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.