1. health and fitness

2015/16 Quality Improvement Plan (QIP)
Narrative for Hamilton Health Sciences
April 1, 2015
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 HQO (if required) in the format
described herein.
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Overview
Hamilton Health Sciences’ (HHS) vision of Best Care for All is driven by the pursuit of quality and excellence in
the care and services we provide and in realizing the best use of resources to ensure that our health care system
is sustainable for future generations. To achieve this vision, the work of over 11,000 staff, 1800 physicians and
1300 volunteers is centered around 4 key goals:
 Our Patients: To provide an excellent patient and family experience every time
 Our People: Engage, empower and enable our people to deliver on our mission
 Our Sustainability: Meet the healthcare needs of the communities we serve now and in the future
 Our Research, Innovation and Learning: Lead in research, innovation and learning for the benefit of our
community and the world
HHS’s Quality Improvement Plan (QIP) is one component of our overall planning process. Integration of the QIP
with our strategic goals and planning, our operational plans, the new Health System Funding Reform priorities
and our Hospital Service Accountability Agreement are key. Aligning these components will help to ensure that
we are fiscally responsible, have accountability to our patients and deliver high quality care. In addition, creation
of this plan required internal review of: quality reviews, accreditation reports, safety reports, critical incident
reviews and patient feedback as well as consideration of best practice recommendations from external agencies
such as the Canadian Patient Safety Institute, Institute for Healthcare Improvement, Accreditation Canada, and
the World Health Organization.
In its 2015/2016 Quality Improvement Plan, HHS has chosen to focus on 7 key organizational priorities that are
carefully aligned with our organization’s vision and strategic goals as well as the specific priorities established for
all Ontario hospitals including the need to adapt to the new health system funding reform (HSFR), work with our
healthcare and other service partners toward further integration of care delivery across the healthcare
continuum, and continuing focus on further improving outcomes for our patients. The 7 priorities in this year’s
QIP include:
 Improve the patient experience by implementing best practices
 Enhance patient safety culture by spreading patient safety practices
 Improve patient safety by reconciling medication upon admission
 Reduce Emergency Department wait times
 Ensure that patients who no longer require the services of our hospital are discharged in a timely
manner
 Improve organizational financial health
 Reduce injuries to our workforce
Improving the Patient Experience by implementing best practice: Service Excellence Program and Continued
Implementation of Patient and Family Advisors
Healthcare organizations internationally have turned their focus and priority setting to the “Patient
Experience”. This follows a natural evolution of quality and patient safety and addresses the key aspects of
quality from the eyes of the patient and their families. On a daily basis, examples of exemplary care and
service excellence behaviours that go above and beyond are evident within the walls of HHS but not always
with consistency across the organization. The opportunity lies in creating a culture and practices that
consistently deliver heartfelt best care for every patient, every time, everywhere within HHS. This year we
will focus on implementing 2 best practices related to improving the patient experience related to: the
implementation of a service excellence program to support compassionate patient and family centred care;
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and the continued implementation of a Patient and Family Advisor Program where previous HHS patients
and families are recruited to provide input into care, service processes & practices, or design of facilities.
Enhancing Patient Safety Culture by Hardwiring Patient Safety Practices: Spread and sustainability of Safety
Huddles, Crosses, Purposeful Rounds, and Quality Boards
HHS remains committed to continuously making care safer for patients who have entrusted themselves or
their loved ones to us. We will continue to focus on spreading and sustaining 4 key practices for supporting
safer care: implementation of daily safety huddles (short team briefings that identify and discuss strategies
to ensure safe care for patients), openly displayed quality indicators (to ensure staff know how they are
doing, and where opportunities for improvement may lie), implementation of purposeful hourly rounding
(to enhance communication and collaboration with patients and families to ensure patient needs are being
met)and lastly increase the focus of the huddles and quality indicators beyond a single safety issue via the
implementation of formal “Quality Boards” to monitor progress. HHS had success in implementing these
practices in 18 out of 27 of its adult and pediatric inpatient units last year (and some of these practices in all
27 units). By the end of 2015/16, HHS will continue to spread and sustain these four key practices.
Improving Patient Safety by Increasing the Proportion of Patients with Medications Reconciled upon
Admission to Hospital
When admitting patients to hospital, it is very important to ensure that accurate home or pre-admission
medication lists are captured and then matched against hospital admission orders to ensure all medications
(including over the counter medications, vitamins, supplements and herbal remedies) are accounted for
accurately. This process occurs by healthcare teams every day within HHS, but the creation of a formal
consistent process during history-taking with patients and families can further safeguard patients against
errors. HHS is committed to providing safe, seamless care for our patients and this is one area that can help
us achieve our goal. Last year we were able to improve consistency with these practices across 8 clinical
units. This year we will be continuing to reinforce this practice of medication reconciliation on the current 8
units and include 3 additional in-patient clinical units across HHS.
Reducing ED Wait Times
HHS remains committed to ensuring that patients in our community receive timely access to care through
our Emergency Departments. Over the past several years HHS has focused on improvements to wait times
for both non-admitted patients and admitted patients waiting in the ED for an inpatient bed. There
continues to be increased complexity of the health care needs of those patients who present to the
Emergency Departments. As HHS continues to adapt to these changing needs, we continue to work on
Emergency Department Wait Times to ensure we provide timely, safe and excellent care to patients waiting
in the Emergency Department for an inpatient bed. This year the focus will be on standardizing the
discharge process from acute care through the utilization of the estimated date of discharge. Further work
will determine the feasibility of spreading the previously successful simulation-informed bed map initiative
to other sites at HHS.
Reducing Time Spent Waiting for an Alternate Level of Care (ALC)
Ensuring that patients who no longer require the services of our hospital are discharged in a timely manner
is important. Patients (and their families) want to progress to their next level of care as soon as able and
hospitals need to ensure that their services and resources are available in a timely manner to those who are
in need. Through strong partnerships with community organizations, HHS has made considerable
improvements in the amount of time patients wait for discharge and/or transfer to an “alternate level of
care”. Despite improvements in previous years, performance is not at the target set by the Local Health
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Integration Network and so opportunity to reduce the time waiting still remains. The focus for improvement
this year will be to implement the new LHIN Home First Refresh strategy, introduce the “Senior’s Mobile
Assess and Restore Team”, and improve transitions to Rehabilitation, Complex Care and Palliative beds at
HHS.
Improve Organizational Financial Health
HHS has been very successful at accomplishing significant savings over the past several years while
continuing to serve more patients. Improving organizational financial health is essential given increasing
cost pressures associated with inflation as well as the introduction of new drugs and technologies, the aging
population and limited financial resources. To reach this goal HHS will focus on improving free cash flow by
implementing cost savings initiatives and continuing to strive for responsible stewardship and innovation
that will allow HHS to continually improve care processes while making the best use of limited resources.
Reduce Injuries to our Workforce
Hamilton Health Sciences is committed to supporting the health, safety and well-being of staff, physicians,
and volunteers. In the healthcare environment, the health and well-being of the workforce and the quality
of the work environment has a significant impact on the effectiveness and efficiency of the services HHS
provides to patients. The focus for 2015/16 will be to reduce the lost-time injury frequency by utilizing
workplace inspection and hazard assessment tools and preventing Musculoskeletal Disorders.
Integration & Continuity of Care
HHS has formed strong partnerships with the LHIN and with community partners to ensure that we provide
seamless care for patients as they return to the community. In 2015/16 we will continue to work closely with
the CCAC and partners to reduce the number of ALC days to Long-Term Care, Supervised/Assisted Living and to
Home with CCAC supports. This will be done through a joint work plan in collaboration with the CCAC, with
initiatives focused on reducing the time patients wait in hospital for transition to alternate levels of care.
Improvements in continuity of care are also a high priority at HHS through the implementation of several other
initiatives that are not captured in the QIP. For example, HHS is leading two local HealthLinks and implementing
Quality-Based Procedures— two key provincial initiatives aimed at improving the continuity of care.
Challenges, Risks & Mitigation Strategies
HHS will continue to strive to improve the care we provide to our patients, despite the many factors that will
continue to challenge our organization. Ongoing fiscal challenges related to global and provincial economies will
require HHS to continue to use resources wisely to support this work towards Best Care for All. We continue to
focus on our relationships with the LHIN and community agencies to ensure that patients receive timely, safe
and coordinated care throughout their entire journey.
Finally, HHS recognizes that in order to be successful in our efforts we must support our staff in quality
improvement. We have demonstrated a strong and sound commitment to safety and quality in our organization
and have invested in education and training so staff have the necessary tools and knowledge to support quality
improvement initiatives. Each initiative will have executive sponsorship and focused resources to support the
initiatives and for ongoing monitoring of progress at all levels of the organization.
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Information Management Systems
Hamilton Health Sciences has access to many information management systems that are leveraged to help
understand our various patient populations in order to improve care. For example, HHS has been a leader in
building both Clinical Connect as well as the Integrated Decision Support (IDS) Business Intelligence tool to be
able to follow a patient’s continuum of care from the emergency department to hospital acute care, to postacute care, to CCAC/CHC follow-up in the patient’s residence, and potentially readmission to hospital. Both are
multi-LHIN solutions, allowing for the real time viewing of healthcare activities and results for patients being
treated by those in the circle of care and retrospective system-wide analysis of readmissions, gaps in service,
chronic conditions, Health Links cohorts, and the presentation of “patient journeys”. In addition, the HNHB
LHIN has implemented a Regional Ambulatory Oncology System (MOSAIQ) and HHS and St. Joseph’s Healthcare
Hamilton are embarking on an Integrated Ambulatory Clinic System (EPIC) to better track, treat, and manage the
care of patients in clinic settings.
Regarding the key indicators on the QIP, HHS uses data from these and other systems, in order to narrow the
scope of the problem and provide focus to the teams involved in the initiatives, amongst other uses.
Engagement of Patients, Clinical Staff & Broader Leadership
There has been a significant effort at an organizational level through HHS’ FY14/15 strategic initiatives to
address the key drivers of engagement identified by staff and physicians. Strategies and action plans to address
improved recognition, growth and development, enhanced communication and team effectiveness are
underway. The culmination of these initiatives and activities will have a positive impact on our workforce
engagement. This is critical as staff and physicians are the foundation of the provision of safe and excellent
care. Our most recent staff engagement survey which was administered in 2014 demonstrates continued
improvements across HHS. Patients are engaged in multiple ways to inform quality. The Quality Improvement
plan considers feedback through Patient Experience surveys and the patient relations process. In addition,
through an initiative in this year's QIP, HHS has recruited, oriented and implemented Patient and Family
Advisors to support quality improvement activities. The focus this year will be to further recruit patient and
family advisors to represent diverse patient populations to support quality improvement work across HHS.
Accountability Management
Our executives' compensation is linked to performance in the following way:
All eligible Executive Council members, including the CEO, have a portion of their total compensation deemed to
be “at-risk” under the Hospital’s Variable Compensation Program(s). The Hospital’s Variable Compensation
Program for Executive Vice-Presidents, Presidents and Vice-Presidents is broader than the minimum statutory
applicability established within the Excellent Care for All Act – HHS believes strongly in accountability for results
and therefore, all eligible Executive Council members have a portion of their pay at-risk.
The percentage of base salary at-risk for the President & CEO as well as eligible Executive Council members
(Executive Vice-Presidents, Presidents, Vice-Presidents, Chief Nursing Executive) is 5%, linked to achieving the
targets set out in the QIP on the indicators below:
 60% of the at-risk compensation will be based on the achievement of the targets for
Huddles/Crosses/Rounding, Medication Reconciliation and Lost Time Injury Frequency
 30% of the at-risk compensation will be based on the achievement of the targets for Free Cash Flow and
the overall Patient Experience Survey rating
 10% of the at-risk compensation will be based on the achievement of the targets for ED wait times and
Alternate Level of Care rate.
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Health System Funding Reform
Ontario’s Health System Funding Reform has changed the focus from activity-based funding where funding is
based on historical types and volumes of patients, to population-and quality-based funding. Focus is now on
meeting community needs by improving access, and by maintaining or further improving quality and efficiency.
This model is aligned with the priorities of the QIP and HHS’s strategic goals as it supports moving best evidence
to practice, improving access to services for the community, and ensuring best value for money which aligns to
our goal of high quality, efficient and fiscally responsible care.
HHS’s focus on implementing Quality-Based Procedures as part of its strategic initiatives ensures that these key
improvement initiatives in the organization are aligned with the new health system funding model.
Sign-off
I have reviewed and approved our organization’s Quality Improvement Plan.
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