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

3/21/2017

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.

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Overview Saint Francis Memorial Hospital (SFMH) is a small rural hospital located in Barry's Bay Ontario about three hours west of Ottawa. It services a catchment area including the Township of South Algonquin, The Madawaska Valley, Killaloe and Hagarty/Richards, and areas of the Hastings Highlands and Bonnechere Valley. The hospital offers a wide range of services and has 20 inpatient beds which includes 10 inpatient medical/surgical beds and 10 complex continuing care beds. The emergency department sees approximately 10,000 patients each year and the hospital also has a unique partnership within the Madawaska Communities Circle of Health (MCCH) to further enhance partnerships and relationships with community based partners. The MCCH which includes hospital, long-term care, hospice,community health and support services, CCAC and mental health holds a collaborative mandate to enhance and support health of all residents in the Madawaska Valley. The population served by SFMH grows from 10,000 to approximately 30,000 in the summer months due to recreational attractions such as Algonquin Provincial Park. SFMH embarked on a journey in 2016 to refresh the strategic direction for the organization. Our mission “to provide quality, patient centred healthcare in collaboration with partners” and our vision “to be a leader in rural health care delivery “ align with our QIP journey. We have been engaged in the development of a yearly quality improvement plan for many years and will continue our journey with focus on success of the new strategic plan for the organization. The mission, vision, values and strategic direction provides the direction for the delivery of quality health services. The quality improvement plan is aligned with the hospital’s four key strategic directions below, with an emphasis on the provision of quality health care services: Quality of Care We commit to providing high quality care to improve the patient and family experience by: - Providing safe and timely care through best practices - Integrating patient and family experience into the planning and decision making - Emphasizing performance measurement and reporting: while focusing on the patient safety, quality and transparency Strength in People We commit to nurturing a healthy and safe workplace in order to: - Be a preferred employer resulting in the ability to attract and retain qualified staff - Foster an environment which encourages innovation and quality across a continuum of care - Promote a healthy work life balance System Integration We commit to working collaboratively and creatively with partners to: - Keep a patient centred approach when coordinating timely and equitable care - Deliver effective , integrated quality care Demonstrate leadership in collaborative plans to advance a more coordinated and consumer friendly system Financial Performance

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We commit to responsible financial planning to ensure sustainable financial stability inorder to meet the needs of those we serve by: - Working as a resource-conscious provider of care - Continuing to actively seek improvement through efficiency and sustainability The Quality Improvement Plan (QIP) is based on the priorities identified by the Continuous Quality Improvement Committee of the Board, Senior Management team and care teams. The QIP is a tool to affirm and map the commitment of the Board of Directors and all staff in the continuous pursuit of positive clinical outcomes, positive patient experiences and positive staff work life. The plan is aligned with accreditation standards and recommendations. The balanced scorecard approach ensures key improvement initiatives in the areas of safety, effectiveness, access to care and integration and patient-centred care. CQI is a method that evaluates and continuously improves the caliber of care and service delivered from a patient perspective. CQI embraces quality by focusing on continuous process improvement, teamwork, staff and patient empowerment. Each member of the senior administration team will work with his/her departments to have defined improvement targets and initiatives to the strategic priorities. The model for improvement used to effectively analyze and implement change will be the "Plan, Do, Study, Act" (PDSA) model. The 2017/18 aims and measures can be viewed in the attached work plan . Below is a summary of the key priorities identified for the upcoming year. RVH will be undergoing accreditation in December 2017 so some priorities focus on areas that will ensure success related to the standards and required organizational practices that must be met. AIMS & MEASURES Safe Care - Increase medication reconciliation compliance on discharge to 80% Effective Transitions - Reduce Functional Decline amongst seniors in hosptial by completing Barthel Index on 90% of admissions and ensuring up for meals is completed for 60 to 80% of patients on complex continuing care unit - Implement patient oriented discharge summary for patients over 65 years of age Person Experience - Improve patient satisfaction to >80% Timely - Reduce wait times in ER for admitted patients to 9 hours Other Quality Initiatives for 2016/17 include: - reduce 30 day readmission rates for select HIGs - reduce unnecessary time spent in acute care - reduce delirium episodes in seniors in hospital - increase proporation of patients receiving medication reconciliation upon discharge - reduce rates of deaths and complications associated with surgical care - Increase number of patients identified as appropriate for health links - Ensure successful transitions from hospital to home with follow up phone calls

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QI Achievements From the Past Year SFMH has seen significant success and maintenance of some targets that were considered high performing areas when compared with other hospitals across the province. Most areas of the work plan were successfully implemented resulting in maintenance of safe hospital care and increased communication between health care providers and patients and families admitted to the hospital. The National Research Council has changed the questionnaire for patient satisfaction which has altered the achievable targets for all hospitals. As we continue our quality improvement journey emphasis on the home first philosophy to continue to decrease the alternative level of care rates in our hospital will continue. This indicator requires continuous emphasis to ensure we are meeting targets and benchmarks that are part of our quality improvement plan. The implementation of Best Practice Guidelines through our work as a partner of a Best Practice Spotlight Organization (RVH) has resulted in significant achievements this past year. SFMH has implemented some new best practice guidelines in the past two years. The guidelines include screening for delirium, dementia and depression in older adults, reducing the incidence of hospital acquired pressure ulcers, assessment, prevention of functional decline and person and family centered care.

Population Health The population health data for Renfrew County our catchment areas has been obtained from the Renfrew County Community Health Profile .This report was developed in March 2016 and provides a brief overview of the socio-economic and health status of residents served by the Renfrew County and District Health Unit. It is intended to inform the work of Health Unit staff, community partners, government decision-makers and community members as we work to address local health issues and improve health. Population size, growth, age and fertility: Just over 105,000 people live in Renfrew County and District. The area is characterized by a large rural population (almost half) and a relatively low population density. A higher proportion of the population is over age 45 compared to Ontario. The population is aging and growing slowly. The fertility rate has increased in recent years to 50 live births per 1,000 females age 15 to 49, and is higher than Ontario. Culture and language: Prominent cultural groups are German and Polish. A small proportion of the population (2%) belong to a visible minority and only 5% are immigrants. About 2% are registered or treaty Indians and almost 8% claim Aboriginal identity. The population is predominantly English-speaking. Income: Median incomes are lower than Ontario as a whole. However, the prevalence of low income is lower than Ontario (12% vs. 14%). Employment and education: Employment indicators such as labour force participation rate, unemployment rate, and full-time vs. part-time work are similar to those for Ontario. A smaller proportion of the population age 15 and over has a post-secondary certificate, diploma or degree. Life expectancy: Life expectancy for females (82.8 years) is significantly lower than Ontario. Life expectancy for males (79 years) is similar to Ontario.

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Availability of physicians: There are more general family physicians per 100,000 population than Ontario, but there are fewer specialist physicians. Well-being: The proportion of the population that perceive their health and their mental health as very good or excellent is similar to Ontario. However, the proportion that perceives that most days are quite a bit or extremely stressful (29%) is significantly higher than Ontario. Reportable infectious diseases: Incidence rates of selected reportable infectious diseases are comparable to or lower than Ontario. Health risk factors: Rates of high alcohol intake, smoking and obesity among adults are higher than Ontario. Other health risk factors such as overweight, vegetable and fruit consumption 4 or fewer times per day, and physical inactivity during leisure time are comparable to Ontario. The prevalence of these risk factors is concerning in both jurisdictions. Causes of death: The leading causes of death are cancers, circulatory diseases, respiratory diseases and injuries. Mortality rates are similar to Ontario except for circulatory diseases, which is higher.

Equity Health equity refers to the study and causes of differences in the quality of health and healthcare across different populations. Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remediable aspects of health. SFMH embraces the opportunity to ensure quality of healthcare across different populations. Aboriginal Cultural Safety training was completed for Senior Management staff at the hospital this past year. In 2017, 20 front line staff will be participating in cultural sensitivity training. This will ensure a significant number of staff better understand how to provide excellent care to this patient group.

Integration and Continuity of Care Saint Francis Hospital understands that a strong focus on integration across all areas of the patient journey, beyond the care delivered in the hospital setting will help to ensure patients receive safe, high quality, accessible and coordinated care. The hospital works with numerous partners including CCAC, Assisted Living, primary care physicians and health links to plan appropriate, safe care after discharge. Such existing partnerships is creating more coordinated care and improving access for patients through the entire continuum of care. Many initiatives have started, evolved and been implemented in the last few years. Some of these Integration Successes include: • Rural Healthcare Hub (St. Francis Health Center) SFMH built the St. Francis Health Center, connected to the hospital via a tunnel, to help promote integration and create the rural health care hub model. SFMH Board actively encourages and supports the innovative solutions by the CEO and the leadership team to improve access and co-ordination of services for better health and well-being of the people in our communities. Clinical integration successes include: Primary care with 5 General Practitioners, Laboratory Services, CCAC,

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Dialysis, Ophthalmology & Optometry, Public Health, Orthopedics, Geriatric Mental Health, Outpatient Clinics for Internal Medicine, Audiology and Addiction Treatment Services. • Madawaska Communities Circle of Health (MCCH) SFMH was instrumental in the creation of the first full community integration working group in the Champlain representing all health service providers in Madawaska Valley to implement integration opportunities in collaboration with the LHIN. • Integration of Rainbow Valley Community Health Center (RV CHC) with the SFMH (Nov. 1, 2011) is the first full integration of a CHC with a hospital in the Province. This integration has provided sustainability and vital primary care services for the CHC through recruitment of 2 family physicians and a nurse practitioner. SFMH Board created an effective governance model for the CHC with the support of the LHIN and established a Community Advisory Committee which includes SFMH Board members. • Expansion of the health care hub with the co-location of Barry’s Bay and Area Seniors Home Support (Community Support Services) with SFMH (June 30, 2011). This initiative improved co-ordination of services. Madawaska Valley Hospice Palliative Care •A beautiful two bed hospice palliative care unit opened its doors April 2015. The hospice is located within the hospital and utilized vacant space. Since beginning in December 2012 this program has been successful in training 50 volunteers who provide care to hospice/palliative care clients in the facility or in their homes. The Home First Philosophy promotes seamless integration of services from hospital to home. Home First policies protocols, joint discharge rounds, huddle boards and white boards in patient rooms ensure integration with all interdisciplinary team members and family involvement. The implementation of health links has provided opportunity for the hospital to link complex patients with care providers that can advocate and navigate their care needs after discharge. Discharge planning follow up phone calls also provide opportunity to speak to patients after discharge and provide additional support.

Access to the Right Level of Care - Addressing ALC Issues

Initially announced in 2007, Aging at Home is a strategy that provides a continuum of community-based services for seniors and their caregivers, allowing seniors to stay healthy and live independently at home, with dignity, for as long as possible. The program also aims to decrease the number of visits to emergency departments and reduce the number of seniors waiting for admission to long-term care homes (LTCHs), as well as reduce delays in transitions to these settings. The SFMH has been an active participant in the aging at home strategies in our Champlain and supported the implementation of an assisted living program in our community in 2010. This program continues to be successful and allows seniors in our community to remain in their own homes with the right supports. This community program works very closely with the hospital to share information related to potential clients.

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The quality improvement plan for 2017-18 continues to focus on initiatives to address ALC pressures within our own hospital. Our focus on senior friendly hospital initiatives that will maintain or improve functional decline in the elderly will enhance probability for this patient population to return home safely. Other initiatives such as follow up phone calls from our charge nurses on the inpatient unit can provide support beyond the hospital stay. SFMH in partnership with RVH has recently been provided funds to support the implementation of a patient oriented discharge summary to ensure elderly patients have increased knowledge and understanding of their conditions at the time of discharge. All of the above initiatives are embedded into our quality improvement plan for this year. Additionally, continuing with a focus on the Home-First Philosophy we continue to meet as a team twice weekly for detailed discharge rounds. The team includes CCAC care Coordinators, Health Links, Physio, the Charge Nurse, and the Director of Patient Care Services. Once this meeting has taken place Family Care Team meetings are organized with the patient, family, and physicians for continuity of care. Our Restorative Care approaches also support our frail elderly and clinically complex populations to discharge destinations outside of the hospital environment.

Engagement of Clinicians, Leadership & Staff CQI is a method that evaluates and continuously improves the caliber of care and service delivered from a patient/resident/customer perspective. CQI embraces quality by focusing on continuous process improvement, teamwork, staff and patient/resident empowerment. Quality projects are identified by departments, key committees, team members and compiled by the Director of Patient Care Services. Key projects are presented throughout the organization to appropriate committees and staff. The model for improvement follows the Plan/Do/Study/Act cycle. Key projects and quality reports are shared at the CQI committee of the board on a quarterly basis. Indicator reports are reviewed quarterly at this committee to ensure excellence in service is maintained. All indicators for the 2016/17 Quality Plan are included in this quality indicator report to the CQI Committee to ensure oversight at the Board level. Each Department completes the SFMH Balanced Scorecard for the June Annual Report to highlight accomplishments and new initiatives. Staff empowerment is one of the most important means for achieving high-quality services. SFMH has embraced a philosophy of teamwork where all staff members participate on teams and key committees to enhance the quality of care provided in the hospital. Examples of staff participation include: Care Team, Nursing Practice Council, and the Quality, Risk, and Safety Committee. Care team committee meets on a regular basis to determine quality projects for the year. Care team monitors departmental goals and objectives in line with strategic directions and pillars of quality. Clinical staff, physicians, team leads, managers and Senior Management participate and provide input at the care team committee.

Resident, Patient, Client Engagement The patient/family advisory committee was established at SFMH in the fall of 2015. The terms of reference/reporting structure for the hospital was developed in fall

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2015 and the first meeting of the patient /family advisory committee was held in January 2016. The advisory committee continues to meet regularly and members are involved in Care Team and Quality, Risk and Safety Committees. The Patient and Family Advisory Committee advise the hospital on matters pertaining to patient experience as one example of their role. The Committee has been involved in the numerous change initiatives including: -Implementation of revised visiting hours policy -Implementation/endorsement of 17 recommendations for change related to improving the patient experience from the RNAO Patient/Family Centered Care guidelines. These 17 recommendations include visiting policies, name badges, staff introductions and patient white boards as examples of change requiring endorsement. -Implementation of Suggestion Box, "We're Listening" and policy for managing complaints & compliments SFMH uses a variety of other approaches to engage patient/families: - Charge Nurses make post discharge phone calls to all patients >65 after discharge to get feedback on care at SFMH. The information is tracked and trended as well as reported back to teams and Board CQI committee. - NRC Patient Satisfaction data is used to make changes in care as well. A structured process is in place for patient/family feedback at our hospital and this feedback is tracked/trended and changes are made when required For the upcoming year SFMH will continue our work to implement further Best Practices. The key Best Practice for evaluation this coming year is person centered care so numerous strategies will be evaluated to measure success with patient and family engagement.

Staff Safety & Workplace Violence Violence in the workplace presents a risk to the well-being of SFMH staff, physicians, volunteers, patients and visitors. It is everyone's responsibility to prevent violence in the workplace. At RVH, we strive to create a positive environment with mutual respect and open communication. In response to Bill 168 (Act to amend the Occupational Health and Safety Act with respect to violence and harassment in the workplace and other matters) SFMH has updated its violence and harassment policies and programs, employee reporting and incident investigation procedures, an emergency response procedure for violent events and a process to deal with incidents, complaints and threats of violence. Extensive education has taken place for all SFMH staff and staff in key areas of the hospital have received non violent crisis intervention training, gentle persuasive approach training and general education on the new policies, procedures and protocols.

Performance Based Compensation Two percent of compensation for executives (defined as Chief Executive Officer, Chief of Staff, Director of Patient Care Services/CNE, Chief Operating Officer and VP Financial Services) is linked to three of the four following indicators: - Reduce unnecessary time spent in Acute Care - Reduce wait times in Emergency Department - Medication Reconciliation - Improve patient satisfaction The Senior Executive team will be responsible to ensure success in the four key indicators. Refer to the QWIP Workplan for specific performance targets for 2017/18.

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As per the above statement, two percent of executive compensation will be associated with three of four QIP indicators within the SFMH 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 Board Chair Quality Committee Chair Chief Executive Officer

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

St. Francis Memorial Hospital 7 St. Francis Memorial Drive, PO Box 129

AIM Measure

Quality dimension Issue Measure/Indicator Unit / Population Source / Period Organization IdCurrent performance Target

Target justification

Efficient 3.00 Strive to continue to keep ALC numbers low recognizing existing challenges (waitlisted services; barriers such as transportation and costs for supportive housing)

Access to right level of care

Percentage of acute hospital inpatients discharged with selected HBAM inpatient Grouper (HIG) that are readmitted to any acute inpatient hospital for non-elective patient care

% / All acute patients

CIHI DAD / 2017-2018

768* 12.82 12.00 Would like to maintain current rate or reduce by 5%; may be difficult to achieve as dependent on other facilities

Reduce 30 day readmission rates for select HIGs

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)

768* 2.82

85.00 85% of patients will see no decline in their functional status

Reduce Unnnecessary tiem spent in acute care

Timely

Reduce functional decline among seniors in hospital

% / # of patietns 75 and older

In-house survey / 2016-2017

768* 80

7.75 7.50 8.0 is the provincial average

Timely access to care/services

Safe

Total ED length of stay (defined as the time from triage or registration, whichever comes

Hours / Patients with complex conditions

CIHI NACRS / January 2016 – December 2016

768*

78 85.00 Continue to see a slow improvement

Safe care

Medication safety

Number of times that hand hygiene was performed before initial patient contact during the reporting

% / Health providers in the entire facility

Publicly Reported, MOH / January 2016- December 2017

768*

95.00 Continue to exceed target

Medication reconciliation at discharge: Total number of discharged patients for whom a

Rate per total number of discharged patients / Discharged

Hospital collected data / Most recent quarter available

768* 75 80.00 Newer initiative

Medication reconciliation at admission: The total number of patients with medications

Rate per total number of admitted patients / Hospital admitted patients

Hospital collected data / Most recent 3 month period

768* 90

CB 80.00 Historically have performed very well related to patient satisfaction and

Person experience "Would you recommend this emergency department to your friends and family?"

% / Survey respondents

EDPEC / April - June 2016 (Q1 FY 2016/17)

768*Patient-centred

p

within 30 days of the discharge for index admission

ChangePlanned improvement initiatives (Change Ideas) Methods Process measures

Target for process measure Comments

1)Continue with Complex Medical or Complex Restorative Designation

Discharge Planner/Charge Nurse and Physician determine patient need for a longer restorative period

Data collected and shared at Quality, Risk and Safety Committee in which Utilization is standing item as well as Medical Advisory Committee. Number of patients admitted to restorative and discharge destination

Reduction in ALC designation

2)Continue to integrate discharge planning with CCAC, Home First, whiteboards and bullet rounds

# of bullet rounds per week; Compliance by all disciplines with whiteboard

Monitor use of whiteboards per audit; Average of 2 bullet rounds per week

Reduction in ALC numbers

3)Health Links to continue to see 200 clients per year

Data elements will be monitored on patient group; ED visits; readmissions

Monitor data elements and health link staff attendance at bullet rounds

100% of team attendance at rounds; 100% of patients admitted to health links will

1)Improve use of white boards to enhance patient and family centered care through communication

Frequent discussions between patient/family and care team to ensure white boards contain timely information to plan for discharge

Survey patients and families to ensure white boards are an effective communication tool. Incorporate question into the post discharge phone calls.

Patient Satisfaction

2)Continue Home First Discharge Rounds

Meet twice weekly with CCAC Care Coordinator, Health Links Social Worker, Physiotherapist, and charge nurse to discuss appropriate discharge destination. All potential patients awaiting LTC will be reviewed prior to designation.

Stats will be reviewed quarterly at the Quality, Risk, and Safety Committee

Reduction of patients who become awaiting LTC and 100% of team attends

3)Improve the timing of the discharge phone calls to be completed within 48 hours of discharge

Discharge Planner/Charge Nurse calls all patients >65 after discharge to ensure smooth transition to home

Data reviewed quarterly at Quality, Risk, and Safety Committee where we discuss utilization stats; also reviewed at Nursing practice Council to ensure all staff understand the importance of the calls

Data will be trended and action plans developed

1)Maintain a positive patient centered environment

Share survey results at Care Team, ED staff meetings, patient and Family Advisory Committee and highlight trends

Report survey results quarterly 80% or more would recommend ED to friends and family

1)Strengthen knowledge of best practices for all disciplines

Online (eLMS) education tool for nursing staff; present a short review and areas for improvement to physicians via MAC

Continue to encourage and track nursing online education

75% of nursing staff will complete education annually

1)Re-educate nursing staff on the importance of Best Possible Medication history (BPMH) at discharge

Develop and Implement/reassign education on the eLMS (Learning management System)to facilitate online completion Education will stress the importance of BPMH for safe hospital stay and discharge

Compliance/Percentage of staff completion of education

80% of staff complete education

1)Measurement and feedback through hand hygiene audits

Formal audits will be conducted and compliance will be measured

Formal audits will be conducted in all areas of the hospital and compliance tracked

80% of staff will improve hand hygiene prior to contact

1)Continue to monitor patient flow

Share data and trends with QRS Committee in which Utilization stats are discussed

Areas of improvement identified at the committee level will be discussed with Care Team and MAC

Identify action plan and implement

1)Continue full implementation of Program

Audit Barthal tool completion and trend results % of patients not experiencing functional decline while in hospital

85% of patients will see no decline in function at the time of discharge