

Maria van Dyk, Team Lead, Planning and Negotiations, LHIN Liaison Branch, MOHLTC

Shannon Magennis, Senior Communications Advisor, MOHLTC

For more inormation, please contact [email protected]
mailto:[email protected]:[email protected]


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A. Purpose

Purpose o this Guidance DocumentThe purpose o this guidance document is to oer assistance to health care organizations in their eorts to

complete a Quality Improvement Plan (QIP) along with the QIP short orm or submission to the Ontario Health

Quality Council (OHQC).

Purpose o theExcellent Care for All Acts Quality Improvement Plan

The Excellent Care or All Act (ECFAA), which received royal assent in June 2010, is a landmark piece o legislation

or Ontario. It osters a culture o continuous quality improvement where the needs o patients come rst. The

introduction and implementation o this legislation is a clear indication to the people o Ontario that their health care

providers and their government:

g Are committed to creating a positive patient experience and delivering high quality health care;

g Are responsive and accountable to the public;

g Believe that quality should be the goal o everyone involved in delivering health care in Ontario; g Understand that all health care organizations should hold their executive teams accountable or

its achievement; and

g Recognize the value o transparency.

The legislation requires that every health care organization (currently dened as a hospital within the meaningo the Public Hospitals Act):

g Establish a quality committee to report on quality-related issues; g Develop an annual quality improvement plan and make it available to the public;

g Link executive compensation to the achievement o targets set out in the quality improvement plan;

g Conduct patient / care provider satisaction surveys;

g Conduct sta surveys;

g Develop a patient declaration o values ollowing public consultation, i such a document is not currently

in place; and

g Establish a patient relations process to address and improve the patient experience.

According to the legislation, the annual QIP must be inormed by the ollowing:

g The results o the patient and employee surveys;

g Data relating to the patient relations process;

g In the case o a public hospital, its aggregated critical incident data as compiled based on disclosures

o critical incidents pursuant to regulations made under the Public Hospitals Act (PHA) and inormation

concerning indicators o the quality o health care provided by the hospital disclosed pursuant to regulations

made under the PHA.

The annual QIP must contain at a minimum: g Annual perormance improvement targets and the justication or those targets;

g Inormation concerning the manner in and extent to which, executive compensation is linked to the

achievement o those targets

The QIP provides the means or hospitals to communicate to their public, patients, and sta that they are


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Planning Submission (HAPS), and Hospital Service Accountability Agreement (H-SAA). The integration o these

documents helps ensure nancial responsibility, accountability to patients, and high quality care.

The QIP Short Form has been established to assist hospitals in meeting their legislative requirements and toproviding the OHQC with quality improvement data and inormation in a ormat that permits province-wide

comparison and reporting on a minimum set o quality indicators. This QIP short orm is not intended to replace

any existing quality improvement plans or strategies already in place in Ontario hospitals.

B. Background

The QIP Short Form has been established to assist hospitals in meeting their legislative requirements and to

providing the OHQC with quality improvement data and inormation in a ormat that permits province-wide

comparison and reporting on a minimum set o quality indicators. This QIP short orm is not intended to replace

any existing quality improvement plans or strategies already in place in Ontario hospitals.

Defnition o Quality

The preamble to the ECFAA denes a high quality health care system in this way: accessible, appropriate,

eective, ecient, equitable, integrated, patient centred, population health ocused, and sae.

The Ministry o Health and Long-Term Care, through the Excellent Care or All Strategy are committed to leveragingall nine o these attributes to advance quality initiatives across the province. In the all 2010, a working group was

ormed to provide advice to the Ontario Ministry o Health and Long-Term Care around the design o QIPs. The

consensus was that while all nine attributes are valuable, the QIP should specically ocus on our o them or

streamlined provincial and public reporting:

1. Sae

2. Eective

3. Accessible

4. Patient Centred

Process Guidance

The QIP Short Form has been developed as a sample template Quality Improvement Plan to assist organizations

with their quality improvement eorts while meeting the legislative requirements under the ECFAA. The QIP Short

Form is a word document with an accompanying excel document that should be completed to show improvement

targets and initiatives. Hospitals need to complete the ollowing sections with any relevant inormation rom their

Quality Improvement Plans and submit to the OHQC (by emailing [email protected]) to ensure compliance with the

section 8(5) o ECFAA1:

1. Overview o Our Hospitals Quality Improvement Plan (Part A)

g This section is a brie description o an organizations QIP. It is divided into our areas:

Overview:Ageneralstatementthatdescribestheorganizationsplanforthecomingyear.

Focus: A description of the objectives measures and initiatives that have been identied to


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2. Our Improvement Targets and Initiatives (Part B)

g The Improvement Targets and Initiatives Spreadsheet is an excel le that should be completed to show the

improvement targets and initiatives that are part o the QIP. g This section o the QIP has been designed to align with the Model or Improvement,2 with three essential

questions driving the improvement process:

Whatarewetryingtoaccomplish?AIM

Howdoweknowthatachangeisanimprovement?-MEASURE

Whatchangescanwemakethatwillresultintheimprovementsweseek?CHANGE

g The excel le also contains a supporting read-me sheet that has been developed to provide more detailed

inormation to help organizations complete the section.

3. The Link to Perormance-based Compensation o Our Executives (Part C)

g As required by the Legislation, organizations need to provide inormation concerning the manner in and

extent to which executive compensation is linked to the achievement o perormance improvement targets.

This section gives an overview o how this can be done.

4. Accountability Sign-o (Part D)

g This section ensures that all legislative requirements have been considered in the development o the QIP.

Roles & Responsibilities or the Quality Improvement Plan

Ontario Health Quality Council:

In an era o transparency and accountability, members o the public are increasingly well-inormed and interested

in the status o their health system. The OHQC was established to report to the public on the quality o health care

in the province and support its improvement.

With the passing o the ECFAA, the OHQC remains committed to monitoring and reporting to the people o

Ontario. Starting in 2010, every hospital is required, under the Act, to provide a copy o its annual QIP to the

OHQC in a ormat established by the Council that permits province-wide comparison o, and reporting on,a minimum set o quality indicators.

Ministry o Health and Long-Term Care

Improving the quality and value o the health care received by Ontarians is one o the Ministry o Health and

Long-Term Cares priorities and a main goal o this legislation. The ECFAA supports this priority by strengthening

the health care sectors organizational ocus and accountability to deliver high quality patient care. The Ministry o

Health and Long-Term Care established an implementation working group to assist Ontario organizations in their

eorts to comply with the ECFAA. The ECFAA Implementation Working Group (ECFAA IWG) supports, guides,

acilitates and coordinates implementation o the ECFAA and its regulations, as well as related quality initiatives,as detailed in its terms o reerence. The working group consists o representatives rom the Ministry o Health and

Long-Term Care, the OHQC, OHA, LHINs, and hospitals across Ontario, and has led the process o developing

the QIP template.

Local Health Integration Networks:

Health care organizations may be asked to provide their LHINs with a drat o their annual QIP or review beore
http://www.health.gov.on.ca/en/ms/ecfa/pro/docs/tor_ecfaa_iwg.pdfhttp://www.health.gov.on.ca/en/ms/ecfa/pro/docs/tor_ecfaa_iwg.pdf


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across organizations within their geographic area to identiy, share and support the advancement o system-level

strategies where a larger system-wide perspective may be appropriate (e.g. transitions o care).

The PublicThe Act requires that every year, health care organizations make their QIP available to the public. Inormation on

how to make the QIP available to the public is described below.

Responsibilities within the hospital

The diagram below shows the various responsibilities within the hospital and how they may contribute to the

development o a QIP.

Hospital Board

Because the board is accountable or hospital governance, the Chair o the hospital board is encouraged to certiy

(via accountability sign-o section o the QIP) that it ullls the requirements o the ECFAA.

Hospital Quality Committee

The Quality Committee is required, under the ECFAA, to oversee the preparation o the annual QIP. In addition to

this oversight role, Quality Committees may be engaged by their organizations to provide regular (i.e. quarterly)

updates on the status o the QIP, the planned initiatives, and progress. The Chair o the Quality Committee isencouraged to certiy (via accountability sign-o section) that the organizations QIP ullls the requirements o

the ECFAA. Please see ontario.ca/excellentcare or more inormation on the role o the quality committee, and its

relationship with the Medical Advisory Committee.

Chie Executive Ofcer/ Hospital Administrator

The Chie Executive Ocer/Hospital Administrator is an integral member o the Quality Committee and it is
http://www.ontario.ca/excellentcarehttp://www.ontario.ca/excellentcare


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Development and Submission Process:

The ECFAA denes an organization as a hospital within the meaning o the Public Hospitals Act and as a result,

multi-site organizations need only submit one plan or the corporation.

Organizations with existing Quality Improvement Plans

Organizations with existing QIPs are encouraged to use these plans to populate the QIP Short Form. The short

orm consists o a word document and an accompanying excel le. Once completed, both les must be submitted

to the OHQC by April 1, 2011 by emailing [email protected].

Organizations without existing Quality Improvement Plans:

For organizations without existing plans, the QIP Short Form has been designed as a sample template based on

leading practice to help them meet their legislative requirements, and also to use or internal quality improvementactivities. The short orm consists o a word document and an accompanying excel le. Once completed, both les

must be submitted to the OHQC by April 1, 2011 by emailing [email protected].

In both cases, the ollowing diagram illustrates the recommended QIP development and submission process:
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Reporting to the OHQC:

On or beore April 1, 2011, every organization must submit the completed QIP Short Form (word document and

excel le) to the OHQC by emailing [email protected]. The OHQC will then start a review process to aid in comparative

analysis over the 2011/12 scal year.

Public Posting:

Every scal year, organizations are required to make their QIP available to the public. The 2011/12 QIP must be

available to the public by April 1, 2011. Hospitals should post the ull QIP Short Form (both the word document and

the accompanying excel spreadsheet) on their website. They may also include other related documents i they wish.

C. Content GuidancePart A: Overview o Our Hospitals Quality Improvement Plan

This section is a brie description o an organizations QIP. It provides a ramework or the organization to express

what its quality improvement aims, objectives and initiatives are or the next year. The narrative should be short

(2 pages maximum) and easy to ollow. For more inormation, please see Appendix D.

Part B: Our Improvement Targets and Initiatives

The Improvement Targets and Initiatives Spreadsheet http://www.health.gov.on.ca/en/ms/eca/pro/updates/

qualityimprov/qip_spreadsheet.xls is an excel le that should be completed to show the improvement targets and

initiatives that are part o the QIP. It has been designed with:

g Flexibility or organizations to add hospital-specic and regional priority areas and measures; and g A core set o indicators to permit province-wide comparison and reporting.

Please remember to include this spreadsheet as part o the QIP Short Form package or submission to the OHQC

([email protected]), and post this material publicly.

1.Columns

The columns o the QIP Short Form are described below. There are three sections:

AIM (columns A-B) - What are we trying to accomplish

Quality dimension The template has been organized into our quality dimensions or ease o use and streamlined

provincial and public reporting: Sae, Eective, Accessible, and

Patient-Centred.

Objective This is the objective o the improvement initiative. For examples o eective aim statements, visit:

http://www.ohqc.ca/en/defning_project.php
mailto:[email protected]://www.health.gov.on.ca/en/ms/ecfa/pro/updates/qualityimprov/qip_spreadsheet.xlshttp://www.health.gov.on.ca/en/ms/ecfa/pro/updates/qualityimprov/qip_spreadsheet.xlshttp://www.ohqc.ca/en/defining_project.phphttp://www.ohqc.ca/en/defining_project.phphttp://www.health.gov.on.ca/en/ms/ecfa/pro/updates/qualityimprov/qip_spreadsheet.xlshttp://www.health.gov.on.ca/en/ms/ecfa/pro/updates/qualityimprov/qip_spreadsheet.xlsmailto:[email protected]


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MEASURE (columns C-F): How will we know that change is an improvement

Outcome

Measure(s)/Indicator(s)

This column has been pre-populated with the core set o recommended indicators

(seeAppendix B).

It is recommended that additional indicators be added or each o the quality dimensions (by

adding rows to the table) to address organizational priorities. For examples o other measures to

add, seeAppendix C.

Current Perormance What is the organizations current perormance data or rate associated with the outcome

measure? For the core indicators, a specifc timerame is indicated.

Perormance Goal 2011/12 This column should indicate the outcome the organization expects to achieve by the end

o the year.

Priority Though it is implied that all o the objectives defned within the QIP are organizational priorities,

the priority level urther refnes the importance o key indicators.

The change section, describing the organizations high-level improvement plan, is only

required or high priority indicators (indicated as Priority 1). It is recommended that indicators be

prioritized based on the ollowing 3 criteria.

1 highest priority:

current performance below benchmark (if one exists) or below long term goal; signicant

improvements required or improvement initiatives underway.

aligned with organizational priorities/strategic plan

dened accreditation priority or recommendation

funding tied to initiative

aligned with government agenda

2- moderate priority:

current performance just below benchmark (if one exists) or below long term goal; room for

improvement

aligned with organizational priorities/strategic plan

dened accreditation priority or recommendation

funding tied to initiative

aligned with government agenda

3- lower priority:

current performance at/above benchmark, provincial rate or long term goal

organizational priority


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CHANGE (columns G-K): What changes can we make that will result in improvement?

Note: this section is only to be completed for indicators that have been assigned as Priority 1 (column F)

2. Rows

A number o recommended core indicators within each o the our quality areas have been identied to permit

province-wide comparison o and reporting by the OHQC.

1. Saety (hospitals are requested to choose at least one): CDI, VAP, Hand Hygiene, CLI, Pressure ulcers, alls

2. Eectiveness: HSMR, Readmission, ALC, Total Margin3. Access: ER wait times

4. Patient Satisaction: Patients who would recommend the hospital to others

These core indicators (seeAppendix B or more inormation) were identied based on the ollowing principles: g Compliance with the ECFAA

g General applicability across sector g Supports standardization

g Strategically aligned and ocused

g Easily understood by the public g Flexible enough to accommodate hospital-specic priorities

g Simple and brie

Some o the core indicators listed may require a system-level approach beore real improvements can be made

(e.g. reducing ALC days is partly dependent on long-term care and home care). However, wherever possible,

hospital-level change activities should be identied so that progress can be achieved in improving the perormance

Improvement initiative The Improvement initiative column provides details about the quality improvement initiative

(i.e. the changes) being put in place that will lead to the improvement

being sought.

Depending on the priority level assigned, objectives may not have detailed improvement

initiatives listed or all indicators. At a minimum however, organizations are to complete the

change section or all Priority 1 indicators.

Methods and results

tracking

This column identifes how the organization will be tracking its success on process measures

related to the indicators tied to the QIP. There should be a general statement included on what

the organization is doing to track its improvement, as well as more specifc data or targets related

to the high level improvement plan.Target or 2011/12 This is the organizations target or 2011/2012. In some cases, the target will be the same as the

value established in the Performance goal column. In other cases, targets can be set based

on the processes/initiatives laid out in the Improvement initiative column. Organizations should

aim to review their existing data over time to set reasonable and appropriate targets.

For more inormation about setting targets, reer toAppendix A

Target Justifcation As described in the legislation, organizations are required to justiy their annual perormance

improvement targets. This can include explaining whether the target is based on research

literature, best practice, provincial or other defned benchmarks, scientifc evidence, or an

internal organizational targeting exercise.

Comments This is the place or any additional comments about the initiative. These may include

success actors or additional inormation which may assist the OHQC in understanding the

improvement objective.


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Not all o the core indicators are relevant to all hospitals. For example, or hospitals that do not meet the reporting

threshold or HSMR, this indicator should not be completed. Similarly, hospitals that do not treat complex

continuing care patients do not need to complete the indicators or pressure ulcers. Other indicators may

not be relevant to some hospitals at this time, but over the next two years will become increasingly important(such as data rom patient and employee surveys). It is recommended that wherever possible, hospitals add similar

indicators to the ones listed that are relevant to their patient populations.

In addition to the core indicators (seeAppendix B or more inormation), organizations should identiy other priority

indicators within each o the our quality dimensions to include in their QIP. Equity is another key attribute o quality,

and although it is not explicitly reerenced in the QIP Short Form, hospitals are encouraged to incorporate

it in their QIP as a strategy or improvement. Suggestions can be ound in Appendix C.

Part C: The Link to Perormance-based Compensation o Our Executives

ECFAA requires that the compensation o the CEO and other executives be linked to the achievement o

perormance improvement targets laid out in the QIP. As executive compensation is to be tied to the QIP,

organizations are expected to include a perormance based compensation component o the QIP or the scal

year beginning April 1, 2011.

Organizations need to ensure that compensation or the ollowing executives is linked to the organizations

achievement o the targets set out in their annual QIPs:

g

CEO (Administrator) g Chie o Sta

g Chie Nursing Executive g Senior Management reporting directly to CEO (or person with position equivalent to CEO)

The QIP Short Form (Part C) requires organizations to identiy the manner in and extent to which executive

compensation is linked to perormance. The legislation and regulations do not include specifc

requirements regarding the percentage o salary that should be subject to perormance-based

compensation, the number o targets that should be tied to executive compensation, weighting o

these targets, or what the targets should be. These are decisions that should be made by the organizations

Board o Directors and senior management team.

For more inormation about perormance-based compensation, reer toAppendix E or the update on Perormance

based compensation at Ontario.ca/excellentcare.
http://www.ontario.ca/excellentcarehttp://www.ontario.ca/excellentcare


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Part D: Accountability Sign-o

The QIP Short Form includes a section to allow or accountability sign-o (rom the Board Chair, Quality Committee

Chair and CEO). This will assist organizations in ensuring that their legislative obligations under the ECFAA havebeen considered during the development o the QIP. While this is not a legal requirement under ECFAA, it is

recommended as a best practice. More specically, the Board Chair and Quality Committee Chair are asked to

certiy that the QIP has been inormed in part by:

A. The patient relations process;

B. Patient and employee/provider surveys3;

C. Aggregated critical incident data; and

D. Inormation concerning indicators o the quality o health care provided by the organization pursuant to

regulations made under the Public Hospitals Act.

The sign-o also certies that the QIP contains:

g Annual perormance improvement targets;

g Target justications; and

g Inormation concerning the manner in and extent to which executive compensation is linked to the

achievement o the targets.

As well, the sign-o certies that the QI plan was reviewed as part o the planning submission process and is

aligned with the organizations operational planning.


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Appendix A: Quality Improvement 101

Quality improvement is a structured organizational process or planning and executing a continuous fow oimprovements to provide quality health care that meets or exceeds expectations.4 Since change/improvement is

not always easy to implement, it is important or organizations to identiy and prioritize the initiatives that will be

most likely to demonstrate the most visible improvements.

Over time, organizations invested in quality improvement work have applied a variety o quality improvement

approaches, such as Lean, Six Sigma, etc. One very practical and well-established ramework to assist

organizations with their quality improvement eorts is the Model or Improvement, developed by Associates

or Process Improvement.5

The QIP Short Form developed under the ECFAA has been designed to align with the Model or Improvement6

with three essential questions driving the improvement process:

1. SETTING AIMS: What are we trying to accomplish?

g QI projects should have a clear aim statement that lets the entire organization know what the organization

is setting out to do.

g The aim statement should have a specic measurable target and a clear time-rame or completion. g The aim statement should describe the target patient population and be relevant to them; in other words,

it should be clear how they will be better o as a result o the improvement. g The aim statement should be aggressive enough to enable meaningul change, but at the same time attainable. g The SMART mnemonic summarizes these desired characteristics o an excellent aim statement:

2. ESTABLISHING MEASURES: How will we know that change is an improvement?

g Identiy measures that demonstrate whether a specic change led to an improvement.

g Use both qualitative and quantitative measures as well as a mix o outcome measures (patient perspective)

and process measures (systems perspective).

A measure, or indicator, can be dened as7:

A. An assessment o a particular health care process or outcome;B. A quantitative measure that can be used to monitor and evaluate the quality o important governance,

management, clinical, and support unctions that aect patient outcomes;

C. Measurement tools or screens, used as guides to monitor, evaluate, and improve the quality o patient care,

clinical support services, and organizational unctions that aect patient outcomes

S Specic

M Measurable/Meaningul

A Attainable

R Relevant/Results oriented

T Time-bound


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Outcome Indicators:

The voice o the patient. Outcome measures refect the eect o care processes on the health o patients/

population8. They represent the bottom line to the patient: am I happier, eeling better, or likelier to live longer

asaresultofthecarebeingprovided?9

Process Indicators:

The voice o the system. Process indicators assess what the provider did or the patient and how well it was

done. Process indicators are especially useul when quality improvement is the goal o measurement. 10Process

measures check whether or not some process or activity which has been shown to have a positive impact on

outcomes is actually being done. Health care providers are particularly interested in processes because they

answer the question: am I doing all the things Im supposed to be doing to improve health or my patients.11

Both types o indicators are equally important since elements o the process o care do not signiy quality untilthey are validated by demonstrating their relationship to desirable outcomes. (Mainz)

3. SELECTING CHANGES: What changes can we make that will result in improvement?

Organizations can select rom a wide variety o dierent ideas or improvement identied in the literature or by

quality improvement organizations. The OHQCs Quality Monitor report contains ideas or improvement and best

practice stories or all o the core indicators in the plan as well as many other areas. Organizations can also consult

the saerhealthcarenow.ca website or ideas.

g

Not all changes result in improvement, and not all ideas rom other hospitals can be adapted to local settings.It is important or organizations to rst understand the root causes o quality problems in their own setting,

and then tailor their strategies to address those causes. This will help organizations to prioritize and identiy

the types o activities/changes most likely to result in signicant improvement.

4. TARGET SETTING

Organizations are ree to set whichever targets they wish. Dierent hospitals will have dierent priorities, and

local actors will also infuence the targets that are set. The ollowing are ideas and suggestions to help guide

this process.

A.VAP and CLI: evidence suggests zero is possible. Many hospitals have already attained this threshold (or

example, most ICUs in Michigan under a state-wide initiative). Organizations already at zero or approaching zero

may wish to set a target o zero. Organizations which are signicantly above the average may wish to consider

an interim target o decreasing the rate by hal in 2011/12, and then eliminating them by 2012/13.

B. HSMR: it would not be prudent to suggest a numeric target because the measure was designed to help a

hospital compare itsel against a previous baseline, rather than to compare between dierent hospitals. Instead,

hospitals may wish to consider targets that constitute improvement compared to previous results. Consider

aiming or a 5 to 10 point decrease compared to the baseline year (2009/10). Organizations with HSMRs

currently over 100 may wish to consider targets at the aggressive end o this range. Many hospitals in Ontariohave achieved improvements o this magnitude in the past, and some have done even better. Note that some

hospitals HSMR may have increased in 2009/10 compared to previous years; in such instances, a hospital may

wish to consider a target based on improving on its previous best year.


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We caution that the uncertainty and variability around a hospitals HSMR in any given year is typically large (or

Ontario hospitals, there is a typical range o 5 to 12). This means that the HSMR could drop by ve points by

pure chance even i no improvements took place. It may take more than one year beore a statistically signicant

improvement can be detected. Thus, i an organization wants to report a target o a ve point reduction or thecoming scal year (2011/12), it may want to state in the verbal section that this goal is part o a longer-term plan

or reduction (e.g. 15 points over three years), where the statistical signicance o the larger reduction can more

likely be conrmed.

C. Total Margin: The ideal or this indicator is 0% - in other words, revenue equals expenses in a given year

(excluding the impact o acility amortization). Hospitals are encouraged to describe, in their change ideas,

clinically ocused strategies that both improve quality and contain or reduce costs in order to maintain a

balanced budget. See Appendix C or examples.

D. ED wait time: Two options have been provided below. Hospitals may develop change plans or either o these

indicators, depending on local priorities. Depending on local actors, current perormance and the extent to

which important ideas or improvement have yet to be implemented, hospitals may wish to choose any o the

ollowing guidelines in setting targets or the next year:

g Aim to match those with current best results g Aim to match provincial average, i signicantly ar rom average

g Aim or a rate o reduction comparable to the province-wide annual reduction in this indicator

E. Patient experience: The current provincial average or patients denitely recommending the hospital to riends

and amily is 74%. Leaders in North America have attained rates o in the 85-90% range.12


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Appendix B: Indicator defnitions and technicalinormation

The ollowing recommended core indicators are included in the QIP Short Form.

Quality dimension Core Indicators Defnitions Technical Inormation

Saety There are many dierent aspects o patient saety in hospitals, including hospital acquired inections,missed diagnoses, medication errors, avoidable surgical complications or errors, avoidablethromboembolisms, and avoidable injuries. At present there is no single big dot indicator in Ontariothat encapsulates all o these dierent aspects o saety. We recommend that organizations include intheir QIPs at least one indicator rom the ollowing list o standardized indicators. Hospitals may choosemore than one o these indicators:

Clostridium Difcile Inection(CDI):

CDI rate/1,000 patient days

(January December 2010))

CDI rates are determined bythe number o patients newlydiagnosed with hospital-acquired CDI, divided by thenumber o patient days in thatmonth, multiplied by 1,000.Patient days are the number odays spent in a hospital or allpatients.

See http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_o_clostridium_difcile_inections.pd

To calculate baseline or 2010,take the average o the monthlyrates reported rom January2010 to December 2010 (seePatient Saety Indicatorswebsite)

Ventilator Associated Pneumonia(VAP)

VAP/1,000 ventilator days

(January December 2010)

VAP rates are determined by thetotal number o newly diagnosed

VAP cases in the ICU ater atleast 48 hours o mechanicalventilation, divided by thenumber o ventilator days inthat reporting period, multipliedby 1,000. Ventilator days arethe number o days spent on aventilator or all patients in theICU 18 years and older.

See http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_o_ventilator_associated_pneumonia.pd

To calculate baseline or 2010,take the average o the quarterlyrates reported rom January2010 to December 2010 (seePatient Saety Indicatorswebsite)

Hand Hygiene compliancebeore patient contact

(2009-2010 data as o April 30,2010)

The number o times that handhygiene was perormed beoreinitial patient/patient environmentcontact divided by the numbero observed hand hygieneindications or beore initialpatient/patient environmentcontact multiplied by 100.

See Patient Saety Indicatorswebsite

Central Line Associated BloodStream Inection (CLI)

CLI//1,000 central line days

(January December 2010)

CLI rates are determined by thetotal number o newly diagnosedCLI cases in the ICU ater at

least 48 hours o being placedon a central line, divided by thenumber o central line days inthat reporting period, multipliedby 1,000. Central line days arethe number o days spent on acentral line or all patients in theICU 18 years and older.

To calculate baseline or 2010,take the average o the quarterlyrates reported rom January

2010 to December 2010(see Patient Saety Indicatorswebsite)
http://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_ventilator_associated_pneumonia.pdfhttp://www.health.gov.on.ca/patient_safety/public/ps_pub.htmlhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/cases_of_clostridium_difficile_infections.pdf


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Falls

(CCRS, FY 2009/10)

Percentage o complexcontinuing care residents who do

not have a recent prior history oalling, but ell in the last 90 days

Eectiveness

Hospital StandardizedMortality Ratio (HSMR)13

(2009-2010 data as oDecember 2010)

Number o observed deathsdivided by the number oexpected deaths, multiplied by100 and based on diagnosisgroups that account or 80% oall deaths in acute care hospitalsand adjusted or other actors

aecting mortality, such as age,sex, and length o stay

30 day readmission rate toany acility (specifc Case MixGroups)

(Q1 2010/11)

Readmission within 30 days orselected CMGs to any acility

Consistent with H-SAA reporting.

This data will be providedto hospitals via FIM inmid-February

% ALC days

(DAD, CIHI)

(Q2 2010/11)

Total number o inpatient daysdesignated as ALC, divided bythe total number o inpatientdays


See http://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_o_care_days.

pd. It is requested that hospitalsprovide the methodology orcalculating this indicator tothe OHQC when the QIP issubmitted.

Hospital - Total Margin(OHRS)14

(Q3 2010/11)

Percentage by which totalcorporate (consolidated)revenues exceed or all shorto total corporate (consolidated)expense, excluding the impacto acility amortization, in a

given year


See:

http://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pd

Access Two options have been provided below. Hospitals may develop change plans or either o theseindicators, depending on local priorities.

90th percentile ER Length oStay or Admitted Patients

(NACRS, CIHI)

(Q3 2010/11)

90th Percentile ER length ostay or Admitted patients (ERlength o stay is defned as thetime rom triage to registration,whichever comes frst, to thetime the patient leaves the ER.)


See http://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_or_admitted_patients.pd

90th percentile ER length o

Stay or Complex Conditions

(NACRS, CIHI)

(Q3 2010/11)

90th percentile ER Length o

Stay or Complex conditions/requiring more time ordiagnosis, treatment or hospitalbed admission (Reers to themaximum amount o time 9 outo 10 patients with complexconditions requiring more time ordiagnosis, treatment or hospitalb d d i i t ithi th

Consistent with public reporting.

Seehttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_or_complex_patients.pd

and

http://www.health.gov.on.ca/en/public/programs/waittimes/edrs/deault.aspx

http://www.health.gov.on.ca/en/

public/programs/waittimes/edrs/

default.aspx
http://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_for_admitted_patients.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_for_admitted_patients.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_for_admitted_patients.pdfhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/edrs/default.aspxhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_for_admitted_patients.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_for_admitted_patients.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/er_los_for_admitted_patients.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/hospital_total_margin.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdfhttp://www.health.gov.on.ca/en/pro/programs/ris/docs/alternate_level_of_care_days.pdf


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Patient Centred

Patient satisaction indicator Please choose the question thatis relevant to your hospital:

NRC Picker / HCAPHS: Wouldyou recommend this hospital toyour friends and family?

In-house survey: provide thepercentage response to asummary question such asthe Willingness of patientsto recommend the hospital tofriends or family

Most hospitals use NRC Pickeror both hospital in-patients andemergency department (ED)patients. Hospitals may chooseto select the in-patient version othe indicator, ED version o theindicator, or both indicators intheir plan, depending on wherethey see the greatest areas orimprovement. Hospitals thatdo not treat these patients canuse patient satisaction datarom other patient care areas asapplicable.

Numerator: # o respondentswho responded Denitely Yes(HCAHPS) or yes, denitely(NRC Picker)

Denominator: # o respondentswho registered any responseto this question (no not includenon-respondents)

Please list the question and therange o possible responseswhen you return the QIP.

For both options, take theaverage across all surveyresponses collected romthe most recent consecutive12-month period (or mosthospitals, this will be Oct 2009to Sept 2010).

I hospitals do not currentlyinclude this question in theirpatient satisaction survey, it isrecommended that it be included

in uture surveys.


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Appendix C: Examples o other indicators to include inthe QIP

In addition to the core indicators set out above, organizations should identiy other priority indicators to include

in this plan. Dierent hospitals will have dierent priorities, and their QIPs and targets should refect this variation.

Below are some suggestions:

SAFETY

1) Critical Incidents

Organizations need to review the aggregated critical incident data when developing the QIP. Based on regulations

under the Public Hospital Act, the Quality Committee will receive aggregated critical incident data (rom the

administrator) at least twice per year, with data about all critical incidents occurring at the hospitals. For ease

o reporting and interpretation, organizations may wish to aggregate critical incident data by incident types (i.e.

medication, surgical process, clinical administration, medical device etc.) to identiy the specic ocus/area or

improvements within the QIP. For more inormation, including guidelines or critical incident reporting, please see

the latest update on critical incident reporting.

For example, i a large proportion o the organizations aggregated critical incident data is medication-related

incidents, a hospital may identiy a medication saety improvement initiative and indicator (i.e. medication

reconciliation at transer) within its QIP. However, i upon analysis it appears that a large proportion o all incidents

relate to documentation and/or communication ailures, organizations may identiy objectives and indicators tomake improvements in these related processes.

2) Required Organizational Practices

High priority action items and Required Organizational Practices highlighted through the accreditation process may

also be worthwhile addressing and including within the QIP. The list below are just a ew examples:

A. Suicide prevention

B. VTE prevention

C. Medication Reconciliation

3) Hospital Acquired Inections (HAI)

Although hospitals have been reporting publicly on a number o hospital acquired inections, not all o these

indicators are part o the core set in the template. However, improvement initiatives may be underway or other

indicators (i.e. MRSA, VRE), and hospitals may consider including these as well.

4) Saety Culture

The ECFAA requires organizations to consider results rom the employee/service provider surveys in the

development o their QIPs. Organizations are encouraged to include survey data (including data relating to

employee/service provider saety) as well.

EFFECTIVENESS

1. Total margin: Hospitals are encouraged to describe, in their change ideas, clinically ocused strategies that both

improve quality and contain or reduce costs in order to maintain a balanced budget. This could include:

g Measuring and reducing inappropriate hospitalizations. Many hospitals use tools like MedWorxx or Interqual to

it d i i hi h d t t it i it th d i i
http://www.health.gov.on.ca/en/ms/ecfa/pro/updates/criticalincident/update.aspxhttp://www.accreditation.ca/accreditation-programs/qmentum/required-organizational-practices/http://www.accreditation.ca/accreditation-programs/qmentum/required-organizational-practices/http://www.health.gov.on.ca/en/ms/ecfa/pro/updates/criticalincident/update.aspx


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2. Employee and Physician surveys: As stated above, the ECFAA requires organizations to consider results

rom the employee/service provider surveys in the development o their QIPs. Where possible, organizations are

encouraged to include survey data in the QIP.

3. Compliance with best practice guidelines:

A. Percentage o patients discharged or acute coronary syndrome compliant with all (16) best practice

guidelines. (Approximately 20 hospitals are already reporting this inormation internally, using the Guidelines

Applied in Practice (GAP) tool in collaboration with Ottawa Heart Institute).

B. Percentage o patients with other conditions discharged with guideline-recommended drugs and tests.

4. Sepsis mortality rate: Eective early recognition, screening, timely antibiotics and control o blood pressure

and blood sugar can reduce this major cause o mortality.

5. Prophylaxis or Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE): Percentage o surgicalpatients with DVT or PE, or percentage o eligible patients who receive adequate prophylaxis or these conditions.

This is one o the major causes o avoidable mortality and morbidity in hospitals.

ACCESS

1. Wait times: In addition to Emergency room wait times, organizations could include other indicators rom

Ontarios Wait time strategy, such as wait times or surgery, CT or MRI. Hospitals can choose specic procedures

o interest, and can use either 90th percentile overall wait time, or percentage o patients who meet the target wait

time or their priority category. Both are ound on the Ministrys public reporting website and both are acceptable.

However, the OHQC notes that the latter has one particular advantage: it highlights the problem that or mostsurgical procedures, high priority patients are ar less likely to have their surgery done within the target time rame

than those at lower priority. For example, the percentage o priority 2 cases done within the target time is 60% or

cancer, 45% or neurosurgery and 68% or orthopaedics. Use o overall 90th percentile wait time tends to obscure

this problem altogether.

2. Equity: Equity is a key attribute o quality, and although it is not explicitly reerenced in the QIP Short Form,

hospitals are encouraged to incorporate it in their QIP as a strategy or improvement. For many hospitals, the

ability to improve in a particular area may depend on how well services are tailored to more vulnerable groups or

those with special needs (e.g. low income, low education or those with language barriers). Oten, the room orimprovement in patient care is greatest or these groups. For example, a hospital may aim to reduce readmissions

or selected conditions by 10% overall, but also aim to reduce readmissions by 15% or those who reside in

certain low-income neighbourhoods or those with no xed address. Change ideas include simplied patient

teaching materials or those with low literacy, improved access to translators, early case management to address

the individuals more complex non-medical needs, and ensuring access to more intensive support services in the

home (e.g. homemaking) or those who are socially isolated.

PATIENT-CENTREDNESS

1. Patient Experience: Organizations need to review the results rom the patient/caregiver surveys in thedevelopment o their QIP. Organizations should review this data to identiy i there are areas or improvement that

should be included in their QIP. More detailed indicators that could be added include:

A. Percentage response on any individual question o particular concern to a hospital

B. Percentage o patients who received all the inormation they needed when they let hospital/ED

For more inormation on patient surveys please see ontario ca/excellentcare
http://www.health.gov.on.ca/en/public/programs/waittimes/surgery/default.aspxhttp://www.health.gov.on.ca/en/ms/ecfa/pro/updates/patientsurvey/update.aspxhttp://www.ontario.ca/excellentcarehttp://www.ontario.ca/excellentcarehttp://www.health.gov.on.ca/en/ms/ecfa/pro/updates/patientsurvey/update.aspxhttp://www.health.gov.on.ca/en/public/programs/waittimes/surgery/default.aspx


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2. Patient Relations Process: Organizations need to review data relating to the patient relations process in the

development o their QIP. Organizations should review this data to identiy i there are areas or improvement that

should be included in their QIP. Possible indicators or the patient relations process that could be included are:

g Number o pre-emptive calls g Number o inquiries, supports, suggestions, comments received rom patients, sta and physicians

g Number o complaints/compliments g Number o patients expressing concerns divided by number o surveys received in a particular quarter (per

cent o patients reporting a negative comment) g Distribution o complaints in pre-dened categories

g Method o complaints (telephone, letter, in-person, email, etc.)

g Source o complaints (inpatient versus outpatient)

g Severity o complaints

g Resolution time

Further inormation on the Patient Relations Process will be provided in winter 2011.

3. Other indicators o patient-centredness: Some common areas where patient experience scores indicate that

problems may exist include: g Pain control

g Responsiveness (e.g. response to a call bell) g Communication

g The percentage o patients who get all the inormation they need when they leave. Patients must answer

positively on a ull series o questions in order to have counted as having all inormation needed. The provincial

average or this indicator is around 25% and improvements in this indicator could help reduce readmissions

and adverse events ater discharge.


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Appendix D: Guidance on designing Overview o OurHospitals Quality Improvement Plan (Part A)

Quality Improvement Plans should be seen as a tool that communicates a structured ormat and common

language that ocuses organizations on change. The change plans that result rom a QIP are the most critical

element o a quality improvement initiative. The QIP should guide the design o change plans and acilitate dialogue

to support continuous quality improvement processes.

This section is a brie description o an organizations QIP and provides organizations with a ramework to express

what their quality improvement aims, objectives and initiatives are or the coming year. The narrative should be

brie (2 pages maximum) and easy to ollow. To help organizations construct the narrative, a ramework has been

developed that has our sections: 1. Overview: A general statement that is inspiring and situates the objectives within the Vision, Mission and

Values o the organization.

2. Focus:A description o the objectives that have been identied to improve quality o services and care in the

hospital. This section describes the specic aims, measures and change ideas that orm the core o the plan.

Organizations should also indicate how resources will be used to ensure that the correct nancial levers are

in place to execute the activities listed in the QIP.

3. Alignment: An explanation o how this document links to the other planning documents developed by the

organization and key external partners such as the LHIN and CCACs.

4. Challenges, Risks and Mitigating Strategies: this section describes any existing risks that may threatenaccomplishment o the objectives and the mitigating strategies that have been identied to lower those risks.

The measurement challenges already identied in the materials within this package do not need to be re-

stated here.

1: Overview o our quality improvement plan or 2011-12

What is required in this section is a brie (100 word maximum) description o the quality goals or statements

that describe the organizations overall vision or quality in the next year. The overview should be written in plain

languageanddescribehowpatientswillnoticethattheirexperiencespecicallythecaretheyarereceivinghas

improved. An eort should be made to make this statement inspiring or sta and reassuring or the people youserve. Ideas include:

1. Patients with complex conditions will wait one hour less in our emergency department

2. We will reduce avoidable harm rom adverse events by one hal in our hospital in the next year

3. We will match the best results in Ontario or wait times in large hospitals.

2: Focus: What we will be ocusing on and how these objectives will be achieved

This section should describe the specic aims, measures and ideas or improvement that your organization will

put in place. They should be described in a plain English, with abbreviations or complex terms dened. When

describing ideas or improvement, go beyond generic statements about teamwork or consultation. Talk aboutspecic evidence-based organizational or clinical best practices or dierent models o care or care delivery that

the organization wants to implement, as well as any investments (in sta, sta training or technology) that support

those goals.


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3. Alignment: How the plan aligns with the other planning processes

It is important to situate the QIP as one component o the hospitals broad strategic aims and objectives. While

the QIP is a critical component o a hospitals strategic and operational planning, it does not in itsel communicate

everything the hospital is doing. Instead, it is one component o the hospitals overall planning. A high perormingorganization combines and integrates a strategic plan, a Hospital Service Accountability Agreement (H-SAA), and

the QIP. Organizations can also consider describing how the QIP aligns with accreditation, university-wide plans (or

academic centres) and LHIN-wide improvement plans, particularly in the areas o ED, ALC and readmissions. The

integration o these pieces helps ensure nancial responsibility, accountability to patients, and high quality care.

4: Challenges, Risks and Mitigating Strategies

This section highlights the things that need to happen or change to occur, and the challenges that may exist that

could prevent that change rom happening. It is a realistic view o what needs to be put in place or what needs

to be altered in order or success to be achieved. It also provides an opportunity to explain the use the hospitalmakes o its limited resources, and to demonstrate that that the QIP is part o or linked to the hospitals operating

plan and the H-SAA. Although the QIP does not include inormation related to nancial eciency, indicators or

total margin and current ratio are included in the H-SAA and it is recommended that hospitals provide links to this

inormation in the introductory section o the QIP (Part A - Narrative).


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Appendix E: Guidance on perormance basedcompensation

Excellent Care for All Act Guidance materials

Perormance Based Compensation and the Quality Improvement Plan

The ECFAA requires that the compensation o CEOs and other executives be linked to the achievement o

perormance improvement targets laid out in the quality improvement plan (QIP) o every health care organization

(beginning with hospitals) in Ontario. As executive compensation is to be tied to the QIP, organizations are

expected to include a perormance-based compensation component as part o the QIP or the scal year

beginning April 1, 2011.

A description o the manner in and extent to which executive compensation is tied to perormance must be included

in the QIP and available to the public. This can be described in the QIP in a number o ways. This document

is designed to assist organizations in describing the manner in and extent to which they are tying executive

compensation to targets set out in their QIPs. It does not describe best practices or developing perormance-based

compensation plans in general, as this is a larger undertaking that extends beyond the purview o ECFAA.

A regulation describing the denition o executive under ECFAAhas been led and came into eect

January 1, 2011.

Purpose o Perormance-based compensation:

The purpose o perormance-based compensation related to ECFAA is to drive accountability or the delivery o

quality improvement plans. Perormance-based compensation can help organizations to achieve both short and

long-term goals. By linking achievement o goals to compensation, organizations can increase the motivation to

achieve these. Perormance-based compensation will enable organizations to:

1. Drive perormance and improve quality

2. Establish clear perormance expectations

3. Create clarity about expected outcomes

4. Ensure consistency in the application o perormance incentives5. Drive transparency in the perormance incentive process

6. Drive accountability with respect to the delivery o the Quality Improvement Plan

7. Enable team work and a shared purpose

Organizational positions to which perormance-based compensation applies:

As per regulations, compensation or the ollowing executives should be linked to their organizations achievement

o quality improvement targets set out in their annual Quality Improvement Plans: g CEO (Administrator)

g Chie o Sta g Chie Nursing Executive

g Senior Management reporting directly to CEO (or person with position equivalent to CEO) ....

Organizations should clariy which individuals make up the senior management team. One way to do this is by

establishing ormal terms o reerence or the senior management team. This is important so that it is clear which

individuals are dened as executives with respect to perormance based compensation
http://www.e-laws.gov.on.ca/html/source/regs/english/2010/elaws_src_regs_r10444_e.htmhttp://www.health.gov.on.ca/en/ms/ecfa/pro/legislation/ecfa_notice.aspxhttp://www.health.gov.on.ca/en/ms/ecfa/pro/legislation/ecfa_notice.aspxhttp://www.e-laws.gov.on.ca/html/source/regs/english/2010/elaws_src_regs_r10444_e.htm


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Describing the manner and extent to which compensation is linked to perormance

The QIP Short Form (Part C) requires organizations to identiy the manner in and extent to which their executive

compensation is linked to perormance. The legislation and regulations do not include specic requirements

regarding the percentage o salary that should be subject to perormance-based compensation, the number otargets that should be tied to executive compensation, weighting o these targets, or what the targets should be.

The ollowing recommendations have been provided to guide organizations in completing this section

o the QIP:

1) Outcome vs. process: Executive compensation should be tied to outcome measures (or using quality

improvement vocabulary, Big Dot measures) that are directional and ocus on outcomes rather than process to

communicate the overall change being undertaken.

2) SMART: When setting perormance improvement targets, it is essential to establish S.M.A.R.T.(specic, measurable, achievable, relevant and time-bound) perormance objectives.

3) Focused: Each executives compensation should be tied to no more than 6-8 targets maximum. This

includes other targets (outside o the QIP) that may be part o a larger compensation plan15. I there are too many

objectives, it will be dicult or executives to ocus on all o them.

4) Meaningul: In order or a perormance-based compensation plan to be motivating, it generally should involve a

meaningul portion o the executives base salary. The amount determined depends on the organizations existing

circumstances. It should be based on industry-leading practices and should be determined by the Board.

5) Relevant: Organizations choose targets under the Annual Quality Improvement Plan to which executives have a

direct link. Perormance-based compensation is most eective when incumbents eel they have clear control over

outcomes. Organizations may choose to use dierent perormance targets or dierent executives to best align

targets with individual executives particular scope o work.

6) Gradual: Organizations introducing perormance-based compensation or the rst time should initially link

targets to realistic and achievable goals, while phasing in stretch targets16 over time. Phasing in higher levels o

perormance pay also enables Boards and plan participants to evaluate, modiy and become more comortable

with this type o compensation plan

7) Inclusive: Targets rom each o the strategic areas o the QIP (saety, eectiveness, access, and patient-centred)

should contribute to the perormance-based compensation plan to ensure accountability in all these areas15.

8) Range approach: Having a plan that recognizes dierent levels o perormance achievement (threshold, target

and maximum) allows or more aggressive target setting and helps articulate the objectives that need to be

achieved to receive perormance-based pay. This is in contrast to an all-or-nothing approach where individuals

are compensated only i targets are achieved.

9) Long-term and strategic: In order to encourage consistent behaviour throughout the organization, it isrecommended that organizations use their strategic plan as a starting point or setting perormance improvement

targets. This will ensure that executives are encouraged to achieve objectives that are aligned with the

organizations long-term strategic directions.


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10) Documented: Health care organizations should develop documentation17 that clearly articulates

the manner in and extent to which executive compensation is linked to the targets set out in the QIP.

Documentation should include:

g Explanations o how perormance targets were chosen g Individuals included in the perormance-based compensation plan

g The target size o perormance-based pay, as well as threshold and maximum payout levels

g The basic level o perormance that needs to be achieved in order or a payout to occur g Timing o payouts

g Description o the manner and extent to which compensation is linked to perormance g Any other relevant plan details.

11) Monitored over time: Organizations should monitor target-setting vs. actual payouts, to help determine

whether the incentive plan design was in act eective. I over a ew years executives are reaching maximum

perormance on all their quality improvement targets, this may signal that targets need to be re-calibrated

going orward.

Connection between ECFAA and the Public Sector Compensation Restraint Act

The Excellent Care or All Act (ECFAA) works in conjunction with the Public Sector Compensation Restraint to

Protect Public Services Act, 2010 which provides that the rate o pay in eect on March 24, 2010 or hospital

employees who do not bargain collectively cannot be increased until April 1, 2012, subject to certain exceptions.

Where an executive compensation plan does not provide or payment based on assessment o perormance,

hospitals must ensure that the executive compensation plan is modied to be compliant with the ECFAA. This

means that the payment o a portion o the executives existing compensation must be made contingent on the

achievement o the perormance improvement targets set out in the annual QIP, without increasing the actual or

potential compensation available to the executive on March 24, 2010.

Examples o linking compensation to the QIP

Under the ECFAA, organizations are required to ensure that the payment o compensation is linked to the

achievement o the perormance improvement targets set out in the QIP.

A description o the manner in and extent to which executive compensation is tied to perormance must be

included in the QIP and available to the public. This can be described in the QIP in a number o ways. The

examples below were derived by reviewing best practices in the eld. Hospitals are not limited to using the ormats

provided

Example 1: This example shows the percentage o salary at risk or each individual executive, and the particular

set o targets the individual is accountable or achieving.

CEOX%ofbasesalaryislinkedtoachievingthetargetssetourinourQIPonthebelowindicators

Chie o StaX%ofbasesalaryislinkedtoachievingthetargetssetourinourQIPonthefollowingindicators

Chie Nursing ExecutiveX%ofbasesalaryislinkedtoachieving100%ofthetargetssetourinourQIPonthe

ollowing indicators

Senior ManagementX%ofbasesalaryislinkedtoachieving100%ofthetargetssetourinourQIPonthe


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Indicators:

g ER Wait times

g Pressure ulcers

g

Patient Satisaction g 30-day readmission

The below Perormance allocation plan is used to determine the magnitude o the perormance allocation:

Perormance Allocation Plan

Example 2: This example shows the unique weighting o each target in the QIP. It also provides specic values

that must be reached to obtain the available incentive.

Foreachofourexecutives,X%ofcompensationislinkedtoachievementoftargetslaidoutintheQuality

Improvement Plan.

Progress against Quality and Saety Target % o available incentive Comments

Worse than previous year perormance and no special

considerations

0%

Worse than previous year perormance *with special

considerations

Up to 10% *E.g. H1N1, catastrophic ailure o

systems etc

Maintained previous year perormance **and special

considerations

Up to 20% **E.g. baseline aected by unusual

circumstances

Better than previous year perormance and not met target Up to 50%

Achieved Target Up to 100%


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The below Perormance allocation plan is used to determine the magnitude o the perormance allocation.

Quality

dimension

Objective Outcome

measure/indicator

Current

perormance

Target or

2011/12

Weighting % o available incentive

100% 66% 33% 0%

Saety Avoid new

pressure

ulcers

Percent o

complex

continuing care

residents with

new pressure

ulcer in the last

three months

(stage 2 orhigher)

State current

perormance

(rom Part B

o QIP Short

Form)

State Target

(rom Part B

o QIP Short

Form)

Show how

much each

indicator is

worth (sum

= 100%)

Insert

Target value

(perormance

score

required or

100% pay-

out)

Insert

perormance

score that

would result

in a 66%

pay-out

Insert

perormance

score that

would result

in a 33%

pay-out

Insert

perormance

score that

would result

in a 0% pay-

out

Eectiveness Reduce

unnecessary

hospital

readmission

Readmission

within 30 days

or selected

CMGs to any

LHIN

Access Reduce wait

times in ED

ED wait

times: 90th

percentile ER

length o stayor admitted

patients

Patient-

centred

Improve

patient

satisaction

% o patients

who would

defnitely

recommend

this hospital

to riends and

amily

It should be noted that the examples above are or demonstration purposes only and hospitals are not

limited to using any o the ormats provided.


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AIM MEASURE CHANGE

Objective Outcome Measure/ Indicator

Currentperormance

Perormancegoal 2011/12

Priority Improvementinitiative

Methodsand resultstracking

Target or2011/12

Targetjustifcation

Comments

Improveproviderhand hygiene

compliance

Hand hygienecompliance beorepatient contact: The

number o times thathand hygiene wasperormed beore initialpatient contact divided bythe number o observedhand hygiene indicationsor beore initial patientcontact multiplied by 100- 2009/10, consistent withpublicly reportable patientsaety data

65% 80% 1 monthlyeducationand training

sessions byprogram

audit to show80% o statrained

80% o handhygienechampions

trained

internaltargetingexercisedecided to aim

or getting hal-way towardslong-term goalthis year andattaining long-term goal in theollowing year

Completeinstallationo ABHRoutside allremainingpatient roomsand treatmentareas

environmentalreview toconfrminstallation

Positivedeviancetrainingor HHchampions

100%attendanceat training.75% sel-report usinga positivedeviancetechnique.

Encouragepatients toask providersi theyvewashedhands usingpamphlets,posters.

Surveypatientsto ask ithey werecomortabledoing so; aimor 50%

EXAMPLE

Appendix F: Example o completed row in QIP

Documents

Quality Improvement in a Hospital