1. health and fitness

Quality Improvement Plan (QIP) Narrative for
Health Care Organizations in Ontario
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 Health Quality Ontario (if required) in the format described herein.
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Overview
In 2014, the Central West Community Care Access Centre (CW CCAC), Headwaters Health Care Centre
(Headwaters) and William Osler Health System (Osler) committed to an innovative partnership to integrate nonclinical (administration or back-office) support functions across the three organizations. This cross-sector partnership
is the first of its kind in the Province and will accelerate a regional approach to planning to support the delivery of
quality, timely health care services to those we serve. This year, our quality improvement plans (QIPs) reflect this
bold, new partnership and present a more in-depth and systematic approach to setting improvement targets and
developing change initiatives. Our QIPs also highlight key strategies for quality improvement within our organizations
and across our local health care system and are key components of our comprehensive quality programs.
Collectively we have placed patients at the core of our strategies to help create consistently exceptional patient
experiences. Together, we will work to enhance the safety and effectiveness of the system as a whole, through our
innovative practices and focused QIPs.
What does quality mean to the CW CCAC, Headwaters and Osler?
Quality is the foundation of everything we do and it shapes how we interact with and care for patients, their families
and the communities we serve.
To the CW CCAC, Headwaters and Osler, quality means taking a system-wide approach to ensuring patients get the
care they need, when and where they need it.
We are committed to working with our strategic partners to provide the best experiences, treatments and outcomes
for patients and families every day. Together, we believe quality means:
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Patients are informed about healthy lifestyle choices so they can stay healthy or better manage their chronic
diseases at home or in the community.
Health care providers in our communities can easily identify and access services at our hospitals, so patients
do not make avoidable trips to the emergency department. When emergency care is required, patients have
timely access to services and experience seamless transitions between hospital departments, between
hospitals in our region, and between the care they receive in hospital and the care and support they receive in
the community through the CW CCAC.
Our services are inspired and shaped by patients and the care they receive is personalized to their needs so it
is in keeping with a patient’s belief and values.
Information flows easily between care providers to support clinical decision-making about care and treatment.
We support staff in continuously developing their skills so they can provide the best possible care and services
that are safe, effective and reflective of best practices.
Quality also means investing in innovation and striving for improvements to not only provide the exemplary care that
patients and the community expect but lead the way in creating inspired new approaches that are at the forefront of
care delivery.
How will our 2015-16 QIPs improve care for patients?
The CW CCAC, Headwaters and Osler are committed to evidence-based practices and to providing the best possible
care to meet the unique needs of each patient.
In addition, we are focused on improving how patients transition through programs and services within our hospitals,
and as they return home with support from the CW CCAC or to another destination, such as long-term care, so
their journey is a seamless one.
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We believe we can make a significant impact on improving care for patients in our region by having shared
accountability for success on the following measures:
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Voice of the Patient. We will infuse the voice of the patient in all that we do to create ideal experiences that
are inspired and shaped by patients and personalized to their needs.
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Patient Satisfaction. There is a significant opportunity to transform and improve care across our region by
improving the experience for patients and their families. By listening to patients we understand that satisfaction is
largely based on their experience of how service is delivered, rather than the technical aspects of the medical care
they receive. Every touch point of patient care, whether in the home or an acute care setting, leaves a lasting
impression on how well patients feel they were served.
To help us identify opportunities to create the best possible patient experience, CW CCAC, Headwaters and
Osler will continue to measure how patients rate the care and services they receive at our organizations using our
NRC Canada Patient Satisfaction Surveys. To gather as much information as possible, we will also make phone calls
to patients after they leave our hospitals and, where applicable, as their care transitions to the CW CCAC, to
inquire about their experience. Measuring patient satisfaction with the transition between acute care and the CW
CCAC is unique in Ontario.
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30-day Readmission. Readmission to hospital within 30 days of discharge can be challenging for patients, their
families and the overall health care system. To improve the health, safety and quality of care for our community, as
health care providers, we have a unique opportunity to work together to reduce preventable hospital
readmissions by ensuring patients get the care they need, when they need it and in the most appropriate setting.
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Wait Times. For many people in the community, the Emergency Department (ED) is the gateway to health care
and as more patients come through our doors the impacts are felt across Headwaters and Osler and in the
community.
While Osler continues to navigate through the highest ED volumes in the province, patients coming to
Headwaters through their ED typically experience shorter wait times than others. With consistently increasing
numbers of patients visiting our EDs, Headwaters and Osler will build on past accomplishments and focus on new
opportunities to ensure exceptional care continues.
And, as increasing demand extends wait times, the CCAC is instrumental in supporting the safe and timely
discharge of patients once their acute care needs have been met, helping to reduce hospital wait times further.
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Falls. Falls pose a significant risk to patient safety and wellbeing. The CW CCAC will strive to reduce the
number of patient falls in the home, by working with patients to increase their knowledge, confidence and
independence. Headwaters and Osler play vital roles in supporting the CW CCAC’s improvement focus
on falls prevention by creating consistent documentation standards to better record and share falls-related
information, including fall risk assessment results and fall prevention strategies.
To make improvements in these areas with our partners and to address improvement initiatives specific to each
organization, the CW CCAC, Headwaters and Osler have each developed comprehensive quality improvement
strategies and specific targets in the areas which are highlighted below.
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CW CCAC
How will we improve?
How will we achieve this?
We will innovate with
our partners to ensure
patients continue to
receive coordinated care in
a timely manner.
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We will infuse the voices of
both patients and caregivers
in all that we do to create
optimum experiences that
are inspired and shaped by
patients and personalized to
their needs.
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We will implement new
and leading best practice
initiatives to enhance the
safety of our patients at
home.
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We will work together as
health care providers to
reduce preventable
hospital readmissions by
ensuring patients get the
care they need, when and
where they need it.
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Optimize our role in care coordination, system navigation, and timely
service delivery by more closely aligning CW CCAC staff with primary
care providers and local hospitals.
Strengthen partnerships with our contracted service providers to
develop more effective processes and remove barriers to reducing wait
times.
Bring the voice of the patient and caregiver to the forefront through
enhancement of the Patient and Caregiver Advisor role.
Define the “Patient and Caregiver Experience” so we can better
measure and monitor our actions to improve it.
Gain a comprehensive understanding of the transitions across the
partners and determine what drives satisfaction across the region
through the regionalization of a call centre with our local hospital
partners.
Partner with our contracted service provider organizations to
ensure outstanding care through quality-based performance.
Develop and implement a “Patient and Caregiver-Centered Framework” to
ensure their voices are central to everything we do.
Collaborate with hospital partners to improve communication regarding
patients who are at risk for falls as they are discharged from hospital to CW
CCAC.
Require contracted service providers to complete regular fall risk
assessments and share results with the CW CCAC.
Expand the implementation of the Home Independence Program to reduce
falls and maintain patients’ independence and safety. Optimize the CW
CCAC’s falls prevention and exercise classes to ensure they benefit as many
people as possible.
Select, implement and evaluate the use of a validated hospital
readmission predictor tool.
Connect patients without a primary care provider with one in their
community.
Complete cross-sector case reviews on patients who experience
avoidable hospital readmissions within 30 days of discharge.
Continue to develop formal care plans for Health Links patients.
Embed our Home Visiting Pharmacist, Rapid Response Nursing and
Mental Health and Addiction Nursing programs further into our evolving
models of service delivery.
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Headwaters
How will we improve?
Reduce the wait time for
patients to be transferred to
an inpatient bed from the
emergency department.
Work together with patients,
families and other providers
to ensure accurate and
comprehensive
medication information is
communicated when the
patient leaves the hospital.
Continue to reduce the risk
of patients contracting a
hospital acquired infection.
How will we achieve this?
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Improve existing processes and technologies to facilitate easier access
to information, inform decision-making and communication to
transition admitted patients faster.
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Develop an effective process built on knowledge and experiences
when medication information is gathered on patients upon their
arrival at the hospital and implement tools based on patient, staff,
physician and community partner feedback.
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Implement new practices and auditing tools to improve practices and
enhance compliance to keep patients, visitors, staff, physicians and
volunteers safe.
Continue to enhance antibiotic microbial stewardship.
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Osler
How will we improve?
We will work directly with
patients to better serve their
needs and create the ideal
patient experience.
We will reduce the wait
time for patients to be
transferred to an inpatient bed
from the emergency
departments.
We will introduce innovative
models of care to better meet
patient needs, deliver the
same or better outcomes and,
at the same time, shorten or
avoid hospital stays.
We will reduce the risk of
patients getting a hospital
acquired infection or being
prescribed the wrong
medication.
How will we achieve this?
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Continue to capture patient feedback and action improvements to
enhance services.
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Introduce a new ED customer service model to proactively engage with
patients/families and conduct customer service education and training for
specific roles to enhance the patient/family experience.
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Regionalize the call centre to get a comprehensive understanding of the
transitions across the partners and to determine what drives satisfaction
across the region.
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Continue to implement technology to facilitate easier access to patient
information to inform clinical decision-making.
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Continue to focus on sustainable improvement strategies to better align
and optimize our capacity with demand and improve access for patients in
high-need areas.
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Engage community-based mental health and addiction services and
improve processes in the ED to address mental health patients’ needs and
effectively transition patients to community resources.
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Continue developing Health Links across the care continuum in CW LHIN
to improve the coordination of care for medically complex patients.
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Increase the number of medically complex patients who access
Telehomecare and expand enrollment of diabetic patients in the Centre
for Complex Diabetes Care to effect a decrease in readmission rates for
these patients.
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Continued engagement of proper hand hygiene practices and compliance
to keep everyone at Osler safe from harm.
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Continued focus on improving the collection and documentation of patient
medication information and sharing it with other health care providers
through care transitions.
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Continued expansion of the antimicrobial stewardship program to reduce
the risk of hospital acquired infections directly linked to antibiotic usage.
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Integration & Continuity of Care
How does the QIP align with other planning processes and strategies?
Our QIPs take into account the priorities and common directions of our three organizations, as well as our other
health system partners, the Ministry of Health and Long-Term Care (MOHTLC), and the Central West Local Health
Integration Network (LHIN). These strategic themes are woven through our various quality, safety and improvement
plans to ensure patients and families within our region get the care they need, when and where they need it, today and
into the future.
Our QIPs fully align with each of our corporate directions and goals outlined in our multi-year Strategic Plans, Annual
Business Plans and Regional Information Management and Information Technology Plan. For Headwaters and Osler,
our QIPs also align with our respective Clinical Priorities Plans. Priorities identified by Accreditation Canada were also
taken into consideration in the development of our QIP.
By aligning our improvement agendas with our corporate strategies and plans, we sharpen our focus on quality, and
strengthen our ability to successfully achieve the Vision of each of our organizations as we embed innovation and
best practice into the quality and safety culture within our and among our partners’ organizations. As one means of
measuring our success, in 2016, the organizations will also seek to maintain its Accreditation with Exemplary Standing
through Accreditation Canada.
To view the Strategic Plan, Annual Business Plan, Accreditation Report and other quality and safety indicators of CW
CCAC, Headwaters or Osler, please visit our web sites:
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www.healthcareathome.ca/centralwest
www.headwatershealth.ca
www.williamoslerhs.ca
Thanks to the dedication of staff, hospital physicians and hospital volunteers, the commitment of our Boards of
Directors and leadership, and the support from and collaboration with our community partners, we are confident we
will achieve the goals outlined in our 2015-16 QIPs.
How will we work with our health care partners?
By working with our partners more closely than ever before, we are creating new opportunities to improve the quality
of patient experience across the Central West region. Our dynamic new non-clinical administration partnership is a
catalyst for further collaboration, joint investment opportunities, system-level planning and improves our combined
ability to meet the health care needs of our community.
Our collective Vision, Mission, Values and corporate priorities demonstrate a strong degree of existing organizational
alignment which will help us successfully achieve our goal of improving care for patients in our region. We are creating
new opportunities to leverage the strengths and expertise of our organizations.
Health Links is a great example of where we’ve taken a leadership role in our region to work with health care
providers across the Central West LHIN, to improve access to health care services and make it easier for patients and
families to get the appropriate level of care in their home, community or in the hospital.
As partners, we believe our 2015-16 QIPs demonstrate our combined commitment to enhancing the quality of care
across the care continuum.
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Challenges, Risks & Mitigation Strategies
How will we overcome challenges to ensure success?
The CW CCAC, Headwaters and Osler have established innovative strategies and stretch targets for each of our
organizations. Our QIPs will require the collective efforts of our staff, physicians, hospital volunteers, partners
throughout the system, and for the CW CCAC, the engagement of their contracted service providers. In order to be
successful, we have identified solutions to help us overcome the challenges we face today.
CW CCAC
Challenges
Demand for services
Our region is home to one of
the fastest growing and
most diverse populations in
the province.
Solutions
• Partner with hospitals, primary care providers and other community sector
partners optimize access to services in our community, so patients get the
care they need, when they need it and in the most appropriate setting.
• Actively seek to gain better insight into the unique health care needs of our
diverse population and link them to appropriate care in a timely manner.
Increased complexity of
patient needs
As people age, the complexity
of their health care needs also
increases.
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Work with local hospitals to help patients stay safely at home longer with
CCAC services.
Improve communication between providers to promote effective, safe care
transitions.
Continue to collaborate with primary care providers and other partners to
support high-needs patients though Health Links and other key initiatives.
Focus on efficiency improvements and standardization within our region so we
can support as many complex patients possible in the community once their
acute care needs are met.
Tailor our programs and services to best meet the needs of patients.
Streamline processes to avoid duplication and improve the flow of patients
through the health care system.
• Continue to identify Health Links patients and create outcome-based care
plans to best manage their chronic conditions.
More chronic conditions
Our region has an increased
number of people with
complex chronic health
conditions.
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Economic constraints
Health funding reforms have
changed the way health care
providers are funded.
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Patient preferences
There is a need for a deeper
understanding of the patient
and caregiver experience.
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Support funding shifts to promote care delivery in the most appropriate
setting.
Improve efficiency by utilizing quality improvement tools and applying leading
practices so we can provide more care with our available resources.
Continue to engage patients through existing channels and implement new
ways of reaching out to patients and caregivers even further.
Involve patients and families at all touch points in their health care journey so
that care is personalized.
Implement leading global practices in customer service and improving the
patient experience.
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Headwaters and Osler
Challenges
Demand for services
Our region is one of the
fastest growing with aging
populations.
Headwaters, as a mediumsized hospital, is dependent on
its partners to help deliver the
right care, when and where it is
needed.
More chronic conditions
Our region has an increased
number of people with
complex chronic health
conditions.
Economic constraints
Health funding reforms have
changed the way health care
providers are funded.
Organizations are doing
more with less.
Patient preferences
Many aspects of patient
experience need more
consideration and
understanding.
Solutions
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Partner with health care providers to identify and access services so
patients get the care they need, when and in the most appropriate setting
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Improve communication between providers to promote effective, safe
care transitions.
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Streamline processes to avoid duplication of services and implement
improvements for better flow of patients through our system
Tailor our programs and services to meet the needs of patients in our
community.
Specific to Osler-Create specialized services and centres of excellence in
order to better meet the needs of patients.
Focus on efficiency improvements and standardization within our region
so that we can provide more with the same resources
Support shifts in funding to promote delivery of care in the most
appropriate setting.
Find effective new ways to communicate with patients.
Involve patients and families at all touch points in the health care journey
so that care is personalized.
Implement leading global practices in customer service and improving the
patient experience.
Information Management Systems
How will we harness technology?
Technology helps to facilitate exemplary patient care. Through the development of a Regional Information
Management and Information Technology Plan with our strategic partners, we will create an integrated
roadmap to leverage technology solutions such as a patient portal and other information sharing platforms to
improve quality of care for patients in our region and quality of the work environment for our staff members.
To inform the targets in our QIPs and corporate scorecards, each of our organizations leverages data from our
own information systems, provincial data sets and information from health care partners. Data quality is a focus
for all of us to ensure data is accurate, complete, timely, reliable and relevant for clinical, statistical and financial
information to support decision-making and performance management.
In keeping with our commitment to quality, we use technology and its tools to regularly monitor, measure,
assess and evaluate our targeted improvement plans to proactively deliver care to enhance health, treatment
and outcomes.
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Engagement of Clinicians & Leadership
Quality improvement is deeply ingrained in each of our cultures and at every level of our organizations, by
those who deliver and support exemplary care.
At Headwaters and Osler, our QIPs were individually developed with the involvement of our respective Boards
of Directors, Quality Committees, senior leadership, clinicians, physicians and staff. By using performance
huddles with aligned quality measures and indicators, as well as a daily access reporting tool, clinicians, staff,
physicians and leadership are frequently engaged in, measured on, and share in the quality goals and
commitments at our hospitals.
In setting its strategic directions for 2013-2016, the CW CCAC’s Board o f D i r e c t o r s articulated a
desired future state that is patient-centric and fueled by fabulous people, engagement and innovation.
Staff from throughout the organization are regularly engaged in the creation, prioritization and implementation
of programs that support the realization of the CW CCAC’s strategic directions, drive quality and add value.
To ensure Headwaters’ continued success on its journey of quality improvement and innovation, clinicians,
staff, physicians and leadership receive training and education opportunities to enhance their capacity for
change, innovation and improvement. This year, the CW CCAC and Osler will work closely with Headwaters
to standardize and implement an evidence-based leadership development framework across all our
organizations.
Patient/Resident/Client Engagement
To create the best possible patient experience and achieve the Visions for our organizations, the voice of the
patient is infused throughout our organizations. Continuous patient feedback helps shape our plans and
initiatives, including our QIPs in order to improve the quality and safety of care. We directly engage patients to
seek input on the quality of their care and their experience, through NRC Canada Patient Satisfaction Surveys
and by connecting with patients directly via phone calls after they are discharged from hospital or from home
care.
In addition, for Headwaters and Osler, our QIPs were developed with the involvement of our communities,
through our Community Advisory Councils.
Our non-clinical integration has allowed for the cross-sector development of quality improvement goals that
will impact our shared patients and provide opportunity to support each other in new ways. As part of our
bold, new partnership, we have created a new cross-appointed position, Chief Patient Experience Officer
(CPEO), to ensure the patient is at the heart of everything we do and to support our collective focus on being
leaders and innovators in the area of patient experience. Through our collective efforts we will create bold,
new strategies that transform the patient experience across the hospital and community settings.
Our passion for quality and philosophy of continuous quality improvement is greater than ever before and is
evidenced by the way in which we are engaging patients and families at all touch points in the health care
journey.
Accountability Management & Performance Based Compensation
Through the Excellent Care for All Act, hospitals in Ontario have a requirement to tie compensation of the
Chief Executive Officer (CEO) and other executives to the achievement of performance targets laid out in the
QIP. While this same regulatory requirement does not extend to the CCAC sector at present, Central West
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CCAC believes the linkage between performance and compensation is an important measure of accountability.
It is a linkage that the organization has decided to implement in keeping with its firm commitment to being
accountable for outcomes, as well establishing yet another means of bringing about closer alignment between
the CCAC and its acute care partners, Headwater Health Care Centre and William Osler Health System.
The purpose of performance based compensation is:
• To drive performance and improve quality of care.
• To establish clear performance expectations and expected outcomes.
• To ensure consistency in application of the performance incentive, accountability and transparency.
• To enable teamwork and a shared purpose.
Central West CCAC’s Executive Team Composition and Portion of Compensation Linked to
Performance:
Members of the Executive Team who report to the CEO have their compensation linked to achieving specific
QIP targets as well as other individual performance targets. The amount of compensation that is performancebased for each Vice President is determined as a percentage of that member’s base salary. The performancebased compensation percentages at risk for the 2015/16 fiscal year are set out below:
Vice President, Patient Care, Quality and Safety: 3%
Joint Vice President, Facilities & Redevelopment: 3% [across a joint portfolio]
Joint Vice President, Finance: 3% [across a joint portfolio]
Joint Vice President, Human Resources & Organizational Development: 3% [across a joint portfolio]
Joint Vice President Information Management & Information Technology: 3% [across a joint portfolio]
Joint Vice President, Patient Experience, Communications & Strategy: 3% [across a joint portfolio]
Application of Improvement Targets to Individual Executives
Targets identified in the QIP form the basis for several performance goals for the leadership team and
staff. Vice Presidents will have their performance-based compensation tied to the achievement of three key
indicators identified for improvement from within the QIP. Specifically, performance on the following
indicators will be the focus for the year: falls for long-stay patients; hospital readmissions within 30 days of
discharge and; patient experience. At the conclusion of the 2015/16 QIP period, performance on each of the
QIP targets will be evaluated. For the key QIP indicators in the performance model, it will be determined what
compensation has been earned based on performance against target.
If an executive joins or leaves the organization mid-year, his or her performance-based compensation will be
paid following the conclusion of the fiscal year, pro-rated according to the position of the year worked at the
CCAC.
Accountability Sign-off
CW CCAC
I have reviewed and approve our organization’s Quality Improvement Plan:
Carmine Domanico
Board Chair
Elizabeth Hull
Client Services & Quality
Committee Chair
Cathy Hecimovich
Chief Executive Officer
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