Quality Improvement Plan (QIP) Narrative for
Health Care Organizations in Ontario
South West
Community Care
Access Centre
2015 March 30
South Wes Commun y Care Access Cent e, 2014 15 Q P
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1. Overview of Our Quality Improvement Plan
Overview
The South West Community Care Access Centre (South West CCAC) is committed to our
vision of 'outstanding care to every person, every day'. Through our culture of Client Driven
Care and a commitment to continuous quality improvement, we seek to achieve our
mission: "To deliver a seamless experience through the health system for people in our
diverse communities, providing equitable access, individualized care coordination and quality
health care."
In 2015/16 the South West CCAC will be further advancing the work started with the
2014/15 QIP on the following five areas: - reducing falls; - reducing unplanned visits to the
emergency department; - reducing unnecessary hospital admissions; - improving access to
care (5 Day wait times); and - improving the experience of care for patients and their
families.
In 2015/16 the South West CCAC will be further advancing the work started with the
2014/15 QIP on the following five areas: - reducing falls; - reducing unplanned visits to the
emergency department; - reducing unnecessary hospital admissions; - improving access to
care (5 Day wait times); and - improving the experience of care for patients and their
families.
The work to advance these Quality Improvement Plan areas fully aligns with the South West
CCAC's Strategic Directions:
1.0 “Work with Partners to provide safe, high quality client driven care”;
2.0 “Be a Great place to work”;
3.0 “Use resources wisely”.
This QIP also aligns with the South West Local Health Integration Network's Integrated
Services Plan priorities: improving access to healthcare, increasing the value of the
healthcare system for the people that we service, driving safety through evidence based
practice, and improving coordination and transitions of care for those most dependent on
health services.
2. Integration and Continuity of Care
The South West CCAC views integration and continuity of care as cornerstones of our
commitment to the people and the communities we serve. The Excellent Care for All Act is a
key part of our cultural foundation to bring to life the South West CCAC’s Strategic Direction
1.0 “Work with Partners to provide safe, high quality client driven care”. We believe
working collaboratively with health system partners is the critical success factor to improve
outcomes and patient experience with each distinct provider, as well as a better patient
journey overall. Through collaborative projects, the South West CCAC and health system
partners will build upon past learning and success to achieve our 2015-16 QIP:
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South West Community Care Access Centre, 2015-16 QIP
Reducing Falls: The South West CCAC will continue to collaborate with health system
partners in Grey Bruce to advance the Grey Bruce Falls Prevention Program (GBFPP). A
stewardship committee comprised of senior leaders from Public Health, Provider
organizations and the CCAC has accepted the challenge to spread and sustain best practices
and performance measurement/monitoring throughout the South West as per the provincial
integrated falls prevention framework. The focus for 2015/16 includes targeted education
sessions with our Care Coordinators and contracted Service Provider partners to support
working with patients and families to ensure that they are able to move about their homes
as safely as possible.
Reducing ED and Hospital readmissions: Health system partners have been successful
in decreasing the number of Alternate Level of Care (ALC) days in the region through the
Home First project – we will leverage this success (and the partnerships) to further reduced
ED and readmissions. A key strategy is the partner role the South West CCAC plays in the
Health Links that are forming in our region. Integration with primary care in combination
with Rapid Response Nurses creates a critical linkage to improve continuity during hospital
transitions and prevent unnecessary ED visits. Technology is another key enabler, such as
e-notification just initiated with our hospital partners that is having a positive impact on the
avoidable emergency department visits and hospital admissions. The CCAC is a key partner
in several Expressions of Interest with hospitals partners regarding Post-Acute projects
focused on reducing length of hospital stay and readmission for targeted populations
including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF)
and stroke.
5 Day Wait Times: For 2014-15 the South West CCAC worked collaboratively with our
contracted Service Provider partners to develop and implement the Service Initiation Tool
(SIT) to improve the prioritization of a patient's first visit for care. Utilization of the tool
has improved the communication of the patient's service prioritization. However work needs
to continue to reflect patient choice where appropriate and to understand the root causes
(and remedies) when care is not delivered within timeline parameters.
Patient Experience: Patients receiving care from the South West CCAC and our
contracted Service Providers have consistently reported a very high level of satisfaction with
their care experience. As the South West CCAC continues to advance quality improvement
initiatives, we will continue to look for opportunities to improve the patient experience.
Patient Experience is covered in greater depth in the section below.
3. Challenges, Risks and Mitigation Strategies
Ontario's health system is transforming and the ‘Modernization of Home and Community
Care’ is a priority for the Government of Ontario. The South West CCAC supports that
transformation. While we remain committed to the QIP aims and targets, there may be
unknown emerging issues/projects that may impact our ability to reach the targets we have
projected in our 2015/16 QIP. Several of the indicators in our QIP are dependent on the
South West Community Care Access Centre, 2015-16 QIP
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collaborative work with our health system partners which can also be impacted by
unknown/emerging issues/trends. For all of our quality improvement work, there are clear
accountabilities and project measures that are utilized to project any challenges in attaining
these targets.
The South West CCAC is dependent on the work of our contracted service providers. With
the increasing demands for CCAC-funded services for more and more complex patients, we
will need to continue to work closely with our contract service providers to ensure that the
'right care is delivered to the right patient at the right time'.
4. Information Management
The South West CCAC uses CHRIS as our central patient electronic record. Our Care
Coordinators use an internationally research based assessment tool called the Resident
Assessment Instrument-Home Care (RAI-HC) as the common assessment tool for long-stay
patients and the Resident Assessment Instrument – Contact Assessment (RAI-CA) as the
common assessment tool for intake/short stay patients. We use an Event Tracking and
Management System (ETMS) to document and track risk events, compliments and
complaints. From these various data sets, we produce and extensive and evolving business
intelligence reports that inform our work at the Care Coordination, team, CCAC and system
level. All quality improvement initiatives have a set of project indicators that the team
utilizes to advance that project's work and demonstrate the added value of that project's
outcomes.
5. Engagement of Clinicians and Leadership
The South West CCAC utilizes various forums to engage with contracted providers, system
partners, Board members and staff. This includes, but is not limited to: monthly meetings
with Service Providers/vendors (both at a leadership and an operational level), regular
meetings with our Hospital partners (both at a leadership and operational level),
engagement with our Long Term Care Home partners, Community Support Service partners
and now with our HealthLink partners. In addition to their role of robust monitoring, our
Board Quality of Care Committee is very active in supporting and challenging the
organization to continually strive for improved patient safety and quality. Engagement with
CCAC staff includes the use of patient stories and reflective practice to advance knowledge
transfer. We also use ‘Quality Improvement Leadership Teams (QILTs), which are
comprised of staff from all functional areas and management.
Given the significant geographical dimensions and number of health service providers
serving the South West, the CCAC is significantly engaged at more than 100 partner ‘tables’
on a regular basis. Through these forums, the South West CCAC engages on our strategic
directions and QIP aims, sharing data to strengthen that engagement process and
collaborating in quality improvement initiatives. Our Board meets regularly and the Board
Quality of Care Committee meets regularly and is accountable for monitoring the
organization's progress and achievement of the PMF and QIP goals and targets.
South West Community Care Access Centre, 2015-16 QIP
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6. Patient/Resident/Care Engagement
The patient/resident care engagement strategy for South West CACC is a multiyear strategy
with an initial focus in Year One on leveraging existing engagement opportunities via the
Health Links work in Huron Perth and London with complex clients, and which will lead to
increasing levels of fulsome patient empowerment and authentic partnership in decision
making (for example attendance on committees/working groups/patient advisory groups,
and patient based design) in each of the subsequent years, for a three year strategy.
A “taking stock” evaluation following year one, will help understand what worked and what
didn’t, time, cost and resource requirements, and quality and other priorities, including
Accreditation in October 2016. The Committee can then reflect on further specifics for Years
2 and 3, with a focus on reflecting a client driven care approach and how we can uniquely
advance to build on our strengths working with patients and families.
Activities for Year One include:
•
Patient/family engagement interviews with Huron Perth and London Health Links;
An experience based design approach will be used as part of a multi-partner
organizational strategy; Outcomes will be reported to Health Links partners;
Focus for the interviews is patients with complex care needs and who have
experience in transitions between providers. The Health Links engagement
process will also be leveraged to provide a system perspective to Client Driven
Care, for example implementing tools with Health Links team such as – guided
conversations/scripts, training etc. Where appropriate patients may be asked to
consider what successful engagement would look like and/or asked if/how they
would like to participate as the CCAC model evolves
•
Review recent complaints (previous 6 months): trend and theme; explore
possible opportunities for engagement with patients/families around “Always
Events” (see below)
•
Always Events: Always Events refer to aspects of the patient experience that are
so important to patients and families that health care providers must perform
them consistently for every patient, every time. Always event interviews are
being undertaken to facilitate a discussion with patients and caregivers to help
CCAC define what “Always Events” might be in supporting clients and put the
patient at the center of the redesign of the health care, providing a roadmap to
rapidly meet long standing patient needs. We will leverage this opportunity as a
launching point to gather patient stories. With consent, these interviews will be
video- taped and transcribed. Experiences will be shared with staff to provide
opportunities for quality improvement. Patients will be asked what they might see
as solutions. CCAC will look to apply these learnings to quality improvement
opportunities (year 2).
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7. Accountability Management
This QIP will be monitored on a regular basis. The Board Quality of Care Committee is
accountable to monitor the performance indicators from the PMF and the QIP at their regular
meetings. All quality improvement projects are assigned an Executive Lead member from
our Senior Team. These projects are all registered through our Project Management Office
with project charters and regular project reporting. We review organizational performance
on the PMF and QIP indicators at All Staff meetings and with our Quality Improvement
Leadership Teams. The QIP goals and targets are incorporated in the CEO pay for
performance compensation framework.
Sign-Off
I have reviewed and approved our organization’s Quality Improvement Plan on this 25th day
of March, 2015.
Original Signed by:
________________________________________
Linda Ballantyne, Board Chair
Original Signed by:
_______________________________________
Sandra Coleman, CEO
South West Community Care Access Centre, 2015-16 QIP
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South West Community Care Access Centre Quality Improvement Plan
2015/16
AIM
Quality
Dimension
Safety
MEASURE
Objective
Measure/Indicator
To reduce falls among
long-stay home care
clients
Percentage of Adult Long-Stay Home
Care Clients who Record a Fall on their
Follow-up (RAI-HC) Assessment.
To reduce the number of
unplanned ED visits
among home care clients
Percentage of home care clients with an
unplanned, less-urgent ED visit within the
first 30 days of discharge from hospital
To reduce avoidable
hospital admissions
among home care clients
Percentage of home care clients who
experienced an unplanned readmission to
hospital within 30days of discharge from
hospital
Current
Performance
35.50%
9%
CHANGE
Target for
2015/16
<=34%
To reduce service wait
times
Percentage of patients requiring
nursing services that are seen within 5
days of service authorization.
To reduce service wait
times
Percentage of complex patients
requiring personal support services
that are seen within 5 days of service
authorization.
92.50%
Set to reflect the
increasing acuity of the
long-stay population
Spread of falls
prevention
programs across
South West
including
standardized care
models and
education.
Methods
We will work with
our provider
partners to spread
components of the
Falls Initiative which
has improved falls
safety in Grey Bruce.
Process
Measures
Goal for
Change Ideas
TBD
100% of areas
implemented
in
2014-15.
9%
Target under review and
will be updated once we
have access to the
information through
Regional Integrated
Decision Support (RIDS).
Robust care plans for
persons with complex
needs including Rapid
Response Nurses and
Nurse Practitioners
Program measures
reviewed monthly
TBD
Prevention of
escalation
18.20%
Target under review and
will be updated once we
have access to the
information through
Regional Integrated
Decision Support (RIDS).
Robust care plans for
persons with complex
needs including Rapid
Response Nurses and
Nurse Practitioners
Program measures
reviewed monthly
TBD
Prevention of
escalation
Ontario Budget
commitment tied to
funding over 2 years
New Service Initiation
Time (SIT) tool
Kaizen event to work
with partners to reevaluate the SIT tool
including ongoing
metrics
TBD
>=95% of SIT
scores
accurately
reflect patient
need.
Ontario Budget
commitment tied to
funding over 2 years
New Service Initiation
Time (SIT) tool
Kaizen event to work
with partners to reevaluate the SIT tool
including ongoing
metrics
TBD
>=95% of SIT
scores
accurately
reflect patient
need.
TBD
Established
"Always event"
will occur
100% of the
time.
Effectiveness
18.20%
Target Justification
Planned
Improvement
Initiatives
>=95%
Comments
South West
CCAC is
continuing to
see more and
more complex
patients who
are increasingly
at risk of falls.
Access
Client-Centred
To improve client
experience
03/30/2015
Patient/caregiver overall rating of South
West CCAC Services.
88.90%
94.20%
>=95%
>=94%
Maintain in top 10th
percentile of CCACs
Establish "Always
Establish the
events" for every care "Always event" then
audit performance.
team.
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