Quality Improvement Plan (QIP) Narrative for Health Care ... · • Empowering the patient and family voice through technology and involvement The priorities in Runnymede’s Quality

Runnymede Healthcare Centre 1 625 Runnymede Road, Toronto, ON M6S 3A3

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

3/28/2017

This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.


Overview Runnymede Healthcare Centre (Runnymede) is pleased to share its seventh annual Quality Improvement Plan. This plan describes some of the hospital’s key priorities for quality improvement supporting our strategic plan of Vision 2020: Redefining Possible. This is Runnymede’s roadmap describing our vision to transform healthcare together and our mission to provide an exceptional patient experience by:

• Placing patients at the centre of their own care and decision-making • Driving innovation in rehabilitation and care for medically complex patients and • Continually raising the bar on quality and safety standards

Together, these have formed the basis for the key initiatives in our Quality Improvement Plan 2017/18, which outlines our commitment to quality, safety and patient experience. Dedication and focus on these important principles guide us in successfully attaining the targets for each of the six key improvement initiatives as outlined below. Our commitments to our patients and families are that: By March 31, 2018, we will be closer to achieving the aim of eliminating preventable harm caused by pressure injury and falls with harm by:

• Conducting regular skin integrity rounds with individualized patient assessments to strengthen care planning and education

• Engaging in international pressure ulcer prevalence survey to further inform pressure injury program • Improving communication and learning through implementation of patient safety huddles focusing on

falls and pressure injury. • Monitoring effectiveness of falls prevention strategies through semi-annual audits

By March 31, 2018, we will be closer to supporting an integrated and efficient health system by improving access and flow for complex continuing care and rehabilitation thereby reducing unnecessary time in acute care for patients with complex, chronic illness by:

• Implementing strategies aimed at reducing the number of long-stay Alternate level of Care (ALC) patients at Runnymede

• Engaging patients and families in discharge planning early in their inpatient stay • Providing important information to patients and families on programs and supports available in the

community to allow for better transition By March 31, 2018, we will be embracing the Patients First Act and putting people and patients first by improving their health care experience and their health outcomes by:

• Adopting a patient and family centred approach and input into quality improvement initiatives • Empowering the patient and family voice through technology and involvement

The priorities in Runnymede’s Quality Improvement Plan support the provision of high quality, patient-centred care. A complete description of these initiatives and how we will be successful can be found in the 2017/18 work plan.


QI Achievements From the Past Year Our achievements over previous Quality Improvement Plans have demonstrated on-going and incremental improvements year over year. These results emphasize Runnymede’s commitment to quality improvement and our drive for excellence in the provision of safe, high quality care. This past year is no exception as Runnymede met or exceeded targets in the following 2016/17 Quality Improvement Plan initiatives: Medication Reconciliation at Admission and at Discharge: Runnymede continues to a provincial leader in medication reconciliation. We sustained performance at theoretical best of completing medication reconciliation for 100 percent of the time when a patient is admitted to Runnymede and when preparing to be discharged. It is well documented that when patients transition from hospital to home, medication discrepancies have been linked to increased acute hospital re-admissions. As part of our process, the pharmacist meets with the patient and family to review any changes in the medication regimen since admission. By performing complete, accurate medication reconciliations involving the patients and families, the Runnymede pharmacists eliminate an important source of potential harm, reduce system pressure through re-admission avoidance and help the patient transition to all care destinations safely and be informed about their care. Reducing Clostridium difficile Infection Rate: In addition to exceeding our target, Runnymede had no C. difficile outbreaks in 2016/17. Our success can be attributed to the adherence to recommended guidelines to reduce C. difficile infections with improved consistency of care across clinicians. Also, to ensure consistency and accountability, an independent audit of cleaning conducted by the infection prevention and control team was also implemented with the results shared to enhance understanding and focus education topics. Lastly, a comprehensive education program about hand hygiene and use of personal protective equipment for families and visitors was a powerful tool to emphasize that everyone has a role in reducing healthcare associated infections. Reducing falls in complex continuing care patients: This indicator is a top priority at Runnymede evidenced by the fact that our performance not only exceeded the TC LHIN average but also, our own stretch goal. This was achieved through clinicians working with patients to build strength and stamina to reduce falls and help in a safe transition home upon discharge. We also conduct proactive patient assessments and implement universal falls prevention precautions while employing a patient-centred approach. With a falls rate of 3.1% for 2016/17, we strongly outperformed the average rate of 9.4% in the Toronto Central Local Health Integration Network (TC LHIN) and of 10.6% in the province. Enhancing the patient experience: As we strive to deliver excellent patient-centred care, we are particularly proud of the success of our Quality Counts Survey program. Within two weeks of admission, activation therapy staff conducts a face-to-face meeting with patients and families. It is an invaluable opportunity to receive real-time feedback while establishing a relationship of trust and responsiveness. Survey results are also shared with referral hospitals so that together, we can improve transitions of care between organizations again to improve the experience for all of our patients.


Population Health

As a leader in the provision of complex continuing care and rehabilitation, Runnymede understands its role and tailors resources and activities to improve the health of the population it serves. For example, patients frequently do not have a primary care clinician in their community. In these cases, we will work with local community health centres and clinics that are accepting patients to establish that linkage as well as arranging for the patients’ first visit following discharge. This is an important means to support the patient in their on-going health and well-being in the community while preventing hospital readmissions and emergency department visits in acute care. Chronic conditions such as, diabetes continue to be on the rise and Runnymede is addressing this trend through the development and work of its clinical nutrition team that are certified diabetes educators. This enables the Interprofessional team to critically assess patients with diabetes for optimal blood sugar control including other aspects of their care such as, medication management.

Equity

On an annual basis, a patient profile report is developed and reviewed to ensure that we continue to understand changing demographics of our patients. In addition, we complete the health equity survey in a face-to-face interaction with patients and families on admission. As a key dimension in providing quality care, the collection of data related to health equity enables and allows for informed decisions and actions to reduce inequities, and is an important provincial and LHIN level priority. We are proud to say that Runnymede is a leader in the TC LHIN for the collection of health equity data with a completion rate of over seventy percent. This information has been a catalyst in how we provide care and services. Two specific examples include the recent expansion of therapeutic diets to include halal and vegan choices but also finger food options to aid those with cognitive or physical impairments. To better assist patients who have limited socioeconomic resources, Runnymede has a dedicated staff member trained in social service who assists patients in understanding the various alternative income sources and community supports that can be accessed. This activity helps to ensure a successful transition back to the community and for on-going health and well-being of our patients upon discharge.

Integration and Continuity of Care

Runnymede views integration and continuity of care as paramount to improving the health of Ontarians with complex chronic disease. To this end, Runnymede collaborates with multiple system partners to integrate best practice guidelines for individuals with stroke and hip fractures. In collaboration with these partners and our patients, we provide seamless transitions across the continuum of care including from acute care to Runnymede back to the community. Some examples include:

• Partnering with St. Joseph’s Health Centre, Trillium Health Partners and the Greater Toronto Area (GTA) Rehabilitation network to standardize and enhance access to rehabilitation post- hip fracture.


• Collaborating with Toronto Central Community Care Access Centre (TC CCAC) leadership to develop, review and implement strategies together to reduce the Alternative Level of Care (ALC) rate.

• Active participation in the West Toronto Health Links forum where we will continue to provide leadership and expertise in complex chronic disease management.

• Playing an integral role providing an option for the slow stream rehabilitation of patients who have suffered a severe stroke in collaboration with the West Greater Toronto Area Stroke Network and Trillium Health Partners prior to returning to Trillium Health Partners for active rehabilitation

The priorities identified in the Quality Improvement Plan support the provision of high quality and safe care from admission to Runnymede, through to discharge to home or the next care destination. A complete description of these priorities and how we will be successful can be found in the 2017/18 work plan.

Access to the Right Level of Care - Addressing ALC Issues

Our 2017-18 Quality Improvement Plan focuses on a number of change initiatives aimed at ensuring access and flow for all patients awaiting our services in acute care delivering strategies have been targeted at several phases of the care journey from referral and pre-admission to during the in-patient stay to and examples include:

• Attending ALC rounds of referring acute care centres to collaborate on and increase consistency of rehabilitation program goals and discharge expectations

• Early identification and proactive communication and engagement of patients and families to allow for better planning and understanding of what to expect after treatment at Runnymede concludes and community resources available post-discharge;

• Expanded membership for bi-weekly ALC rounds to include local leadership to strengthen consistency of communication with patient and family

• Systematic review with specialized expertise of Community Care Access Centre staff of all long-stay ALC patients including the development of individual action plans for transition to the most appropriate destination and identifying common barriers for discharge.

• Participation in ALC Avoidance and Management meetings at TC LHIN and West Toronto ALC strategy group where best practices and learnings are shared

• ALC Avoidance scorecards that are monitored monthly ensure that there is an organizational focus on the role that everyone has to play.

As this is a challenging problem across the healthcare system, we will also continue to work closely our acute care and community-based partners to enhance frequent communication and strive for seamless, safe and effective transitions from acute care to Runnymede and from Runnymede back to the community. Together, these initiatives will assist the delivery of the right care at the right time in the right place for all of our patients.


Engagement of Clinicians, Leadership & Staff

At Runnymede, our annual Quality Improvement Plan is the result of a collaborative effort of administration and medical leaders within our organization. Additionally, we actively involve patients, families and system partners. This is done through an in-depth analysis of our progress on previous initiatives as well as opportunities for quality improvement feedback from patients, families, staff, physicians and system partners to optimize value for our patients and the broader health care system. More specifically, we use multiple forums that cascade information from the Board to bedside such as meetings of our Board of Directors, Quality Committee of the Board, Executive Advisory Committee, Operations Committee and Medical Advisory Committee. All these committees provide oversight to our quality operations across the hospital. Staff is actively involved at Interprofessional Care Committee, Safe Medication Practice Committee and regular staff meetings. Our results and performance are regularly shared at these forums through the Balanced Scorecard, Clinical Quality Indicator report and patient care area scorecards. To assist in fostering a culture of quality, patient safety and recognition, a comprehensive communication plan to launch the new Quality Improvement Plan and celebrate the success of the 2016/17 plan is in place.

Resident, Patient, Client Engagement

Patients and their families are engaged in the Quality Improvement Plan development process through our annual patient satisfaction survey and the compliment and concerns reporting process. In addition, the Patient Family Council continues to be a key venue to solicit feedback and insight. To generate continuous feedback, we actively meet with patients and families and ask questions on specific initiatives that have the greatest direct patient impact such as, pressure ulcers and patient experience. This approach has actively engaged our patients and families providing us with a more fulsome and rich source of considerations that matter most to our patients. This information has been embedded in the change ideas and action plan to foster a positive patient experience in 2017/18.

Staff Safety & Workplace Violence

Runnymede employs a number of strategies to monitor, reduce and prevent workplace violence to ensure compliance with Bill 168, the Occupational Health and Safety Amendment Act (Violence and Harassment in the Workplace 2000. Reporting and monitoring occurs through an internal online safety reporting system where employees submit reports of actual and potential physical, verbal or psychological threats. These are received, reviewed and acted upon by management as well as the Occupational Health and Safety department. Staff are supported through follow-up by the Occupational Health practitioner, their manager as well as through access to external professional and confidential counselling services through the Employee Assistance Program. Trending reports regarding incidents of workplace violence are monitored and shared at internal committees like the Joint Health and Safety Committee.


In order to reduce and prevent workplace violence, Runnymede takes a proactive approach with staff education on Bill 168, the Respectful Workplace policy and Intimate Partner/domestic violence policy in addition to training on emergency codes specifically, Code White (violent situation), Code Purple (hostage taking) and Code Black (bomb threat) during general orientation which provide closer procedures for crisis intervention. Clinical staff attend educational sessions specific to management of aggressive/violent patients supported by internal policy. Educational material is available on the internal website and mock emergency drills are conducted monthly.

The prevention of workplace violence begins with early identification and awareness beginning when an application for admission is placed for an individual with documented behaviours from the referral site. The patient flow department reviews referrals from Resource Matching and Referral tool from the Toronto Central Local Health Integration Network to ensure that all admissions are appropriate and safe. During an inpatient stay, patients exhibiting signs and behaviours of potential aggression are identified and signage placed at the bedside to increase awareness and preparation for a potential threat.

Performance Based Compensation Subject to compliance with the Broader Public Sector Executive Compensation Act (BPSECA), 2014, a percentage of an executive's base salary is linked to the achievement of a defined number of performance improvement indicators set out in the Quality Improvement Plan.

Sign-off It is recommended that the following individuals review and sign-off on your organization’s Quality Improvement Plan (where applicable): I have reviewed and approved our organization’s Quality Improvement Plan

_________________________

Mr. John O’Dwyer Board Chair

________________________

Ms. Susan Grant Quality Committee Chair

________________________

Ms. Connie Dejak Chief Executive Officer

625 Runnymede Road, Toronto, Ontario M6S 3A3

2017/18 Quality Improvement Plan"Improvement Targets and Initiatives"

AIM Measure Change

Quality dimension Issue Measure/Indicator

Unit /

Population Source / Period Organization Id

Current

performance Target

Target

justification

Planned improvement

initiatives (Change Ideas) Methods Process measures

Target for process

measure Comments

1)Develop brochure for

Substitute Decision Makers

(SDM) regarding their role

in discharge planning.

Ensure roles, responsibilities & expectations of SDM

included in content

% of patients/SDM who receive brochure on admission 100% Increase

availability of

SDMs to

participate in

discharge 2)Standardize and

strengthen pre-admission

screening with referring

hospitals.

Patient Flow staff attend discharge rounds at referring

hospitals with targeted focus on potential barriers to

discharge.

% of external discharge rounds attended 80%

3)Develop information

packet for patients/families

outlining discharge

destination options e.g.

retirement home, long term

care and supports to assist

transition to community ,

activity of daily living (ADL)

community programs

New brochure developed and implemented. % of patients who receive discharge information

brochure

100% Goal is to provide

patients/families

with information

to allow for early

planning for care

and supports

available after

discharge from

Runnymede.

4)Cohorting ALC patients

with focus on long stay

patients i.e. greater than 40

days

Modify programming that is available to facilitate

transition to next discharge destination

Length of stay # of long stay patient discharges per

month

One patient per

month

1)Revise Patient Family

Advisory Committee

structure and mandate

adopting patient and family

centred approach including

input into quality initiatives.

Revise, implement and recruit for Patient Family

Advisory Committee (PFAC). Coordinate meaningful

meetings to engage PFAC members to provide input

into quality initiatives

1. # of meetings held per quarter 2. # of projects and

policies reviewed by patients and families in fiscal year

1. One meeting per

quarter 2. To have

all major policy

changes involve

patients and their

families to provide

the patient

experience

2)Implement Floor based

Patient/Family meetings

- Develop terms of reference, frequency - Develop

communication plan and engagement strategy

# of unit family councils per quarter One meeting per

floor per quarter

3)Implement nursing service

expectation standards

1. Online learning module 2. Incorporate into annual

performance evaluations

1. % of nursing staff who have completed service

standard training 2. % of staff to which enhancing

patient experience” is set as an objective

1. 80% 2. 100%

4)Implementation of online

patient feedback and safety

and risk learning system

including accessibility to

patients/families

-Broad stakeholder engagement -Technical build -

Training -Evaluation

1. % increase in reporting of compliments, concerns and

safety events 2. # of events submitted by patient/family

1. 10% 2. 2 per

month

5)Clinical operation audits

to address experience and

safety related concerns e.g.

medication safety,

environmental

clutter/cleanliness,

customer excellence tenets

Audit compliance with nursing staff completion # of audits completed per week - 2 audits per week

- Spread to Allied

Health and

Pharmacy

Items audited

identified from

patient

compliments/con

cerns and patient

safety reported

data

6)Video story-telling Adopt evidence informed process and structure for

video story-telling

1. # of patient stories videotaped/quarter 2. Percent of

corporate meetings where patient stories are shared

1. 1 2. 80%

7)Develop a Patient

Experience Framework

Framework developed in collaboration with patient

and/or family members of patients that have had care

in hospital in past year

Framework complete Developed and

implementation

begun by May 31,

2017

7.00 Considering the

high reliance on

external factors

for success

(CCAC resources,

patients’ LTC

selection,

supportive

housing) we

have set a target

to match 2016-

17 target.

Access to right level

of care

Efficient Total number of

alternate level of care

(ALC) days

contributed by ALC

patients within the

specific reporting

month/quarter using

near-real time acute

and post-acute ALC

information and

monthly bed census

data

Rate per 100

inpatient days /

All inpatients

WTIS, CCO, BCS,

MOHLTC / July –

September 2016

(Q2 FY 2016/17

report)

850* 10.37

83.10 Match Ontario

Hospital

Association

benchmark.

“Overall, how would

you rate the quality

of care and services

you receive here?”

(add together % of

those who responded

“Excellent, Good”)

% / Complex

continuing care

patients

NRC Picker /

Annual survey

850* 80.6Patient-centred Person experience


Unit /


Current

performance Target

Target

justification

Planned improvement


Target for process

measure Comments

1)Revise Patient Family

Advisory Committee

structure and mandate

adopting patient and family

centred approach including

input into quality initiatives

Revise, implement and recruit for Patient Family

Advisory Committee (PFAC). Coordinate meaningful

meetings to engage PFAC members to provide input

into quality initiatives.

1. # of meetings held per quarter 2. # of projects and

policies reviewed by patients and families in fiscal year

1. One meeting per

quarter 2. To have

all major policy

changes involve

patients and their

families to provide

the patient

experience

2)Implement Floor based

Patient/Family meetings

- Develop terms of reference, frequency - Develop

communication plan and engagement strategy

# of unit family councils per quarter One meeting per

floor per quarter

3)Implement nursing service

expectation standards

1. Online learning module 2. Incorporate into annual

performance evaluations

1. % of nursing staff who have completed service

standard training 2. % of staff to which enhancing

patient experience” is set as an objective

1. 80% 2. 100%

4)Implementation of online

patient feedback and safety

and risk learning system

including accessibility to

patients/families

-Broad stakeholder engagement -Technical build -

Training -Evaluation

1. % increase in reporting of compliments, concerns and

safety events 2. # of events submitted by patient/family

1. 10% 2. 2 per

month

5)Clinical operation audits

to address experience and

safety related concerns e.g.

medication safety,

environmental

clutter/cleanliness,

customer excellence tenets

Audit compliance with nursing staff completion # of audits completed/week -2 per week -

Implemented in

Allied Health and

Pharmacy

department

Items audited

identified from

patient

compliments/con

cerns and patient

safety reported

data

6)Video story-telling Adopt evidence informed process and structure for

video story-telling

1. # of patient stories videotaped/quarter 2. Percent of

corporate meetings where patient stories are shared

1. 1 2. 80%

7)Develop a Patient

Experience Framework

Framework developed in collaboration with patient

and/or family members of patients that have had care

in hospital in past year

Framework complete Developed and

implementation

begun by May 31,

2017

1)Develop and initiate Skin

Injury Committee

Review and refine terms of reference and membership Frequency of meeting Monthly

2)Wound rounds Individualized patient assessment including discussion to

promote self management. Includes education,

development of care plans with patient, families and

staff

# of wound rounds/week 3 rounds per week

3)Engage in International

Pressure Ulcer Prevalence

Survey to monitor pressure

rates and practice

Data collection. Data analysis and reporting. Staff

education of prevalence outcomes. Interdisciplinary

discussion and improvement of practices.

1. % of chart reviews 2. % of staff informed and

educated on practice enhancement resulting from

prevalence study

1. 100% of in-

patients 2. 80%

1)Develop process to

improve presence of and

access to fall prevention

equipment e.g. lap tray,

chair alarms, floor mats

Inventory of existing stock Development of basic

minimum requirement Establish stocking, reordering

process Define centralized storage area

Audit that minimum equipment is ready to use 100% of time

equipment is

available to use

2)Modify the semi-annual

falls audit process to ensure

resulting data is relevant for

program evaluation

Educate new Falls Committee members on revised audit

process

1. Audit will be completed in Q1 & Q3 2. Gather

feedback from committee members on new audit

1. 100 %

completion of

audit in Q1 & Q3

for falls data in Q2

& Q4 2. Overall

positive feedback

3)Implement patient safety

huddles on each floor

focusing on falls prevention

Falls Committee will liaise with professional practice

leaders, Quality department to define a process that is

feasible & sustainable

Process is identified and trialed Implemented on all

patient care floors

by September 30,

2017

“Would you

recommend this

hospital to your

friends and family.

Positive response is

‘definitely yes.’

% / Rehab NRC Picker /

Quarterly

850* 77.3 70.00 Internal target as

insufficient data

collected to

establish

benchmark due

to new survey

questions, rating

through NRCC.

Safe Safe care Percentage of

patients receiving

complex continuing

care with a newly

occurring Stage 2 or

higher pressure ulcer

in the last three

months.

% / Complex

continuing care

patients

CIHI CCRS / July -

September 2016

(Q2 FY 2016/17

report)

850* 2.58 2.47 Five (5) percent

improvement,

well below

unadjusted rate

of 3.4% and

4.8% for Toronto

Central LHIN and

the province,

respectively for

same time

period.

0.65 5% improvementFalls with harm rate

per 1000 patient

days/All patients,

complex continuing

care patient

population

Rate per 1,000

patient days /

Complex

continuing care

patients

Hospital collected

data / Rolling 4

quarters

850* 0.68


Unit /


Current

performance Target

Target

justification

Planned improvement


Target for process

measure Comments

1)Develop process to

improve presence of and

access to fall prevention

equipment e.g. lap tray,

chair alarms, floor mats

Inventory of existing stock Development of basic

minimum requirement Establish stocking, reordering

process Define centralized storage area

Audit that minimum equipment is ready to use 100% of time

equipment is

available to use

2)Modify the semi-annual

falls audit process to ensure

resulting data is relevant for

program evaluation

Educate new Falls Committee members on revised audit

process

1. Audit will be completed in Q1 & Q3 2. Gather

feedback from committee members on new audit

1. 100 %

completion of

audit in Q1 & Q3

for falls data in Q2

& Q4 2. Overall

Positive feedback

3)Implement patient safety

huddles on each floor

focusing on falls prevention

Falls Committee will liaise with professional practice

leaders, Quality department to define a process that is

feasible & sustainable

Process is identified and trialled Implemented on all

patient care floors

by September 30,

2017

Falls with harm rate

per 1000 patient

days/All patients, low

tolerance long

duration

rehabilitation patient

population

Rate per 1,000

patient days /

Rehab

Hospital collected

data / Rolling 4

quarters

850* 1.65 1.57 5% improvement

Documents

Quality Improvement Plan (QIP) Narrative for Health Care ... · • Empowering the patient and family voice through technology and involvement The priorities in Runnymede’s Quality