Kateri Memorial Hospital Centre Strategic Plan 2013-2014 ... · Kateri Memorial Hospital Centre Strategic Plan 2013-2014 to 2015-2016 -DRAFT Year One Operational Plan – 2013-2014

Kateri Memorial Hospital Centre Strategic Plan 2013-2014 to 2015-2016 -DRAFT

Year One Operational Plan – 2013-2014 @ July 2013

2013.07.24 1

GOAL 1: Ensure safety and quality is prioritized throughout all activities of the hospital centre. Indicators of Success: OBJECTIVE 1: Continually improve care and processes 1.2 Self-confidence in manager QI ability increases by 10% 75% Permanent staff attend ALL Staff QI Day 50% attendance of Clinical staff to Clinical QI Day 1.5 50% of 2012-13 recommendations achieved OBJECTIVE 2: Advance Patient Safety 2.2 100% appropriate VTE prophylaxis at STC admission 2.4 Decrease patch medication errors by a rate of 0.1 in IPD OBJECTIVE 3: Broaden Risk Management Ability 3.2 90% Department risk profiles are done and reported on annually 3.3 25% increase in reports 3.5 D to E1severity- Target 75% E2 and above severity – Target 100% 3.6 100% Quarterly drills done OBJECTIVE 4: Engage Clients in Patient Safety 4.1 Establish the Ask, Listen, Talk campaign 4.2 Patient safety bulletins/radio show for the community 4.3 Levels of care spread OJECTIVE 5: Monitor ability to qualify for Family Medicine Group (FMG). 5.1 Identify why number of charts is low 5.2 Put in place a system to register all patients 5.3 Monitor changes at the Ministry level that affect eligibility to qualify as a FMG OBJECTIVE 6: Ensure the overall framework, management and security of information assets 6.1 Electronic Network Management Policy in place 6.4 Revision of Administration Policy 25, incorporating an updated organizational conservation calendar OBJECTIVE 7: Ensure that employees are recruited and/or developed to fill each role within the organization 7.1 Succession Plan in place 7.2 A resource of recruitment tools 7.3 A decision on performance appraisal(s) to be used 7.4 Trainings scheduled



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Objective 1: Continually improve care and processes ACTIONS RESPONSIBLE

PERSON/S TIME

FRAME COMMENTS EVALUATION

1.1 Develop Integrated Quality Management includes - Elaborate the IQM Framework - Format for QI Initiatives - Risk Management process - Ethics consultation policy and procedure - Revision of Policy A 20 - Organize/collate/coordinate audits and results

QIC/clinical ethicist/RQMC/QI TL QIC/managers

January ‟14

Approved Framework 2 QI projects presented to hospital community Revised Incident /Accident Reporting P&P Approved Ethics consultation P&P Outlined reporting structure of indicators Collate and communicate a file of audits/results/actions

1.2 Promote knowledge of Quality improvement - QI Cord Participation in Management Team

meetings

- Education sessions in RQMC and QI TL mtgs - ALL Staff QI Day - Clinical QI Day - General Orientation

QIC Ongoing “ “ June, „13 Nov July

Needs a self-confidence questionnaire Pre and Post

10 instances of QI related education sessions 75% of permanent staff attend (NOT Achieved 73 of 110 staff = 66%) 50% of clinical staff attendance 30% of new employees attend

1.3 Prepare Cycle 4 Accreditation - Orient new team members to Qmentum - Elaborate the self-assessment schedule

QIC and QI TL

October March

Orientation of 18 new members Schedule done

1.4 Determine work plans for Cycle 3 Survey Recommendations - Categorize the recommendations and

determine a priority group - Develop a work plan for the priority category - Realize the plan - Complete the online portal information

QIC and QI TL June Sept Jan March

Achieve compliance in 30% of the recommendations (=9)

1.5 Facilitate Board of Directors oversight of Quality and Patient Safety

- Annual education session for directors

Directors ED QIC

June

Quality is an agenda item at 50% of Board meetings Making the Link conference summary (done)



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- Address request for RM education - Presentations to the board by QI TL - Simple to understand reports - Tehotirihwaienawá:kon (Watchdog Committee)

review of recommendations - Use of the Effective Governance Manual at

Tehotirihwaienawá:kon

March ongoing “ Oct +March Ongoing

Risk Management education provided 2 QI TL presentations Anecdotal by Board members 50% of 2012-2013 recommendations achieved 2 prepared education sections from the manual

1.6 Promote Interdisciplinarity

- Establish communication method for directives

- Plan for revision of the IPD nursing structure (modular nursing and job roles and supervision for RN, RNA, PAB, bather PAB)

- Develop system of follow-up by nurses of laboratory reports

- Investigate the use of a Health Promotion checklist screen by OPD nurses

- Visit CSSS Verdun Sud-Ouest for model of care

- Development of a Chronic disease management nursing position pilot project

QIC, Med Rec, DPS DON, IPD NM DON, OPD NM, HC NM DON, OPD NM DON, OPD NM DON, OPD NM

March „14

? data base and validity of denominator Develop Web and paper based questionnaire could include INR, Vit D CP ? if can get # of critical INR results if so then evaluation is a decrease of these

Decrease in # of clients without a family doctor (10%) Satisfaction with rapidity of appointments improves for all OPD clients by 10% compared to 2011-12 results Communication method in place Plan elaborated Staff satisfaction with communication questionnaire developed and PRE test done Collective Prescription on INR and Coumadin dose elaborated Briefing note accepted Health Canada approval Client satisfaction survey questions indicate increased interventions directed towards self-management

1.7 Explore how to implement fall prevention in Home Care

DON, HC NM Mar „14 Proposal submitted MOU



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OBJECTIVE 2: Advance patient safety.

ACTIONS RESPONSIBLE PERSON/S

TIME FRAME

COMMENTS EVALUATION

2.1 Establish Medication Reconciliation - Elaborate draft process (Interdisciplinary manual) - Include a physician in present workgroup - Develop an organization plan to implement and

sustain medication reconciliation (resources?) - Ensure comprehension of the process

- Establish the forms and placement in the chart - Establish measures and set targets in PDSA cycles

Med Rec work group

March September September March September March “

After establishing program measures are: 100% Admission BPMH to IPD STC and LTC are done 60% Home hospital HC 100% Transfer BPMH LTC are done

Draft Process (protocol) elaborated, risk group ID Physician participating Identified as a strategic priority and consideration of resources possible, e.g. chronic disease nurse Education session for STC TL, LTC nurses, HC and 2 OPD nurses, all physicians Placement clear Long term measures determined

2.2 Monitor VTE prophylaxis practice - Audit Sept 24, 2013 and March 24, 2014 - - Investigate leg compression possibilities - Count and investigate Pulmonary Embolism in STC

STC QI Team + QIC

Sept ‟13 and Mar „14

Oct „13 Mar „14

Med Echo warehousing work required for PE investigation

100% appropriate VTE prophylaxis at STC admission

2.3 Continue development of Preventive Maintenance (PM) of Biomedical equipment

- Translate the pertinent elements of the GBM report - Establish the PM schedule - Establish the P&P on PM - Contribute to the process for equipment inventory - Contribute to the process of general preventive

maintenance

August „13 Sept. „13 Nov. „13 March „14 March „14

Electrical, bracelets, restraint alternatives

Report presented and understood by managers 100% compliance with schedule P&P elaborated

2.4 Complete a Prospective Analysis :Decrease medication errors related to Patches

- Select team - Establish work plan - Report and communicate

July „13 Oct. „13 Nov. „13

Should try to do the one suggested for OPD last year (e.g. confidentiality)

Decrease errors by a rate of 0.1 in IPD Team selected (done)

2.5 Elaborate a P&P on sample medications August „13 P&P elaborated

2.6 Communicate ROPs to staff

QIC March 2013 2 articles on ROPs in Well Poster session on Patch error process



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OBJECTIVE 3: Broaden risk management ability.


TIME FRAME

COMMENTS EVALUATION

3.1Develop front line staff capacity in risk management - Audits performed by RQMC members and front line

staff - Improvement plans elaborated in response to

deficits in process identified through audits

RQMC

ongoing

Anecdotal – auditors confident in Ability Anecdotal – auditors find process useful 50% of Improvement plans realized

3.2 Revise Risk Management process - Revise and establish use of hospital risk map - Risk Management education for managers - Revise A-21 to incorporate Human Factors

QIC March

90% of managers elaborate a risk profile Part of the 10 sessions above in 1.2 Approved revisions

3.3 Promote reporting on AH-223 - New laminated posters in each area - Printing of 200 pamphlets for staff - Articles in the Well

QIC Ongoing Oct. „13 Oct. „13 Ongoing

25% increase in reports Posters in place Pamphlets distributed (100 done) 4 articles

3.4 Retain Risk Identification and follow-up process in RQMC

- Multiple forms risk - Mattress/rail compatibility risk - Helios confidentiality risk

RQMC committee Mar. „14 Central ordering of forms Labeling of beds Education session for Helios users

3.5 Revise Disclosure education with staff - Develop a pamphlet for staff - Develop a pamphlet for users - Revise the P&P

QIC March „14 Pamphlets developed Approved P&P Rate of disclosures D to E1severity- Target 75% E2 and above severity – Target 100%

3.6 Review Rapid Response Teams - Literature review from Safer Healthcare Now - Determine responsibilities

Management Team and QIC

Dec. „13 100% Quarterly drills done



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OBJECTIVE 4: Engage clients in patient safety.


TIME FRAME

COMMENTS EVALUATION

4.1 Establish the Ask Listen Talk campaign - Posters and bulletin for OPD - HC nurses spread of the program to Home hospital

QIC Dawn Montour Tracy Johnson

Oct. „13 Campaign rolled out

4.2 Patient safety bulletins /radio show for the community - Medication safety pamphlet - Ask Listen Talk concept - Patient Safety Week radio show

QIC plus Oct. „13 Nov. „13 Oct. „13

2 radio shows 3 bulletins

4.3 Levels of Care spread - Recorded video of ethicist and user committee - Community/user meeting on Levels of Care (User

committee)

QIC User Committee Clinical Ethicist

Dec. „13 Dec. „13

Video done 1 community/user meeting

OBJECTIVE 5: Monitor ability to qualify for Family Medicine Group (FMG). ACTIONS RESPONSIBLE

PERSON/S TIME


5.1 Identify why # of charts is low DPS Mar. „14

5.2 Put in place a system to register all patients DPS Mar. „14

5.3 Monitor changes at the Ministry level that affect eligibility to qualify as a FMG.

DPS Mar. „14

OBJECTIVE 6: Ensure the overall framework, management and security of our information assets, i.e., electronic and hard copy. ACTIONS RESPONSIBLE

PERSON/S TIME


6.1 Finalize and approve the electronic network management policy

DOO /Information Management Committee (IMC)

Mar. „14 Administrative Policy, requiring Board of Directors‟ approval

6.2 Consider data warehousing as recommended by ASSSM in 13-14

DOO/IMC



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6.3 Explore the deployment of an electronic health record DOO/DPS/IMC Electronic Health Record Agence pilot site a possibility

6.4 Establish and update the organizational conservation calendar

DOO/MRD Manager/IMC

Being done in phases: Administration Policy 25 presently being revised - October 2013

6.5 Acquire client database and appointment-scheduling software as recommended by ASSSM

IMC/DPS Needs to occur before 6.3 Dr. Jones to prepare Briefing Note for Senior Management

OBJECTIVE 7: Ensure that employees are recruited and /or developed to fill each role within the organization. ACTIONS RESPONSIBLE

PERSON/S TIME


7.1 To develop a succession/retention plan Directors HR Team

March 2014 Screening consultants to aid in plan development

7.2 To explore recruitment tools to insure a superior workforce

DOO HR Manager

March 2014 Use of Facebook profiles, possibility of psychological testing, personality and skill assessment tools, performance-based/behavioral- based interviews

7.3 To research performance appraisal formats DOO HR Manager

March 2014 Explore the simultaneous use of various, job-specific appraisals within KMHC

7.4 To identify Management training necessary to detect problematic employee areas

DOO/HR Manager

March 2014 i.e. training directed at identifying mental health issues in the workplace, as well as interviewing



2013.07.24 8

skills

GOAL 2: Renovate and Expand the KMHC facility in order to meet the present and future needs of clients. Indicators of success:

KMHC has done everything possible to help the project move forward Completion of Phase II

OBJECTIVE 1: Achieve signed agreement with SIQ for the development of definitive plans and construction. ACTIONS RESPONSIBLE

PERSON/S TIME


1.1 Reach an agreement with the CHQ (now, the SIQ) outlining its level of project management technical support to KMHC throughout the definitive plan and construction phase

ED, KMHC Board, Project Manager (PM)

May 2012 SIQ and Interim PM agree on terms of service; will be signed once Treasury Board (TB) approval is received which is anticipated in April 2012.

Agreement with SIQ reached in early 13-14.

OBJECTIVE 2: Evaluate and incorporate infection prevention and control measures in the definitive plans for renovation and expansion.


TIME FRAME

COMMENTS EVALUATION

2.1 In collaboration with Project Mgt. Team, amend IP & C Nurse job description to include role/responsibilities/level of authority during the renovation and expansion project.

PM/DON/IP&C Nurse

Aug. 2013

2.2 Coordinate between Infection Control and the design professionals integration of infection control measures into the design plans

PM, IP & C Nurse Sept. „13

Verification and review to be carried-out throughout course of design



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2.3 IP & C Committee to present learning from IP&C during construction training to the Management Team

IP & C Nurse/DON

Sept. „13 Outstanding @ March 31, 2013; Valerie Diabo to follow up.

OBJECTIVE 3: Complete the development of the final construction plans in collaboration with the professional services team and the SIQ.


TIME FRAME

COMMENTS EVALUATION

3.1 Complete, review and approve the final construction plans.

PM, Building Committee

Aug. ‘13 65% plans delivered early May 2013; 95% plans expected July 19, 2013.

Detailed project schedule; project within the allocated budget.

OBJECTIVE 4: Finalize financial agreement with MSSSQ (Financement du Quebec). ACTIONS RESPONSIBLE

PERSON/S TIME


4.1 Collaborate with MCK representatives as they negotiate the terms and conditions of the proposed short and long-term agreement with MSSSQ.

July – Aug „13

MCK uncomfortable with the level of risk taking on the proposed short and long-term loan agreement with MSSSQ. Unable to reach an agreement on the terms of the loan agreement at an administrative level; requires political intervention. @ mid-June 2013 political intervention

Signed financial agreement between MCK and Financement du Quebec well before the tender date of September 6, 2013



2013.07.24 10

successful; agreement to move forward; details of the agreement to come. @ mid-July 2013 details of the agreement still being hammered out.

OBJECTIVE 5: Tender for and hire a general contractor. ACTIONS RESPONSIBLE

PERSON/S TIME


5.1 Implement a call for tender process PM, Building Committee

Sept. 6, 2013

Call for tender scheduled for September 6, 2013

Tender process completed

5.2 Sign contract with a general contractor PM, Building Committee

Oct. 2013 Scheduled for October 2013

Signed contract with a general contractor

OBJECTIVE 6: Address operational budget needs with MSSSQ for post renovation & expansion. ACTIONS RESPONSIBLE

PERSON/S TIME


6.1 Contact Kim Lefebvre @ MSSSQ (person responsible for KMHC budget at MSSSQ) to commence discussion re: proposed increased operational budget post renovation and expansion.

ED Aug. „13

6.2 Revisit and amend proposed increased operational budget as needed.

Sr. Mgt. Mar. „14

OBJECTIVE 7: Ensure that operations continue during expansion and renovation. ACTIONS RESPONSIBLE

PERSON/S TIME


7.1 Relocation of day center, kitchen, outpatient and inpatient as per construction schedule.

Begin Sept. 1, 2013

Day Centre move to TBEL scheduled for September 2013; kitchen relocation scheduled for



2013.07.24 11

approximately November ‟14; outpatient scheduled for phase 3; inpatient scheduled for phase 2-3.

7.2 Work with architect to revise the phasing plan. Phasing plan presented to KMHC management @ May 2013; most updated phase plan.

7.3 Update the Emergency Response Plan for Phase I of construction.

DOO/ Safety Committee/ Project Management Team

Sept. „13

OBJECTIVE 8: Support a smooth transfer during and after renovation and expansion by applying a conscientious planning process for changes in key work flow areas (inter-department/inter-discipline processes).


TIME FRAME

COMMENTS EVALUATION

8.1 Contract a consultant to facilitate the planning process for changes in key work flow areas (inter- department/ inter-discipline processes).

ED Aug. „13

8.2 Confirm the steps/timeline of the planning process with management.

Mgt. Team and Consultant

Sept. „13

8.3 Identify key work flow/process work that will need to change during and/or after renovation/expansion.

Consultant/Mgt. Team/Sr. Mgt.

Fall „13

8.4 Classify work flow/process changes as simple or complex and decide who should develop a proposal for new ways of working on that work flow.

Consultant/Mgt. Team/Sr. Mgt.

Fall „13

8.5 Small teams will propose new ways of working on each specific work flow item identified.

Lead for each Team to be identified.

Winter- Spring „14



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8.6 Debrief meeting with Management Team/Council of Physician Representatives to identify learning.

Consultant/Mgt. Team/Sr. Mgt./CPDP Reps.

Action for 14-15 (summer of ‟14)

8.7 Management/Council of Physicians Representatives will finalize proposals from teams.

Consultant/Mgt. Team/Sr. Mgt./CPDP Reps.

Spring „14

8.8 Trial of new work flow/process, re-evaluation and revision as needed.

Lead for each Team to be identified.

Action for 14-15 (Nov. ‟14 onward)

8.9 Ongoing communication with other staff about the changes.

OBJECTIVE 9: Respond operationally to phase 1 of construction.


TIME FRAME

COMMENTS EVALUATION

9.1 Meet regularly with the Project Management team and respond/ collaborate/operationalize as required

Senior Management

Sept. ‟13 – Nov. „14

OBJECTIVE 10: Revisit the post renovation and expansion staffing plan. ACTIONS RESPONSIBLE

PERSON/S TIME


10.1 Determine increased staffing needs and associated contingency costs as a result of phasing during construction project, and submit to Project Manager.

Senior Management

Before Sept. „13

10.2 Develop and implement the plan for increased contingency staffing.

Senior Management

Summer/ Fall „14

10.3 Revisit post renovation and expansion staffing plan as needed.

Senior Management



2013.07.24 13

GOAL 3: Integrate Mohawk Culture into KMHC Operations Indicators of success: OBJECTIVE 1: Implement Traditional Medicine Services 1.1 Pilot Project operating 1.2 3 presentations occurring 1.3 DRAFT framework of additional service/programs offered in the TMU OBJECTIVE 2: Develop a Kanien’keha Language Personnel Policy based on the Kaianerenhseron:ni ne Onkwawenna’on Aontston ne Kahnawa:ke DRAFT Language Personnel Policy developed OBJECTIVE 3: Offer Employees traditional healing services as part of KMHC’s Employee Assistance Program DRAFT policy in place OBJECTIVE 4: Develop formal mission and vision statements for the Traditional Medicine Unit DRAFT mission and vision statements OBJECTIVE 5: Utilize mentoring and peer learning as a way of ensuring that the Traditional Medicine program and services remain culturally appropriate and relevant to the needs of our clients OBJECTIVE 6: Explore how Mohawk culture can be integrated into other KMHC departments A resource of departments‟ ideas

OBJECTIVE 1: Implement Traditional Medicine Services. ACTIONS RESPONSIBLE

PERSON/S TIME


1.1 Begin the Pilot Project DOO/Culture and Language Coordinator/Pilot Project Nurse

April 2013 Formal evaluation report available at year‟s end



2013.07.24 14

1.2 Continue Traditional Medicine Unit education through training, presentations

DOO/Culture and Language Coordinator/Pilot Project Nurse

March 2014

1.3 Draft a framework of services to be offered by the TMU DOO/Culture and Language Coordinator/ Pilot Project Nurse/ Council of Elders

March 2014

Provide programs and services that are culturally-based incorporating traditional knowledge and practices of healing and wellness, e.g., pre and postnatal care, smudging, healing circles, use of eagle feather, caring for medicine bundles, nutrition, education re roles and responsibilities…

OBJECTIVE 2: Develop a Kanien’keha Language Personnel Policy based on the Kaianerenhseron:ni ne Onkwawenna’on Aontston ne Kahnawa:ke.



2013.07.24 15


TIME FRAME

COMMENTS EVALUATION

2.1 Participate in community events on language strategies Director of Operations Language and Culture Coordinator

March 2014

Community language Summit being planned

2.2 Review the requirements of the Law Director of Operations Language and Culture Coordinator

December 2013

2.3 Explore EDC organizations‟ language policies and procedures

Director of Operations Language and Culture Coordinator

December 2013

2.4 Explore EDC organization‟s use of the Rosetta Stone language software

Director of Operations Language and Culture Coordinator

October 2013

OBJECTIVE 3: Offer Employees traditional healing services as part of KMHC’s Employee Assistance Program.



2013.07.24 16


TIME FRAME

COMMENTS EVALUATION

3.1 Draft a traditional healing services policy Director of Operations

February 2014

3.2 Offer services under EAP Director of Operations Language and Culture Coordinator

March 2014

Additional costs will be incurred.

OBJECTIVE 4: Develop formal mission and vision statements for the Traditional Medicine Unit, e.g. to assist FN people in ensuring the integration of FN philosophies, beliefs and healing ways into a clinical setting.


TIME FRAME

COMMENTS EVALUATION

4.1 Consult with the Council of Elders and Traditional Medicine Sub-Committee

Director of Operations

March 2014

Statements to be aligned with KMHC‟s mission and vision statements

Approved by Board of Directors

OBJECTIVE 5: Utilize mentoring and peer learning as a way of ensuring that the Traditional Medicine program and services remain culturally appropriate and relevant to the needs of our clients


TIME FRAME

COMMENTS EVALUATION

5.1 Explore “stage” placements DOO Encourage individuals with healing gifts

5.2 Secure a Summer Student Director of



2013.07.24 17

Operations

OBJECTIVE 6: Explore how Mohawk culture can be integrated into other KMHC departments. ACTIONS RESPONSIBLE

PERSON/S TIME


6.1 Consult the Management Team Director of Operations

March 2014

Managers to take back to their teams

Risk and Quality Management Committee to be consulted

6.2 Conduct a staff survey Director of Operations

December 2013

6.3 Partner with the Kanien‟kehaka Onkwawen:na Raotitiohkwa Language and Culture Center

Director of Operations

January 2014

Rotational art exhibits

Book launch

Host April activities

Viewing of presentations on lobby TV

GOAL 4: Implement the Community Health Plan (CHP) in partnerships. Indicators of success:

Internal implementation of the plan Collaboration with partners Clear roles and responsibilities with accountability in place for each partner



2013.07.24 18

OBJECTIVE 1 – Work with Onkwatakaritahtshera to develop sub-committees with multi-organizational involvement to develop a plan for each health plan priority.


TIME FRAME

COMMENTS EVALUATION

1.1 Ensure KMHC participation, either through Onkwa membership or KMHC clinical/technical staff, on health priority sub-committees as necessary.

Senior Management

Mar. „14

Build on success of the work on Mental Health, incorporate written work plans with clear roles and responsibilities for each partner.

OBJECTIVE 2 – Develop and implement a communications plan to promote the CHP in partnership.


TIME FRAME

COMMENTS EVALUATION

2.1 Collaborate on Onkwa to develop a communications plan for the community.

Senior Management/KMHC Communications

Mar. „14

2.2 Communicate the plan internally with the Board of Directors, Management and Staff.

Senior Management/KMHC Communications

Mar. „14

OBJECTIVE 3 - Implement the plan internally.


TIME FRAME

COMMENTS EVALUATION

3.1 Review CHP KMHC logic models/programs/services, and adjust as necessary as per CHP sub-committee direction.

Senior Management/Team Managers

Documents

Kateri Memorial Hospital Centre Strategic Plan 2013-2014 ... · Kateri Memorial Hospital Centre Strategic Plan 2013-2014 to 2015-2016 -DRAFT Year One Operational Plan – 2013-2014