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2015/16 Quality Improvement Plan for Ontario Hospitals
"Improvement Targets and Initiatives"
Hamilton Health Sciences | Hamilton, ON
AIM
Measure
Quality dimension
Objective
Measure/Indicator
Access
Reduce wait times in ED Wait times: 90th
the ED
percentile ED length
of stay for Admitted
patients
Unit / Population
Source / Period
Organization Id
Hours / ED patients CCO iPort Access 942*
/
Jan - Dec 2014
Current
performance
28.6 hours
(Jan - Dec 2014)
Target
Target justification
27.6 hours
A one hour reduction
represents a 3.5%
improvement.
Target aligns closely with the
provincial average of 27.8
hours and aligns with the
Ministry-LHIN Performance
Agreement (MLPA) target of
28 hours.
Change
Planned improvement
initiatives (Change Ideas)
Methods
1. Introduction of Estimated 1a. Revise and update current EDD methodology
Date of Discharge (EDD)
1b. PDSAs – Pilot utilization and uptake of EDD on predictable
population (surgical unit) and test EDD methodology on unit
with variances in EDD to Actual (medicine units)
1c.. Implement EDD across organization
2. Application of Bed Map
Methodology
Process measures
Goal for change ideas
1a. Meet EDD LOS expectations (Acceptable variance of 1a. 10% variance
EDD compared to Actual Discharge Date)
1b. Number of units with EDD implemented
1b. 60% Compliance
2. Test feasibility of Bed Map approach at McMaster Children’s
Hospital, St. Peters Hospital, Juravinski Hospital and West
2. Feasibility evaluation report completed
Lincoln Memorial Hospital sites, and evaluate availability of
expert resources at each site
2. 100% Complete
3. Selected initiatives tested at each site that improve the flow
of inpatients from the ED
Effectiveness
Improve
organizational
financial health
Free cash flow
$
Integrated
Reduce unnecessary Percentage ALC days: % / All acute
time spent in acute Total number of
patients
care
acute inpatient days
designated as ALC,
divided by the total
number of acute
inpatient days *100
Finance
3. Concurrent strategies
within site based Innovation
& Learning Patient Flow
Committees
3. Selected Initiatives meet milestones
Execution of initiatives
Completion of initiatives aimed at reducing administration and
intended to achieve plan of support costs, increasing revenue, and achieving program
balanced budget.
efficiencies.
Variance to budget
942*
$21M
(Apr - Dec 2014)
$27.5M
A 28% improvement and
aligns with the LHIN H-SSA.
Internal ALC data 942*
warehouse / Jan Dec 2014
14.4%
(Jan - Dec 2014)
12%
A 12% target aligns with the 1. Home First refresh
LHIN target for HNHB
hospitals and the CCAC. The
absolute 2.4% decrease
represents a 16%
2. Implementation of
improvement.
Seniors Mobile Assess and
Restore Team (SMART)
3. Optimize the use of
transitional beds
4. Rehabilitation and
Palliative strategies
1a. Standardized discharge planning
1b. Adherence to targeted timelines for key process steps
1. Percentage of patients with CCAC referrals 48 hours
before ALC designation (for appropriate patients)
2. The SMART team develops and provides an intensive
2. Number of frail seniors served by the SMART team
restorative program that targets the patient’s specific recovery
needs with the goal of earlier discharge home with or without
supports. The interventions would be provided to patients in
their current location e.g. emergency department or acute care.
3a. Increase capacity of transitional beds
3b. Reduce the percentage of clients with length of stay > 60
days in transitional beds
3c. Increase discharges to non-LTC destinations from
transitional beds
4a. Improve transitions for ALC patients in Neuro rehab, MSK
rehab, geriatric rehab and complex care restorative streams.
4b. Improve transitions for ALC patients waiting for palliative
care in hospital.
3. 100% completed
0% variance
1. 10% improvement
2. Greater than or
equal to the rate of
2014 pilot.
3. ALC days to transitional beds
3.
5% improvement
once stable level is
attained.
4a. Percentage reduction of ALC days for respective
streams
4. Between 10%-25%
reduction depending
on stream..
4b. Percentage reduction of ALC days for palliativehospital patients
Patient-centred
Improve patient
satisfaction
In-house survey: % of % / inpatients,
patients rating their outpatients and
Overall Patient
emergency
Experience at 8 or
greater (on 10 point
scale).
In-house survey / 942*
Jan - Mar 2014
77.5%
(Jan - Mar 2014)
77.5%
No increase in 15/16
identified given current
baseline based on pilot
results. This metric aligns to
the Our Patient Strategic
Goal and 3 year target of
80%.
1. Respectful Partnerships 1. Increase recruitment of patient and family advisors to
# of Patient and Family Advisors recruited
with Patients - Recruit,
represent diverse patient populations and quality improvement
orient and implement
work.
Patient and Family Advisors
to support quality
improvement activities
2. Continue to support
activities to "hear the
patient's voice"
3. Implement a service
excellence program
2a. Continue ongoing real time Patient Experience surveys with # of quarterly data collections completed
quarterly reporting at all sites
2b. Continue Leadership rounding with Patients in at least 5
pilot areas
# of units conducting Leadership Rounding with
patients/families
3a. Implement a service excellence and recovery program train the trainer
Quarterly service excellence training offered
3b. Toolkit developed and available to support and align with
Pt Experience Survey to support unit level improvements
10 Advisors
4 quarters
5 units
3 quarters
Comments
2015/16 Quality Improvement Plan for Ontario Hospitals
"Improvement Targets and Initiatives"
Hamilton Health Sciences | Hamilton, ON
AIM
Measure
Quality dimension
Objective
Measure/Indicator
Safety
Increase proportion
of patients receiving
medication
reconciliation upon
admission
Medication
% / All patients
reconciliation at
admission: The total
number of patients
with medications
reconciled on
selected units as a
proportion of the
total number of
patients admitted to
the selected units.
Enhancing Patient
Safety Culture:
Hardwiring Patient
Safety Practices
Reduce injuries to
workforce
Spread of safety
huddles, calendars,
rounding, and quality
boards
Unit / Population
Percentage of the
four elements
completed over
selected 27
inpatient units.
Source / Period
Organization Id
Hospital collected 942*
data / most
recent quarter
available
Internally
collected /
Oct - Dec 2014
Lost Time Injury Rate The number of lost Internally
time injuries
collected /
(including illnesses Jan - Dec 2014
and exposures) per
100 insured
workers
942*
Current
performance
Target
TBD
10% absolute
(new units will be improvement
added in 2015/16 from baseline
and so a new
baseline is
required)
65%
(Oct - Dec 2014)
75%
* based on
denominator of 27
units x 4
opportunities per
unit
942*
1.23
(Jan - Dec 2014)
1.11
Target justification
Since 3 new units will be
included in 2015/16
initiative, a new baseline will
need to be established. The
improvement of 10%
matches the target set for
2014/15.
Broadening focus to expand
calendars to at least 2
measures (to increase focus
beyond falls) and include
quality boards with at least
one indicator the unit is
trending.
Change
Planned improvement
initiatives (Change Ideas)
1.
- Review of current processes for med. rec. on admission on
each focus unit to determine effectiveness and opportunities
for improvement.
- Process confirmed and implemented for med. rec. on each
2. Audits for medication
focus units.
reconciliation on admission 2.
for admitted patients on
- Complete new baseline audit
focus units to sustain or
- Review and confirm ongoing audit process for focus units
monitor improvement
- Audits completed quarterly for focus units - change in Med
Rec on admission rate calculated for each unit
3. Education for Med Rec on - Audits results reported back to Clinical Manager/Med Rec
admission
leads to work with team to improve or sustain uptake of Med
Rec on admission process
4. Improvements to Med
3.
Rec process and uptake
- Education plan developed for Med Rec on admission
identified
improvement on additional focus units
- Education complete for nursing, pharmacy and physician team
members on additional focus units
4.
- Identification of any units achieving and sustaining 75% or
greater rate of Med Rec on admission
- Focus group with high achieving teams : apply positive
deviance methods to identify opportunities to improve Med
Rec process and uptake
- Implement improvements with teams not meeting 10% or
greater improvement target
1. Refinements to the
written standards for these
methods needs to occur
given our past year of
experiences. Need to also
expand the standards to
include incorporation of
trending of key
Absolute 10% increase
performance metrics, and
represents a 15%
expectations regarding
improvement. The target of countermeasures
75 % was chosen to reflect methodologies.
the fact that if all selected
units were able to
2. Group Support and
implement 3 of the 4
creation of a community of
practices, that would result practice.
in performance of 75%.
3. Local accountability for
implementation and
sustainability of this bundle
of practices.
Strategic plan target is 10%
reduction from 2014/15.
This matches the 10%
targeted reduction per year
from baseline 2011/2012 to
achieve the goal of a 50%
reduction by 2016/17.
Provincial average for the
sector was 1.06 for 2013.
Methods
1. Map the process for
medication reconciliation on
admission for each focus
unit.
Process measures
1a. Percentage of focus units completed by June 2015.
1b. Percentage of focus units that have process mapped
by September 2015
1c. Percentage of focus units that have process
implemented by December 2015
2a. Percentage of baseline audit for focus units
complete by April 2015
2b. Percentage of units with audit process in place by
June 2015
2c. Percentage of focus units audited for Q2, Q3, and Q4
2d. Percentage of units with audit result report for Q2,
Q3 and Q4
3a. Percentage of education plan complete by October
2015
3b. Percentage of nursing, pharmacy and physician
team members on focus clinical units have received
education on Med Rec on admission by December 2015
4a. Percentage of focus units with March and April
audit data studied by June 2015
4b. Percentage of focus group meetings complete with
improvement opportunities identified.
4c. Percentage of focus units that have had
improvement opportunities shared with them
1. Chiefs of Interprofessional Practice & Patient Safety
1. Revised standards, and tools for auditing and
Specialists will meet one-on-one with each Clinical Manager (of countermeasures methodologies disseminated.
the 27 target units).
2. # of Community of Practice Forums held & % of the
2. Community of Practice Sharing Forums will be held to share 27 units with representation at their site specific forum.
success stories and build a community dedicated to the
implementation and sustainability of the patient safety bundle. 3 % of 27 units with full implementation by March 31,
2016.
3. Clinical Managers will self-report implementation and
sustainability of the 4 components of the bundle. Validation
4. % of target units reporting status to program quality
methodologies will be introduced to clinical managers and
councils
engage staff and potentially students in auditing.
4. Implementation and sustainability measures are on program
quality boards and will be discussed at program quality councils.
1. Workplace inspection and 1a. Analyze hazard assessment data
hazard assessment tools.
1b. Analyze workplace inspection results
1c. Prioritize risks
1d. Develop communication strategy
1e. Develop targeted communications
2. Musculoskeletal disorder
prevention
2a. Establish dedicated training space at designated sites
2b. Development of video-based training
2c. Development and dissemination of communication
materials/resources
Goal for change ideas
1. 100% for all
2.. 100% for all
3a. 100%
3b. 90%
4. 100% for all
1. Release new
standards and
support materials by
May 15, 2015.
2. Minimum of 4
forums in the year &
65% of target units
will be represented at
the forums.
3. 75% by end of Q4
for implementation.
4. 50% of target
areas discuss at
quality councils.
1a. Hazard Assessment Tool completion
1a. 10% increase
1b. Compliance with workplace inspections as measured 1b. 10% increase
over 2015-16
2a. Number of employees receiving in-person (handson) patient handling training
2b. Number of employees receiving video-based MSD
prevention training
Comments
Clinical units included in focus for
2014/2015 and continuing for
2015/2016:
• Ward 2 Geriatric and complex
medicine rehab (JH)
• E2 Orthopedic Surgery (JH)
• E3 CTU Medicine (JH)
• 6W Spine - Surgery (HGH)
• 4W Cardiology (HGH)
• Restorative Care (SPH)
• 3Y Pediatric Hematology/Oncology
(MCH)
• 3G Pediatric /Adolescent Mental
Health (MCH)
2a. 10% increase
2b. 10% increase
Additional Clinical units included for
2015/2016 year for QIP and
improvement measure:
• F3 CTU Medicine (JH)
• 8S CTU Medicine (HGH)
• 8W Medicine (HGH)