2017/18 Quality Improvement Plan-Hospitals
"Improvement Targets and Initiatives"
AIM
Change
Measure
Quality
dimension Issue
Efficient
Access to
right level of
care
Measure/Indicator
Unit / Population
Percentage of Alternate % / All acute
Level of Care (ALC) days patients
(Discharged ALC days
from Acute in reporting
period)
Current
performanc
Target
Source / Period
e
Target
justification
Internal / Q2 2016 AGH
Equal or less Our current
2.5%
than 14.22% performance is
Planned improvement
initiatives (Change Ideas)
Continued
implementation of
lower than
Estimated Date of
provincial and
Discharge (EDD) and
NELHIN targets
destination
in two of our
three acute
care sites. Our
goal is to
achieve
decrease the
percentage of
acute care
beds in which
there are ALC
days
Patient
Centered
Person
experience
Percentage of
respondants who
positively responded
(very good and
excellent) to "How
would you rate the
quality of care or
services provided by
the staff"
Anson General Hospital
% /ED Survey
respondents
Internal/Q3 2016
MICS
83%
10%
increase
Our goal is to
increase the
positive
responses by
10% (91.3%)
Introduce role of
Discharge Planner
Spread of Bed Map
Methodology and utilize
during bullet rounds
Optimize access to
appropriate discharge
destination utilizer
interdiscplinary team
(discharge planner, PATH
program, HOME FIRST
program)
Methods
Review the current referral
processes to transitional beds
Process measures
Average ALC days per
patient to transitional
bed
Goal for change
ideas
Reduce % of ALC in
acute care beds
Analyze the length of stay in the
transitional beds (CCC) to ensure it Number of referrals to
is optimal
discharge planner
Comments
Changed this indicator
to focus on acute care
beds as this is the area
which would impact
wait times for care the
greatest.
Work with community partners to
expand the existing capacity of
Reduction in ALC-Rehabservices and improve efficiency in CCC-Discharge home
patient flow
Review use of ISAR screening tool
and initiate early intervention in
the ED for patients > 65 at
consideration for admission
Provide education on
client and family centered
care for health care
providers
Deliver presentation at block
training in May/June 2017.
Include video, best practice
guidelines, patient stories
Create partnerships with
patients and their families
in the Emergency
Department setting
Review current brochure "Your
Healtcare be Involved" by OHA
and consider using alternate
brochure or changing process for
partnering
Percentage of staff who 100% staff who
received CFCC
receive education
education/training
*Executive
Compensation
Priority indicator (HQO)
Number of brochures
shared with patients
Long term goal is
100%
2017/18 Quality Improvement Plan-Hospitals
"Improvement Targets and Initiatives"
AIM
Change
Measure
Quality
dimension Issue
Safe
Medication
safety
Measure/Indicator
Medication
reconciliation at
admission: The total
number of patients with
medications reconciled
as a proportion of the
total number of patients
admitted to the hospital
Unit / Population Source / Period
Rate per total
Hospital collected
number of
data / Q3 2016
admitted patients /
Hospital admitted
patients
Current
performanc
e
Target
AGH
Equal or
100%
more than
90%
BMH
100%
LMH
88%
Reduce
hospital
acquired
infection rates
Number of times that
% / Health
hand hygiene was
providers in the
performed before initial entire facility
patient contact during
the reporting period,
divided by the number
of observed hand
hygiene opportunities
before initial patient
contact per reporting
period, multiplied by
100.
Publicly Reported,
MOH / Jan 2016 Dec 2016
AGH
95%
87.3%
Target
justification
Our current
performance
is goal is
100% in two
sites. Third
site to
achieve equal
or greater
than 90%
Planned improvement
initiatives (Change Ideas) Methods
Review med rec process Monthly audits
with nursing staff and
Identification of any units
during orientation
achieving and sustaining 90% or
greater rate of Med Rec on
Review audit tool and
admission
policy/process
Our goal is to
achieve equal
or greater than
87.3% (Ontario
provincial
average for
2015/16)
Recognize staff who show
high compliance with
hand hygiene practices
prior to patient contact
Include pharmacy
department in process
Identify barries to hand
hygiene with front-line
staff
Process measures
Percentage of units
where medication
reconciliation is
reviewed
Goal for change
ideas
Comments
Continue
*Executive
performance or
Compensation
improve if necessary
Percentage of focus
group meetings
Focus group with high achieving complete with
teams : apply positive deviance
improvement
methods to identify opportunities opportunities identified.
to improve Med Rec process and
uptakePercentage of focus
Implement improvements with
units that have had
teams not meeting 90% or greater improvement
improvement target
opportunities shared
with them
Provide recognition via MICs
newsletters, site meetings, and
email. Update "Every
Patient/Resident, Every time"
posters and identify high
performers.
Number of times high
performers are
recognized
Develop and administer survey via
Survey Monkey and have staff
complete to identify barries and
evaluate hand hygiene program.
Develop stategies to identify gaps
in meeting goals
Number of staff who
complete survey
Number of barriers
identified
Recognition of high
performers may
motivate staff to
continue with their
hand hygiene efforts
Goal is to identify
and eliminate
barriers for front
line staff to
maximize hand
hygiene compliance
*Executive
Compensation
**Chief of Staff
Compensation
2017/18 Quality Improvement Plan-Hospitals
"Improvement Targets and Initiatives"
AIM
Change
Measure
Quality
dimension Issue
Reduce
functional
decline while
hospitalized
Measure/Indicator
Percentage of patients
with no decline in ADL
function from hospital
admission to hospital
discharge as measured
by the Barthel Index
Tool
Unit / Population
% / Patients 65
years of age or
older
Current
performanc
Source / Period
e
Target
Internal / Oct 2016 - AGH
50.0%
Dec 2016
79%
Target
justification
Our goal is to
achieve equal
or greater
than 50% of
patients with
no decline in
functions
Planned improvement
initiatives (Change Ideas) Methods
Ensure Barthel Index tool Monthly audits
is used on admission and
discharge
Educate staff on MOVE
ON program
Introduce MOVE ON
program across all three
hospitals
Identify
patients 65
years and older
with delirium
Percentage of patients
who receive CAM
screening daily (total
number of CAM
screening performed
divided by total # of
days)
% / Patients 65
years of age or
older
Internal / Oct 2016 - AGH
Dec 2016
91%
75.0%
Our goal is to
achieve equal
or greater than
75%
compliance
with CAM
screening
every day
Consider alternate ways
to deliver education re:
importnce of CAM
screening with nursing
staff at all three acute
care sites
Implement the use of
CAM "spot delirium" ID
card
Process measures
Number of patients with
Barthel Index tool
completed on admission
and discharge
Goal for change
ideas
Maintain or improve
functional mobility
status for inpatients
age 65 years and
older
Number of staff
completing education
on MOVE ON
intervention
Comments
*Executive
Compensation
Seniors Friendly
Hospital Improvement
initiative
Number of patients
engaged in the MOVE
ON functional mobility
intervention
Group education, review at staff Percentage of staff who 90% staff received
meetings, 1:1 training/reminders. received CAM
education
Share audit results as it becomes education/training
available.
Form ad-hoc group to develop and
Full implementation
implement "spot delirium" tools 100% completion by Dec of CAM "spot
and associated policies.
2017
delirium" card by
Dec 2017
Seniors Friendly
Hospital Improvement
initiative