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2015/16 Quality Improvement Work Plan
1
"Improvement Targets and Initiatives"
London InterCommunity Health Centre, 659 Dundas Street, London, ON, N5W 2Z1
AIM
Quality dimension
Access
Measure
Objective
Access to primary
care when needed
Reduce ED use by
increasing access to
primary care
Measure/Indicator
Percent of
patients/clients able
to see a doctor or
nurse practitioner on
the same day or next
day, when needed.
Percent of
patients/clients who
visited the ED for
conditions best
managed elsewhere
(BME).
Unit / Population
% / PC
organization
population
(surveyed
sample)
% / PC org
population
visiting ED (for
conditions BME)
Source / Period Organization Id
In-house survey / 92235*
April 1 2014 March 31 2015
Ministry of
Health Portal /
April 1 2013 March 31 2014
92235*
Current
performance
40.22
3.6
Target
65
2
Target
justification
Target
decreased 10%
this year. Area of
focus is to return
to original rates.
Although the
relative target is
quite high, we
believe that by
focussing on our
highest ED users
we can reduce
this number
further, since
our current
performance is
already lower
than the
provincial
average of 11.7%
Change
Planned improvement
initiatives (Change Ideas)
1)Explore "Open Access" as
an option for increased
access to primary care.
Methods
* Primary Care and Medical Secretary Team Leads will
explore possible Open Access Models. * Plan to pilot
open access with one clinical area.
Process measures
* # of clients seen through pilot of Open Access Model
* % of increase of clients seen same day in Open Access
Model
Goal for change
ideas
* Review of Open
Access Models by
end of second
fiscal quarter. *
Pilot Completed by
end of fiscal year.
2)Explore walk-in model of * Pilot walk-in model one day a week in one clinical
care for our rostered
area in first quarter fiscal * Increase walk-in days in
primary care providers
clinical areas
using Nurse Practitioners.
* 20% increase in clients being seen in the primary care 85% of clients
clinic * # of hours being offered in walk-in hours *
report being able
increase in availability of primary care appointments
to have a same day
or next day
appointment
3)Review of how
appointments are being
scheduled in primary care
providers schedules.
Review of schedules and identify if appointments can
be used in a different manner.
# of appointments identified that could be used
differently and more effectively
4)Identify new triage
process for RNs and medical
secretaries in order to
better allocate resources
* Process mapping of triage and appointment booking * # of PDSAs identified and used * # of medical
process * Identify areas for PDSA cycles of improving
directives written and implemented
efficiencies within triage * Identify areas where scope
of practice of RN, RPN, NPs can be used more
effectively
The goal is to
increase the
number of
appointments that
are booked with
the appropriate
provider relative to
scope of practice.
1)Expand hours to 8 to 8,
including Saturday access
begin conversations with staff as to what a shifted
# of staff engaged in making the shift in service delivery
schedule would look like consideration consolidation of hours # of additional appointment times available for
location of our two homeless program areas (already clients Project plan developed
planned for) Develop project plan and staff
engagement process
100% engagement
of all staff in
organization
around expanded
hour 100%
improvement in
utilization of
clinical time
2)Explore walk-in model,
instead of appointments, or
open access model for
appointments
pilot project walk-in hours with NPs in one clinical
# of walk-in clients seen compared to traditional
program area research open access models from other appointments research is completed and pilot projects
chcs and propose a model using PDSA principles pilot undertaken
project open access with one MD provider
100% increase in
utilization of
clinical time Pilot
projects are
implemented and
evaluated
3)partner with other
community agencies to
provide outreach
community services to
clients in vulnerable
situations (RN and
community partners)
focus group with community partners (particularly
# of community partners willing to work with us # of
mental health and addictions) and see how we can
PDSA cycles of piloting and improving outreach services
support efforts with primary care services development
of a pilot project involving at least 2 primary care
providers (NP/RN) and community partners
minimum of 2
community
partners come to
the table to
discussion 6 PDSA
cycles of outreach
complete
Review of provider
schedules and
types by end of
second quarter
fiscal.
Comments
Change is
dependent on
being able to
recruit additional
primary care
physicians.
2015/16 Quality Improvement Work Plan
2
"Improvement Targets and Initiatives"
London InterCommunity Health Centre, 659 Dundas Street, London, ON, N5W 2Z1
AIM
Quality dimension
Integrated
Measure
Objective
Timely access to
primary care
appointments postdischarge through
coordination with
hospital(s).
Measure/Indicator
Percent of
patients/clients who
saw their primary
care provider within
7 days after
discharge from
hospital for selected
conditions (based on
CMGs).
Unit / Population
% / PC org
population
discharged from
hospital
Source / Period
Ministry of
Health Portal /
April 1 2013 March 31 2014
Organization Id
92235*
Current
performance
19.6
Target
80
Target
justification
We are wanting
to dramatically
improve the
follow-up of
client care 7 days
post-discharge
because of the
complexity and
acuity of our
client population
Change
Planned improvement
initiatives (Change Ideas)
1)Increase in client
education including : add to
appointment cards for
clients "if admitted to the
hospital, please contact the
Health Centre within 7 days
of being discharged." Make
materials available in top 8
languages.
Methods
the only way to accurately gather this data is through
our practice profile which is only provided twice per
year. Will also track client and staff feedback whether
there is an increase in clients reporting they were
recently in hospital. Will use LENs reports to identify
clients who were in hospital and did not call.
2)Improve triage process to process mapping of triage process for incoming calls
identify clients who were
requesting appointments
recently in hospital
3)Use LENs reports to
identify clients recently
admitted to hospital and
provide follow-up phone
call for appointment.
Reduce unnecessary Percentage of acute
hospital
hospital inpatients
readmissions
discharged with
selected CMGs that
are readmitted to
any acute inpatient
hospital for nonelective patient care
within 30 days of the
discharge for index
admission, by
primary care practice
model.
% / PC org
population
discharged from
hospital
Ministry of
Health Portal /
April 1 2013 March 31 2014
92235*
7.8
6.2
Achieving the
provincial
average would
be a 20%
reduction.
Receiving and
utilizing feedback
regarding
patient/client
experience with the
primary health care
organization.
Percent of patients
who stated that
when they see the
doctor or nurse
practitioner, they or
someone else in the
office (always/often)
give them an
opportunity to ask
% / PC
organization
population
(surveyed
sample)
In-house survey / 92235*
April 1 2014 March 31 2015
80.17
90
Target is to
return to
previous level.
Decrease is in
part likely due to
change in how
we asked
question and
challenges in
100% of all clients
call for
appointment
triaged if in
hospital recently.
75% of clients
identified in LENs
reports are booked
appointments
Clinical Connect implemented and adoption rate of tool 100% of clinical
providers using
Clinical Connect
Leveraging our trainers already in self-management,
# of clients contacted from EMR generated list # of
plan with Chronic Disease Self Management
clients registered and completed entire SM group # of
Collaborative to run this group Generate list from EMR groups run
to identify client population to invite Contact all clients
and invite to attend session
3)Telehomecare strategy
Review of telehomecare strategy for in home
review for applicability with COPD/CHF monitoring Identification of client subset
client subset
who might be eligible through EMR identification and
chart review Client case conference with appropriate
planning to consider implementation
Patient-centred
# of clients identified by triage process of having been
in hospital within last 7 days
LENs reports are submitted to data analyst who will
100% of physicians are submitting their LENs reports on
screen for clients with appropriate CMGs List of clients a daily basis # of clients called for appointments
are provided to medical secretaries to make follow-up
phone call appointments
1)Leverage Clinical Connect implementation of Clinical Connect Staff training on
resources to improve
Clinical Connect Data from Clinical Connect used for
information access for
planning for improved care for clients
clients in hospital or who
have been recently
discharged
2)Establish a selfmanagement program
focussing on COPD (take
Lung Association’s model)
Goal for change
Process measures
ideas
Comments
# of clients identified in LENs reports being in hospital # 100% of physicians the data lag on
of clients calling for appointments
submitting their
this indicator is
LENs reports to our signficant and
data analyst 100% therefore
of clients educated challenging to
on process for post- identify how
hospital
progress is being
made; high
percent of clients
do not speak
English or French
and
communication is
a barrier in this
education
100% of clients
contacted 24
clients attend
group 2 groups
conducted during
the year
Strategy review # of clients identified # of case
5 clients identified
conferences # of clients implementing telehomecare re as potential
COPD/CHF
candidates 3
clients implement
telehomecare
1)Staff education on
We will collect data through our client satisfaction
# of staff trained on motivational interviewing # of
motivational interviewing - survey; data is reviewed on a quarterly basis. Staff
clients with whom staff use motivational interviewing
this helps clients identify
feedback on success of motivational interviewing tools techniques
they concerns for them and
to ask questions on the
issues that they are
addressing
100% of clinical
staff trained on
motivational
interviewing
Many clients do
not have phones,
or change #
regularly with pay
as you go
systems; contact
is difficult
2015/16 Quality Improvement Work Plan
3
"Improvement Targets and Initiatives"
London InterCommunity Health Centre, 659 Dundas Street, London, ON, N5W 2Z1
AIM
Quality dimension
Population health
Measure
Objective
Reduce influenza
rates in older adults
by increasing access
to the influenza
vaccine.
Measure/Indicator
opportunity to ask
questions about
recommended
treatment?
Unit / Population Source / Period
Percent of patients
who stated that
when they see the
doctor or nurse
practitioner, they or
someone else in the
office (always/often)
involve them as
much as they want to
be in decisions about
their care and
treatment?
% / PC
organization
population
(surveyed
sample)
Percent of patients
who stated that
when they see the
doctor or nurse
practitioner, they or
someone else in the
office (always/often)
spend enough time
with them?
% / PC
organization
population
(surveyed
sample)
Percent of
patient/client
population over age
65 that received
influenza
immunizations.
% / PC
EMR/Chart
organization
Review / na
population aged
65 and older
Organization Id
In-house survey / 92235*
April 1 2014 March 31 2015
In-house survey / 92235*
April 1 2014 March 31 2015
92235*
Current
performance
Target
77.54
97
82.03
45
92
50
Target
justification
challenges in
clinical staffing
levels.
Change
Planned improvement
initiatives (Change Ideas)
2)Review of scheduling
appointments - identify
areas where there may be
opportunities to adjust
appointment times as
required
Methods
Review of clinical schedulers Data from client
satisfaction survey
Process measures
# of appointment types adjusted in the scheduler
Staff to be trained on coordinated care plans Pilot
# of staff trained in coordinate care planning # of
project to be developed with test population of clients clients involved in a client -centred care plan
Improvement in client satisfaction rates
development
Goal for change
ideas
Comments
100% review of all
provider schedules
Return to
baseline - we
saw a significant
decrease in
performance this
year as we use
HQO exact
wording which
our clients found
very confusing.
1)Development of
coordinated care plans for
clients
2)Staff training on
Train all staff in motivational interviewing
motivational interviewing to
assist clients in being more
in control of their health
care goals
# of staff trained in motivational interviewing
100 % of staff
trained in
motivational
interviewing by
end of December
215. 80% of clients
seen between
January and March
2016 will be met
with motivational
interviewing
return to
baseline - we
saw a significant
decrease in
performance this
year as we use
HQO exact
wording which
our clients found
very confusing.
1)Staff education on
# of staff trained client satisfaction survey results
motivational interviewing - reported on quarterly
this helps clients identify
they concerns for them and
to ask questions on the
issues that they are
addressing
# of staff trained client satisfaction survey results
reported on quarterly
100% of staff
trained
2)Review of clinical
appointment times to
ensure we are using the
time appropriately
Will review appointment scheduler, reason for visit,
and visit encounter note to assess appropriate of
appointment time Patterns will be identified across
provider types
# of schedules reviewed
100% of schedules
reviewed
Looking to
increase by 10%;
a number of
different
strategies this
year increased
us by 1%, looking
to reasonably
grow this.
1)Pull data of all clients over
65 in fall 2015 and call each
person for reminder of the
flu shot
Using our EMR will pull the data for all clients over 65
Medical secretaries or system navigators will call all
clients Documentation of reasons why clients do not
want flu shot will be documented for analysis
# of clients identified for flu shot # of clients who came 100% of clients are many clients do
in as a result of the phone call
called for an
not have phones,
appointment
so phone calls
can be difficult;
we have had
some increase in
success with this
with other areas
2)Active offer of flu shot to All providers (community and clinical) will offer flu shot # of clients offered flu shot while here for another
all clients 65+
to any client over 65 regardless of reason for visit
appointment
Providers will provide flu shot outside of a regular visit
By end of year top
5% of complex
clients have a
coordinated care
plan that involved
client participation
100% of staff are
offering flu shots
to clients
We will be
leveraging the
work of Health
Links in
developing the
coordinated care
planning tool.
2015/16 Quality Improvement Work Plan
4
"Improvement Targets and Initiatives"
London InterCommunity Health Centre, 659 Dundas Street, London, ON, N5W 2Z1
AIM
Quality dimension
Measure
Objective
Reduce Cancer
mortality through
regular screening.
Measure/Indicator
Percent of eligible
patients/clients who
are up-to-date in
screening for breast
cancer.
Percent of eligible
patients/clients who
are up-to-date in
screening for
colorectal cancer.
Percent of eligible
patients/clients who
are up-to-date in
screening for cervical
cancer.
Unit / Population Source / Period
% / PC
EMR/Chart
organization
Review / n/a
population
eligible for
screening
% / PC
organization
population
eligible for
screening
% / PC
organization
population
eligible for
screening
EMR/Chart
Review / n/a
EMR/Chart
Review / n/a
Organization Id
92235*
92235*
92235*
Current
performance
53.8
62
69.5
Target
60
65
75
Target
justification
increased
previous
performance by
10%, will
continue along
this trajectory
We increased
our FOBT rate
significantly the
last year and
would like to
keep slow and
steady
We are working
on improving
this through
slow and steady
outreach
Change
Planned improvement
initiatives (Change Ideas)
1)Pull client list of all
women eligible for
mammogram
Methods
Data pull from EMR by Data Management Coordinator
Medical Secretaries or System Navigator will call clients
and request they come for an appointment to discuss
preventative health issues (PAP, Mammogram, FOBT)
Process measures
100% of eligible clients are contacted for an
appointment # of women who book and showed for
their appointment
2)Provide education
sessions to women on
preventative health issues
with capacity to (a) book
mammogram right on the
spot and (b) have PAP
immediately
RNS, RPNs, NPs, will provide education session on the # of educational sessions provided # of women booking 2 workshops
importance of these preventative health issues to
mammogram appointments at the day of the workshop throughout the
populations focusing on language and lifestyle barriers
year 50 new
women attend
workshops in total
1)data pull on all clients
eligible for FOBT and
arrange to call them for an
appointment to pick up
screening kit
Data pull from EMR by Data Management Coordinator # of clients call for appointment # of screening kits
Medical Secretaries or System Navigator will call clients distributed
and request they come for an appointment to discuss
preventative health issues (PAP, Mammogram, FOBT)
Provision of easy to use screening kits with all supplies
available
100% of clients
eligible are called
for an
appointment 50%
of clients book and
show for an
appointment for
FOBT
2)Education session for
clients on preventative
health issues with the
capacity to receive a FOBT
screening kit immediately
RNs, NPs, RPNs will conduct health education
workshops on preventative health issues Distribution
of FOBT kits to appropriate client population
2 workshops held
50 kits distributed
1)data pull by DMC for all
eligible women for PAP
screening, followed by
System Navigator or
medical secretary calling to
book an appointment
Data pull from EMR by Data Management Coordinator # of clients contacted by system navigator for
Medical Secretaries or System Navigator will call clients appointment # of clients booking and showing for
and request they come for an appointment to discuss appointment
preventative health issues (PAP, Mammogram, FOBT)
# of education workshops held # of FOBT kits
distributed
2)Provide education
RNS, RPNs, NPs, will provide education session on the # of educational sessions # of women getting PAPs
sessions to population
importance of these preventative health issues to
groups to educate on the
populations focusing on language and lifestyle barriers
importance of preventative
screening with the capacity
of having a PAP done
immediately, right there
Other
Other Objective
Percentage of
primary care clients
55+ who report
overall increase in
mobility, flexibility
and balance after
% / PC
EMR/Chart
organization
Review / March
population aged 31 2016
65 and older
92235*
CB
50
Goal for change
ideas
100% of women
contacted 50% of
women book and
show for
appointments
This was a
1)Identify clients based on
program that we age and health data for
tried last year
targeted interventions
and we were
unable to collect
baseline. This
review EMR and pull data on clients fitting profile
contacting all clients to participate identify clients in
Wrap Around program to connect clients in that
program to the service
# of clients identified # of clients contacted
100% of clients
contacted for an
appointment
within the fiscal
year 50% of clients
book and show for
appointment
within the fiscal
year
2 educational
sessions 50% of
women book and
show for PAP
100% of clients
identified are
contacted
Comments
2015/16 Quality Improvement Work Plan
5
"Improvement Targets and Initiatives"
London InterCommunity Health Centre, 659 Dundas Street, London, ON, N5W 2Z1
AIM
Quality dimension
Measure
Objective
Measure/Indicator Unit / Population Source / Period
and balance after
participating in
Health Centre
exercise programs
with an overall goal
of decreasing slip and
fall injuries
Receiving and
utilizing feedback
regarding
patient/client
experience with the
primary health care
organization
% / All patients
Organization Id
In-house survey / 92235*
March 31, 2016
Current
performance
74
Target
81
Target
justification
baseline. This
year we are
trying agin.
Current
performance
indicates a 6%
reduction from
previous target,
but there was
also a 25%
increase in
clients accessing
this space
shortly.
Change
Planned improvement
initiatives (Change Ideas)
2)improve plans of care of
identified clients that
incorporates exercise
programs
Methods
Process measures
primary care and other providers will review plans of
# of client care plans reviewed # of exercise sessions
care for clients and promote the Health Centre exercise offered # of participating clients
programs where appropriate, coordinated care
planning and chart review
Goal for change
ideas
Comments
100% of client
plans of care are
reviewed 100% of
all identified clients
are offered
exercise
programming 50%
of identified clients
participate in
exercise
3)administer a modified pre physiotherapist will review and modify existing client
& post client evaluation tool evaluation tools Physiotherapist administers pre and
that incorproates
post tests
physiotherapy assessment
for all identified clients
participating in exercise
# of pre and post tests completed # of slips and falls
and injuries reported by clients # of clients reporting
improved mobility, flexibility and balance
100% of
participating
clients are
assessed 100% of
participating
clients report a
decrease in slips,
falls and injuiries
50% of
participating
clients report an
increase in
mobility, flexibility
and balance
1)integrating clinical and
non-clinical providers in
program
development/faciltiation
in house survey, training of peer leaders
# of co-lead programs
10% increase in
clients reporting
feeling safe over
the fiscal period
2)1:1 supports by trained
providers
education to providers on outreach Peers support
leaders recruited and trained
# of encounters related by community outreach
providers
50% reduction in
Complytrack
Agressive
Behaviour incident
reports
3)Systemic follow-up on
client issues by clinical
providers as they arise in
Safer Space
survey to track clients in the space and perception of
issues resolved
# of client surveys completed
baseline data
4)Revision of current Safer
Space survey tool
survey
revised to link to increased feelings of safety to Safer
Space program participation
baseline
5)Provision of educational
development sessions on
topics identified by clients
feedback from clients on workshops workshops
developed evaluation of the workshops and changes
implemented survey if workshops met need
# of workshops delivered # of surveys completed on
workshop evaluation % of clients feeling safe in client
survey
12 workshops
delivered 100
surveys completed
85% of client
report feeling safe