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Committee of the Whole
Meeting Date:
April 28, 2015
Submitted by:
A.C. [Tony] Orvidas, Strathmere Lodge Administrator
Subject:
Strathmere Lodge 2015 Quality Improvement Plan
BACKGROUND:
The Ministry of Health and Long Term Care, the South West Local Health Integration
Network [SW LHIN], and Health Quality Ontario [HQO] require all Long Term Care
[LTC] Homes in the Province to complete and post Quality Improvement Plans [QIP’s]
on the HQO website by April 1, 2015, and to update them on an annual basis thereafter.
ANALYSIS:
HQO is an independent agency dedicated to reporting to the public about the quality of
Ontario’s publicly funded health system, supporting continuous quality improvement,
and promoting healthcare based on the best scientific evidence available. A QIP is, by
HQO definition, “a formal, documented set of quality commitments aligned with system
and provincial priorities that a health care organization makes to its
patients/clients/residents, staff and community to improve quality though focused
targets and actions.”
LTC Homes are the last sector of the Provincial heath system [comprised of public
hospitals, inter-disciplinary primary healthcare organizations, LTC, and Community Care
Access Centers] to create and implement QIP’s. Each QIP is based on standardized
templates and guidance materials from the Ministry. Submitted QIP’s will be available
for review by the general public and will be “reviewed and analyzed by HQO… to help
track system – level progress on priority indicators and identify strategies that
organizations can use to further develop and achieve their plans.”
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The 2015 Strathmere Lodge QIP was developed by the Director of Resident Care in
consultation with the Administrator and other members of the Management Team.
Current performance for Ministry determined priority indicators was identified, relevant
indicators for Strathmere Lodge selected, targets set, and both a work plan and
narrative completed to address the 3 selected indicators [falls, restraints and
inappropriate use of anti-psychotics] for the 2015/16 year.
The QIP was shared with and approved by the Lodge QI Committee [comprised of frontline staff, resident and family representatives, and Management], and posted on the
HQO site by the required date. It has also been forwarded to the SW LHIN and posted
on our public information board.
Throughout the coming year levels of performance on achieving the targets for the
indicators will be monitored by the QI Committee and adjustments to the work plan
made as appropriate.
Attachments
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Quality Improvement Plan (QIP) Narrative
for Health Care Organizations in Ontario
2/17/2015
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
Strathmere Lodge has had a robust, multidisciplinary Quality Improvement (QI)
committee since 2013, and has been involved in QI initiatives (both at a home-wide and
provincial level) for many years prior to the inception of this committee. At present, HQO
statistics indicate we are near the provincial average - or better than the provincial
average - on indicators such as 'the percentage of residents with pressure ulcers that
recently got worse,' (our 2013-2014 average = 3.6%, provincial average = 3.0%) and
'the percentage of residents with worsening bladder control' (our 2013-2014 average =
10.3%, provincial average = 19.5%.) Similarly, our statistics related to 'the percentage of
residents who had a recent fall' (our 2013-2014 average = 14.7%, provincial average =
14.2%) are near the provincial average. However, we are looking to improve our
numbers in this area greatly over the coming year, so the reduction of falls will be one of
our major QI undertakings in 2015. In terms of 'the percentage of residents who were
physically restrained' (our 2013-2014 average = 23.8%, provincial average = 8.9%,) we
hope to see our numbers in this area fall considerably in the coming year as well.
Moreover, we will also endeavour to keep Emergency Department (ED) transfers at a
minimum in an attempt to reduce the burden on our province's acute care facilities.
In summary, when reviewing the QI initiatives of greatest concern for the upcoming year
(2015) the staff at Strathmere Lodge will endeavour to: 1) reduce the number of falls
sustained by our residents, 2) reduce the number of restraints used in our home, and 3)
keep our number of ED visits to a minimum. By focussing on these 3 QI topics/areas,
we feel the greatest positive impact can be made for our residents and for the
community we serve. Similarly, by directing our attention and resources largely on these
three topics, we feel we can best meet our mission of providing competent,
compassionate, self-directed and holistic care to all those residing at our home.
Integration and Continuity of Care
At present, Strathmere Lodge has representatives sitting on the regional falls prevention
committee in our area. This committee - known as the Middlesex-London Fall
Prevention Committee - sees our local health unit, CCACs, hospitals, and various other
private care providers come together once a month to discuss fall prevention issues.
Likewise, Strathmere Lodge staff members are working diligently both in internal
committees and in external partnerships (e.g., via relationships formed at our local
FLAG group) to improve restraints-related policies and procedures and reduce our
overall restraints statistics. Lastly, our relationships with our local hospitals (e.g., the
Strathroy-Middlesex General Hospital, London Health Sciences Centre, etc.) remain
strong. We hope to work closely with these acute care centres in the coming year to
reduce our ED transfers.
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Challenges, Risks and Mitigation Strategies
Challenges inherent in the reduction of falls, the reduction of restraints and the
reduction of ED transfers centre around the competition of ethical principles...
In reducing falls or restraints, for example, we're required to skillfully balance our
residents' right to autonomous, self-directed mobility, and their right to be free from
harm. Sometimes, these two ethical principles can seem to be at loggerheads;
preventing injury due to falls is easy if a resident is not given the complete freedom to
ambulate at will. That is, if all residents sat motionless and were restrained at all times,
we could reduce our falls to zero. However, this is neither ethical nor practical. We must
learn to balance the competing principles of autonomy and nonmalfeasance/beneficence if we are to truly improve the lives of residents in the areas of
falls and restraints.
Similarly, To reduce ED transfers, we must balance the assessment and treatment
capabilities of our staff with the humility to know when greater assistance from the
hospital is required. Throughout the coming year, it is our intention to improve the
assessment and treatment skills of our nursing staff and to build better communication
bridges with the hospitals in our immediate vicinity.
By maintaining balance in our ethical decision making, by improving communication and
competence, and by keeping resident needs top of mind, we will undoubtedly succeed
in our QI initiatives in 2015.
Information Management
At Strathmere Lodge, the 'Electronic Health Record' (EHR) system we utilize is known
as 'Med-E-Care'(MEC). MEC has been instrumental in helping us to record the care we
provide to our residents and in allowing us to generate the data/statistics we require to
assess our care over time. In specific, MEC utilizes/integrates data from the 'Resident
Assessment Interface - Minimum Data Set' (RAI-MDS) and allows us to track resident
acuity, evaluate risks, and assess the effectiveness of health-related interventions over
time. We can also assess how our resident population changes to determine trends in
resident characteristics and needs. At Strathmere Lodge, we use a variety of
technologies to provide the best care possible. MEC is perhaps the keystone of these
technologies.
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Engagement of Clinicians and Leadership
With the help of our Education Coordinator, and through an interdisciplinary approach to
care, Strathmere Lodge attempts to keep all staff up-to-date on emerging clinical issues,
and attempts to involve all staff in the various interdisciplinary committees that are
ongoing at our home. These robust committees include: 1) Fall Prevention & Restraints
Minimization, 2) Continence Promotion & Incontinence Management, 3) Skin Care &
Wound Management, and 4) Pain Management & Palliative Care. Similarly, staff are
encouraged to join committees related to - and undertake greater training in - the areas
of Responsive Behaviour Management, Leadership, and QI itself. We have various
leaders in various roles (from nursing to dietary to housekeeping.) All staff are
encouraged to improve quality in any/all ways possible, and to bring forth ideas for
improvement at any time.
Patient/Resident/Client Engagement
Residents and families at Strathmere Lodge are wholeheartedly encouraged to join the
Residents and Family Councils and our QI Committee. Likewise, residents and families
are encouraged to give feedback to our staff using various means (i.e., direct meetings,
satisfaction questionnaires, comment/concern forms, etc.) At each council or committee
meeting, the voicing of concerns is promoted. Management provides feedback to
residents and families on the various QI initiatives being undertaken, and all managers
are available for direct consultation on request.
Accountability Management
Strathmere Lodge takes an action-oriented approach to all aspects of operations especially QI initiatives. Managers are held accountable for specific initiatives at each
meeting, and all issues are followed up until fully addressed or resolved to the
satisfaction of the concerned party - be they a resident, family member, staff member,
or a member of the management team itself. QI plans listing the "Responsible Party,"
Anticipated Date of Completion," and "Actual Date of Completion" for all initiatives are
created to ensure accountability and perseverance, until the issue is
addressed/resolved. Whenever possible, managers attempt to utilize a "Priority
Calculator" of some sort to direct them to the most pressing issue(s), allowing managers
to focus on those issues that have the greatest impact on resident well-being. As time
progresses, traditional meeting minutes are being replaced with "Action Logs" which
focus on the most important, actionable items discussed at each meeting. The staff
endeavour to use the most current and effective QI procedures and materials. At
Strathmere Lodge, quality improvement is woven into daily operations, policies and
procedures and the culture of the building to the greatest degree possible.
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Sign-off
It is recommended that the following individuals review and sign-off on your
organization’s Quality Improvement Plan (where applicable):
I have reviewed and approved our organization’s Quality Improvement Plan:
Administrator
Name (print): _______________________________
Signature: _________________________________
Director of Care
Name (print): _______________________________
Signature: _________________________________
Family Council Chairperson
Name (print): ______________________________
Signature: ________________________________
QI Committee Representative
Name (print): ______________________________
Signature: _________________________________
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2015/16 Quality Improvement Plan for Ontario Long Term Care Homes
"Improvement Targets and Initiatives"
STRATHMERE LODGE 599 ALBERT STREET
AIM
Quality
dimension
Safety
Measure
Objective
To Reduce Falls
Unit /
Current
Priority
Measure/Indicator Population performance Target Target justification
level
Percentage of
%/
15.92
12
This number is approx. Improve
residents who had a Residents
75% of our current value,
recent fall (in the last
suggested as an
30 days)
achievable and realistic
falls target at the QIP
'Workout' attended Jan.
27, 2015, in Markham,
Ont.
To Reduce the
Percentage of
%/
Use of Restraints residents who were Residents
physically restrained
(daily)
22.26
9
Our target value (9.0%) is Improve
approximately the
provincial average (20132014) for this statistic.
While the benchmark set
by HQO (3.0%) may be
our ultimate goal, we
feel a reduction in our
restraints levels to below
10% is most realistic and
achievable for the 2015
year.
Change
Planned improvement
initiatives (Change Ideas)
1)The purchase of
numerous and various
pieces of fall-prevention
and injury mitigation
equipment, such as hi-lo
beds, bed/chair alarms, etc.
Methods
Process measures
The Clinical Support Nurse (CSN) and the DRC will work The number of fall-prevention/injury mitigation pieces
in conjunction to purchase said pieces of equipment
of equipment in the home.
and put them into play with the most fall-prone
residents. The CSN will keep a list of those residents
using such equipment.
Goal for change ideas
Reduce the number of falls
sustained by residents by
alerting staff to risk-laden
situations, and also to reduce
the number of injuries
associated with falls.
Comments
While the injuries sustained by
residents who fall is not a statistic
currently maintained by the MOH &
CIHI, we feel that this related
statistic is just as important as
reducing falls themselves. As such,
one of our goals will be to reduce
the injury due to falls, as well as falls
themselves.
2)Implement a walk-to-dine PT will assess residents and assign 1 - 2 residents per
program, such that specific home area to this program. Nursing staff (i.e., PSWs)
residents are encouraged to will ensure these residents are walked to/from meals.
maintain strength, balance,
and independent
ambulation status.
Number of residents in the walk-to-dine program.
Maintain strength, balance
and ambulation statuses of
applicable residents.
While this program is not designed
to improve poor strength, balance
and ambulation, it may help prevent
further deterioration in certain
residents, thereby reducing falls.
3)Analyze the timing and
PT in conjunction with the Clinical Support Nurse
number of falls that happen (CSN)will keep data on falls, describing the timing and
number of falls each shift/unit/quarter.
per home area, per shift,
per quarter. Adjust staffing
levels and break times
whenever possible to
provide those units/times
with the greatest numbers
of falls with the highest
possible staffing ratio.
The number of falls that happen per shift, per home
area, per quarter, and the associated staffing ratios.
Move staff and adjust breaks
such that the most staff are
on the floor as possible when
falls are most likely to
happen.
While there are limits to how
staffing can be adjusted, certain
changes can be made in this regard
in an attempt to prevent and
respond appropriately to resident
falls.
1)Review the residents for
whom restraints are being
utilized at quarterly
meetings of the 'Fall
Prevention and Restraints
Minimization Committee.'
Find alternatives to
restraints whenever
possible.
Number of residents using a restraint, as defined in the Reduce the number of
home's policies.
residents using restraints, via
staff education and
promotion of alternative
methods.
Via multidisciplinary collaboration with PT, nursing
staff, recreation, and our home's education
coordinator, staff can begin using alternative methods
to restraints to control exit-seeking and
mobility/ambulation safety issues.
Over the course of the past year,
our home has already made major
strides in the reduction of restraints.
We currently have 16.8% of our
residents using some kind of
restraining device, which is down
from our all-time high of 43.3% in
2010-2011.
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Effectiveness
To Reduce the
Inappropriate
Use of Anti
psychotics in LTC
Percentage of
residents on
antipsychotics
without a diagnosis
of psychosis
%/
Residents
32.22
0
Via the process
Improve
described, all residents
taking antipsychotic
medications shall have
an associated diagnosis
(indicating a clear need
for the medication.)
Whenever possible (i.e.,
when safe and
appropriate) residents
are also taken off of
antipsychotic
medications altogether.
1)Ensure all residents taking
antipsychotic medications
have an associated
diagnosis indicating the
need for the
prescription/ingestion of
antipsychotic medications,
and/or whenever
safe/possible, discontinue
antipsychotic medications
for residents altogether.
Strathmere Lodge, in conjunction with Medical
Pharmacies and Lodge physicians, have developed a
new diagnosis (BPSD - "Behavioural and Psychological
Symptoms of Dementia) that is utilized whenever a
resident is prescribed an antipsychotic medication for
dementia-related reasons.
Integrated
To Reduce
Potentially
Avoidable
Emergency
Department
Visits
Number of
%/
emergency
Residents
department (ED)
visits for modified list
of ambulatory care
sensitive conditions*
(ACSC) per 100 longterm care residents
24.15
10
Considering the current Improve
numbers, we feel a
reduction by slightly
more than half is a
feasible number to strive
towards.
1)Communicate with staff
coding RAI-MDS data to
ensure they know the
correct definition of an ER
visit on section P6 of the
RAI (i.e., only ER visits that
do not result in an
admission are counted) to
ensure our statistic is not
artificially inflated by
improper coding.
DRC to send memo to Registered Staff and discuss issue Number of ER visits according to section P6 on RAIat staff meetings.
MDS.
Number of residents taking an antipsychotic medication At each Care Conference
who do not have an appropriate associated diagnosis. (initial and annual) the
pharmacy shall prepare a list
of any/all residents taking a
medication considered to be
an antipsychotic. The
pharmacist and physician
shall add necessary diagnoses
or discontinue the medication
where applicable.
At the time of writing this,
Strathmere Lodge has reduced the
number of residents taking an
antipsychotic medication without an
associated diagnosis to nearly zero.
Ensure statistics sent to MOH
& CIHI represent actual
practices and the coding of
the RAI-MDS is correct.
This change idea may not reduce the
actual number of ER visits, but is
being employed to ensure staff are
thinking about the number of times
a resident is sent to hospital and to
ensure proper statistics are
maintained.
2)Discuss the 'Advanced
Direct discussion with residents and families at Care
Care Directive' with each
Conferences.
resident/family at initial and
annual Care Conferences,
and whenever
safe/possible, encourage
residents and families to
allow our home staff to
manage more acute medical
conditions (e.g., infections)
before immediately sending
residents to hospital.
Number of residents for whom the level chosen on the
'Advanced Care Directive' is either 1 or 2 (as opposed to
levels 3 and 4, both of which involve transferring the
resident to hospital.)
Reduce the number of
residents/families who prefer
ER referral with a decline in
health status before allowing
home staff to assess/treat the
condition.
While some conditions (e.g.,
fractured hips) necessitate a visit to
the ER, for many residents, a decline
in health status can be managed at
the home level. By encouraging
residents and families to allow
home staff to assess/treat
conditions prior to immediate ER
transfer, some ER trips may be
avoided.
3)Promote nursing
competence in IV therapy
via the procurement of IV
supplies and IV education.
Number of staff competent in IV therapy, and the
number of IV therapies initiated and/or maintained at
our home.
Increase the number of
residents treated with IV
therapy at the home level, for
antibiotic therapy, hydration,
etc.
One of the reasons our residents
wind up in ER is because of the need
for IV therapy. If we can assume at
least some of the responsibility for
this kind of therapy, some ER visits
may be avoided.
The DRC will investigate/procure IV-related education
and supplies.