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2017/18 Quality Improvement Plan"Improvement Targets and Initiatives"
The Red Lake Margaret Cochenour Memorial Hospital #51 Highway 105 P.O. Box 5005
AIM Measure Change
Quality dimension Issue Measure/Indicator
Unit /
Population Source / Period Organization Id
Current
performance Target
Target
justification
Planned improvement
initiatives (Change Ideas) Methods Process measures
Target for process
measure Comments
1)Skills intervention:
provide continued
instruction to nurses
regarding Teachback as a
communication tool.
Audit 20 charts/month for evidence of teachback Percentage of discharged patients with documented
teachback on discharge
75% compliance
rate, Q3
continue with
current change
initiatives to
ensure the
momentum for
this tool
continues.
2)"When to return to the
Hospital" section of
discharge form signed off by
patient.
Audit 20 charts per month % of discharged patients having signed the discharge
form.
80%
1)Use of standard order sets
for patients with diagnosis
of CHF on admission.
Quarterly audit of physician use of order sets for CHF % of CHF patients who present and the physician uses
approved CHF standard order sets
50%Q3 Our target is the
same as last year.
Due to a later
than anticipated
implementation
we were unable
to track this
target as
intended in our
previous Quality
Improvement
Plan.
2)Measurement and
Feedback Intervention:
monitoring of daily record
of intake/output for CHF
patients
Verified through use of CHF standard order set being
filled out.
% of patients with intake/output recorded daily 80% With use of the
order set as a
best practice it
will trigger this
process
3)Measurement and
Feedback Intervention:
monitoring of daily weight
for CHF patients during
acute phase.
Daily weigh established as a component of care in
standard order set for CHF: to be recorded in patient
EMR and verified on chart audit.
Percentage of CHF patients with daily weight recorded
daily during acute phase.
80%Q3 with the new
order set based
on best practice
being approved
and in place we
Effective transitionsEffective 85.00 This is conducted
through an in-
house survey
and results will
be recorded
from Q3 data.
Risk-adjusted 30-day
all-cause readmission
rate for patients with
CHF (QBP cohort)
Rate / CHF QBP
Cohort
CIHI DAD /
January 2015 -
December 2015
896* X 15.50 As determined
by our HSAA.
Did you receive
enough information
from hospital staff
about what to do if
you were worried
about your condition
or treatment after
you left the hospital?
% / Survey
respondents
CIHI CPES / April -
June 2016 (Q1 FY
2016/17)
896* 77
1)Use of Standard order set
for patients with diagnosis
of COPD on admission
Quarterly audit of physician use of order sets for COPD % of COPD patients who present with COPD and the
physician uses approved COPD standard order sets
%50 Q3 Based on Quality
Best Practices
2)COPD referral project with
the Family Health Team
do an analysis of current referral process and track
success of program
audit how many COPD patients either bring in their
education book or have had their referral faxed to the
clinic.
80% Step 1 of a larger
plan that looks to
improving our
before and after
education plan 3)Physician prescription of
steroids using QBP standard
order set
Chart audit 20 charts per month % of physicians prescribing steroids for COPD patients
seen in the ED
80%
4)Fax to Family Health Team
after CHF/COPD ED visit
Quarterly chart audit % of patients with COPD in which a fax was sent after
their ED visit to the Family Health Team
80%
1)N/A N/A N/A N/A Our QIP goal for
QBP cohorts will
focus on CHF and
COPD
1)Connect Substance abuse
patients with community
resources at time of ED visit.
Link or refer patients with substance abuse to
community resources.
Chart Audit 50% A Collaborative
Audit with CCAS
1)Connect Mental Health
Patients with community
resources
Ask patients with Mental Health issues about their link
to community services
Chart Audit of all patients diagnosed with Mental Health
illness in the ED.
50% A collaborative
project with CCAS
2)Discharge form is faxed to
CCAS
% of patients with Mental Health issues linked to CCAS
services that have had their discharge form faxed to
CCAS
Chart Audit of all patients with a diagnosed Mental
Health illness.
50% This is a new
project for the
hospital
3)Provide Mental Health
first Aid Training for Nurses
and Ward Clerks (full-time
and Part-time).
Education Sessions with marked attendance (St. John's
Ambulance Mental Health First Aid module).
% of Nurses and Ward Clerks receiving Mental Health
First Aid Training
75%
4)Mental Health Education
for Physicians
Provide Mental health Education to Medical Advisory
Physicians through a lunch and learn by CCAS
% of Physicians present for education session 60%
Effective transitionsEffective
40.00 This target aims
to provide the
support these
patients need
before our
services our
required.
Repeat unscheduled
emergency visits
within 30 days of
total mental health
visits, by hospital.
% / Mental
health patients
CIHI CCRS / 3 896* 23.1 20.00 There is a large
population
readmission for
patients with
Mental Health
Repeat unscheduled
emergency visits
within 30 days as a
proportion of total
substance abuse
visits, by hospital
% / Discharged
patients with
mental health &
addiction
CIHI OMHRS / Q3 896* 47.2
0.00 Based on best
practices
Risk-adjusted 30-day
all-cause readmission
rate for patients with
stroke (QBP cohort)
Rate / Stroke QBP
Cohort
CIHI DAD /
January 2015 -
December 2015
896* 0 0.00 Following QBP
and new stroke
algorithm based
on best practices
Risk-adjusted 30-day
all-cause readmission
rate for patients with
COPD (QBP cohort)
Rate / COPD QBP
Cohort
CIHI DAD /
January 2015 –
December 2015
896* 0
1)Intervention:
Documented discharge
planning process including
flow chart and
communication tools.
Audit 'estimated date of discharge' on admission, spot
audits once/week of the number of patients with EDD
documented on flow chart.
% of acute inpatients with EDD documented on flow
ma.
80%
2)Intervention: Delirium
screen of admitted patients
(65 and older) within 48
hours
Audit of 20 charts/month % of patients (65 and older) receiving at least one
delirium screen within 48 hours of admission to
hospital.
80% Aligned with
Senior Friendly
Hospital Initiative
and NW Hospital
scorecard project.
3)Intervention: Utilization of
the Barthel Assessment tool
Audit of 20 charts/month % of patients with the Barthel tool completed. 80% Aligned with
Senior Friendly
Hospital Initiative
1)Formalize palliative care
volunteer program.
Utilize the Recreation Therapist to create a standardized
volunteer program package including training and
supports
The creation of the program as a deliverable package. At least 2 new
volunteers having
gone through the
volunteer package
Standardizing the
volunteer
program will
make it easier for
volunteers and
organizers.
2)Refer Palliative Care
patients to CCAC
referral listed on discharge form % of palliative patients with documented referral to
CCAC for palliative care
100%
3)Skill Intervention:
Education session for
Nurses and Physicians with
focus on End of life vs.
palliative care.
Palliative vs. End of Life education session for staff and
Physicians focusing on the CCAC scoring system.
% of Full-time/Part-time Nurses and active physicians
who attend training session.
75%
1)Skills Intervention: Use
AIDET as a communication
tool for service providers
Continue to provide training both on orientation and
annually to all staff regarding the AIDET customer
service program
% of Full-time and Part-time staff taking the AIDET
customer service pledge
80% AIDET:
Acknowledge,
Introduce,
Duration, Thank-
you
1)Intervention and
Feedback: Patient family
walk round as an activity of
our Patient Family Advisory
Group
Patient and Family Advisory Committee walk-round of
the patient care areas for improvement, follow-up by
Senior Leadership Team and report back to PFAC
% of PFAC members who rate their satisfaction with
process/outcomes as 'satisfied' and 'very satisfied'
95% Hospital uses in
house survey
Patient-centred
97.00 This is conducted
through an in-
house survey
and results will
be recorded
from Q3 data.
"Would you
recommend this
hospital to your
friends and family?"
(Inpatient care)
% / Survey
respondents
CIHI CPES / April -
June 2016 (Q1 FY
2016/17)
896* 97
100.00 our hospital
continues to
have a very
strong
partnership with
CCAC and an
excellent
volunteer
program for
palliative care.
Palliative care
"Would you
recommend this
emergency
department to your
friends and family?"
% / Survey
respondents
EDPEC / April -
June 2016 (Q1 FY
2016/17)
896* 100 100.00 This is conducted
through an in-
house survey
and results will
be recorded
from Q3 data.
Person experience
Percent of palliative
care patients
discharged from
hospital with the
discharge status
"Home with
Support".
% / Palliative
patients
CIHI DAD / April
2015 – March
2016
896* 100
896* 44.15 12.70 This target has
been specified
by our HSAA.
Total number of
alternate level of care
(ALC) days
contributed by ALC
patients within the
specific reporting
month/quarter using
near-real time acute
and post-acute ALC
information and
monthly bed census
data
Rate per 100
inpatient days /
All inpatients
WTIS, CCO, BCS,
MOHLTC / July –
September 2016
(Q2 FY 2016/17
report)
Access to right level
of care
Efficient
2)Intervention and
Feedback: Patient
Experience Focus group
with outpatients
Focus group with outpatients and team members,
follow-up on suggestions for improvement
% of outpatients who rate overall experience as a 9/10
or 10/10 experience on satisfaction scale
85% Aligned with
Patient Family
Care Best Practice
3)Skills Intervention:
Employee training on
Patient and Family Centered
Care Model
Add training to orientation and staff to complete
annually
% of full-time and part-time staff who receive specific
training on PFCC
80% in 2017/2018 This is a strategic
priority for
RLMCMH
1)Create individualized care
plans for all CCC patients
with dementia
Chart audit % of dementia patients who are CCC that have a
documented Non pharmacological Care plan
90% Under the
direction of our
Recreation
Therapist Intern
2)Education and Training for
staff regarding
Nonpharmacological
Interventions for patients
with dementia
Recreation therapist to educate Nursing staff on Non-
pharmacological Interventions
% of Full-time and Part-time Nurses trained 75%
3)Creation of a new QBP
standard order set for
dementia patients
Chart audit % of documented dementia patients with order set
used.
50%
1)Skills Development:
Ongoing nurse and
physician training to obtain
Best Possible Medication
History.
Documented evidence of Medication reconciliation
training for all staff at orientation and annually
% of staff receiving training in medication reconciliation
process annually.
85% compliance
2)Measurement and
Feedback Intervention:
Chart audit to verify
completion of medication
reconciliation on admission.
Audit 20 charts/month % of patients with medication reconciliation completed
on admission
90% Continue to audit
20 patient
charts/month for
completion of a
Best Possible
Medication
History
3)Complete a FMEA for
Medication errors
Implement change ideas from FMEA analysis Number of change ideas implemented from FMEA
analysis
1 change idea
Safe 80 90.00 We believe as a
hospital we can
continue to
improve in this
area.
Patient-centred
Medication
reconciliation at
admission: The total
number of patients
with medications
reconciled as a
proportion of the
total number of
patients admitted to
the hospital
Rate per total
number of
admitted
patients /
Hospital
admitted
patients
Hospital
collected data /
Most recent 3
month period
896*Medication safety
97.00 This is conducted
through an in-
house survey
and results will
be recorded
from Q3 data.
Individualized
Nonpharmacological
Interventions for
patients with
Dementia
% / Complex
continuing care
residents
EMR/Chart
Review / 3rd
Quarter
896* CB 100.00 Adapted from
HQO's Quality
Standards for
Dementia
"Would you
recommend this
hospital to your
friends and family?"
(Inpatient care)
% / Survey
respondents
CIHI CPES / April -
June 2016 (Q1 FY
2016/17)
896* 97
Person experience
1)Measurement and
Feedback Intervention:
Chart audit to verify
completion of medication
reconciliation on discharge.
Audit 20 charts % of patients with medication reconciliation completed
on discharge.
97% continue to audit
20 patient
charts/month for
completion of a
Best Possible
Medication
Discharge Plan
1)Skills Intervention:
Training and adoption of
Ottawa Ankle Rules
processes for active
physicians
Chart Audit of ED patients presenting with symptoms of
foot and ankle pain
% of patients with negative examination using Ottawa
Ankle Rules that are sent for an X-ray
10% 10%
1)Don’t transfuse more than
one Red cell unit at a time
when transfusion is
required in stable, non-
bleeding patients.
Chart Audit % of Transfusion patients that are stable and non-
bleeding patients and have recieved more than one red
cell unit at a time
0% It is our belief
that no patient
should receive
more than one
Red Cell Unit at
one time which is
in line with the
Choosing Wisely
Campaign
1)Process Intervention:
Documented individual care
plans based on BRAYDEN
risk assessment tool and
identified risk factors
BRAYDEN risk assessment complete and documented
care plans verified by chart audit
% of patients with documented care plan and risk
assessments on admission
80% Q3 Multidisciplinary
team approach,
including nursing,
OT, and
Physiotherapy
Safe care
Safe
0.00 Historically we
have performed
excellently in this
category. The
hospital would
like to continue
with this target
to make sure the
habits become
ingrained before
removing it from
our QIP
Reduce incidence of
pressure ulcers
% / Complex
continuing care
patients
CIHI CCRS /
2017/2018
896* 0
10.00 Following
recommendation
s from the
"Choosing
Wisely
Campaign"
Blood transfusion
process
% / All patients EMR/Chart
Review / 3
896* CB 100.00 Identified from
the Choosing
Wisely Campaign
as a best practice
% of patients
presenting with foot
and ankle pain who
receive X-rays after a
negative examination
using Ottawa ankle
rules.
% / ED patients In-home audit / 3 896* CB
Medication
reconciliation at
discharge: Total
number of discharged
patients for whom a
Best Possible
Medication Discharge
Plan was created as a
proportion the total
number of patients
discharged.
Rate per total
number of
discharged
patients /
Discharged
patients
Hospital
collected data /
Most recent
quarter available
896* 100 97.00 In order to be
sustainable we
have chosen a
number slightly
less than our
performance,
but we believe it
is a number we
can continue to
achieve.
Medication safety
1)Create a standardized
Discharge process for
colonoscopy using best
practices
Audit charts % of charts with documented and standardized
discharge plan.
90% Following best
practices for
Colonoscopy
2)Create pre and post
procedures based on
colonoscopy best practices
Chart audit % of charts with documented and standardized pre and
post procedures
80% Q3 Following
recommendation
s for colonoscopy
best practice.
1)Conduct a PDSA cycle on
LOS to look for any areas of
improvement that will lead
to wait time reduction.
Create a project team to analyze LOS data and assess
areas of improvement that a PDSA cycle could be
conducted with.
PDSA cycle with data Complete at a
minimum 2 cycles
towards
improvement in
Length of stay
time.
Following change
management
strategy
896* 8.00 As defined by
HSAA
Safe care
Safe
Total ED length of
stay (defined as the
time from triage or
registration,
whichever comes
first, to the time the
patient leaves the ED)
where 9 out of 10
complex patients
completed their visits
Hours / Patients
with complex
conditions
CIHI NACRS /
January 2016 –
December 2016
Timely access to
care/services
Timely
Standardize pre and
post procedures for
endoscopy
Number / All
surgical
procedures
In house data
collection / Q3
896* CB 90.00 QMP partnership
for colonoscopy.
Recommended