Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

4/1/2015

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.

Overview Runnymede Healthcare Centre’s (Runnymede) 2015/16 Quality Improvement Plan (QIP) builds on the organization’s strong foundation and the successes achieved over the past five years. Moving forward, we will continue to enhance the quality of care provided, ensuring it is safe, effective, accessible, integrated and patient-centred. For this coming year, Runnymede`s focus will be on the nine priority objectives and indicators listed below:

Objective Indicator Safety • Reduce Hospital Acquired Infection (HAI)

rates • Increase proportion of patients receiving

Medication Reconciliation on admission • Increase proportion of patients receiving

Medication Reconciliation on discharge • Reduce pressure ulcers in Complex

Continuing Care (CCC) residents • Reduce falls in CCC residents

Effectiveness • Improve organizational financial health Accessible • Reduce Emergency Department (ED) use Integrated • Reduce unnecessary time spent in CCC Patient-Centred • Improve patient satisfaction

Alignment with Health Quality Ontario (HQO)’s five dimensions of quality and the Excellent Care For All Act (ECFAA) is demonstrated through our objectives to improve patient satisfaction, embed patient safety incident data and integrate compliments and concerns feedback into the selection of QIP initiatives aimed at reducing falls, pressure ulcers and hospital acquired infections. Ongoing adoption of Accreditation Canada’s Required Organizational Practices (ROP) and standards were also considered and can be seen through our commitment to complete medication reconciliation on admission and discharge. Runnymede has demonstrated itself to be responsible financial stewards reflected in our ability to maintain a favourable total margin. In compliance with the Hospital Service Accountability Agreement (H-SAA) with the Toronto Central Local Health Integration Network (TC LHIN), fiscal accountability continues to inform our operational efforts as we continue to work towards strengthening the organization’s financial health. Our QIP is in alignment with our new Strategic Plan Vision 2020 that highlights quality and safety as key priorities within the five-year plan. The 2015/16 QIP is Runnymede’s roadmap to ensure we continue to be a bridge to home, delivering exceptional care for patients with extraordinary challenges.

Integration & Continuity of Care Runnymede collaborates with multiple system partners to develop and execute quality improvement initiatives that enhance integration, coordination and continuity of care. In collaboration with these partners and our patients, we provide seamless transitions across the continuum of care: from acute

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care and the community to Runnymede, and from Runnymede back to the community. Some examples of these quality initiatives include: • Collaborating with acute care partners to better understand and prevent avoidable transfers of our patients to local Emergency Departments (ED). • Partnering with the Toronto Central Community Care Access Centre (TC CCAC) to develop and implement strategies that reduce the Alternate Level of Care (ALC) rate. • Actively participating and engaging in two local Health Links (West and Central West) groups to provide leadership and expertise in chronic disease management. • Proactively addressing patient feedback and supporting patients to transition back into the community by linking them to primary care upon discharge, providing timely discharge summaries and implementing post discharge phone calls hence, reducing acute care readmissions and improving the patient experience.

Challenges, Risks & Mitigation Strategies Runnymede is committed to meeting the priorities and targets outlined in our 2015/16 QIP. To ensure success, we have taken into consideration current and future opportunities, healthcare system needs and demands outside of our control. As such, we are mindful of the following: • Implementation of Strategic Plan Vision 2020: Runnymede is developing a new strategic plan which will guide the organizational direction over the next five years. • Introduction of an Electronic Patient Record (EPR): The implementation of an EPR has commenced and will be a multi-year project. Until that time, many of the measurement and audit processes will continue to be manual and time consuming and organizational readiness for EPR adoption will require dedicated financial and human resources. • Environmental factors that are beyond our ability to prevent, predict or control: Certain factors pose a risk to our ability to achieve the targets set out in our plan. Our patients have complex medical conditions and most are admitted from acute care facilities. Frequently, these patients have received antibiotics in acute care and thus, are at higher risk for developing Clostridium difficile (C. difficile) infections. Respiratory and influenza outbreaks also impact our ability to discharge and admit patients which can affect patient movement across the continuum of care. We have developed a number of strategies to mitigate these risks, including the implementation of an Enterprise Risk Management (ERM) program that will allow us to identify challenges and develop ameliorating strategies earlier and on an ongoing basis. Monitoring our progress through regular tracking of performance data on our Clinical Quality Indicator Report and Balanced Scorecard will also continue to be essential. Further, when necessary, the reassessment of priorities and the allocation of resources will occur to ensure that high priority initiatives are supported, while gains from previous improvement initiatives are sustained.

Information Management Runnymede uses information management systems to study patient population needs, set targets and identify areas for quality improvement. Some of the clinical information management systems used include Minimum Data Set (MDS) assessments through Continuing Care Reporting System (CCRS); Incident Reporting; Workload Measurement; Pharmacy systems; Admission, Discharge, Transfer (ADT)

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system; Patient Satisfaction surveys, compliments and concerns. The data allows us to monitor our performance, choose appropriate indicators, set targets and course correct as necessary. Overall, the progress towards achieving 2015/16 QIP objectives are measured and monitored across the organization, from the Board of Directors to the bedside through our Balanced Scorecard, Clinical Quality Indicator Report and unit level scorecards. These tools help us cascade our quality improvement priorities throughout the organization, keeping high quality and safe care top-of-mind for stakeholders at all levels. Further, Runnymede will be collaborating with a local acute care facility in the development and implementation of a multi-year strategy for full EPR adoption. Alongside this initiative, we will continue to adopt and adapt other systems and technology to provide clinicians and the leadership team with access to the best available information allowing for better understanding of patient needs and informing future quality improvement initiatives.

Engagement of Clinicians & Leadership Engagement of clinical staff and the leadership team is critical to the success of our 2015/16 QIP. Runnymede utilizes a number of formal and informal methods to engage stakeholders and support buy-in for our shared quality improvement goals. During the development of the priorities for this year’s QIP, we leveraged our Quality of Care framework and formal committee structure, linking direct care providers with patients, management and the Board of Directors. Through active participation in improvement activities, clinical staff and leaders engaged in developing evidence-informed change ideas and action plans for each indicator. This ensures that the action plans and priorities reflect the current improvement efforts of our clinical teams. Further, various committees with direct care provider membership such as, the Interprofessional Care, Safe Medication Practices, Pharmacy and Therapeutics, Falls Prevention, Skin and Wound and Infection Prevention and Control committees advise on evidence-informed change ideas and related action plans specific to each indicator, enhancing the interprofessional team’s innovation while creating opportunities to share knowledge and feedback. Staff at all levels are also involved in setting local quality improvement priorities based on quality and safety data, such as adverse events, Accreditation Canada standards and patient satisfaction scores. Learning from actual, potential and near miss events help us to be proactive and supports the selection of our priority indicators. To assist in further developing an organizational culture of excellence that is focused on quality, patient safety and innovation, a comprehensive communication plan is needed. The plan will not only assist with the roll-out of the new QIP, it will also touch on our success in achieving our 2014/15 QIP goals and align with our Strategic Plan Vision 2020, enhancing stakeholder engagement.

Patient/Resident/Client Engagement Patients and their families are actively engaged in the QIP development process through patient satisfaction surveys, and the hospital’s patient relations process that includes reporting compliments and concerns as they arise. The Patient Family Council is another key mechanism to solicit feedback and insight from patients and families, not only regarding patient programs and services, but also the QIP. This feedback allows us to ensure that our objectives and change ideas resonate with patients and families, and will be effective in helping to enhance the patient experience at Runnymede.

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Accountability Management Runnymede employs a well-established accountability framework for quality improvement. Each indicator has a clearly established executive lead that is responsible for the implementation of change ideas and the attainment of targets set out in the QIP. Reporting on QIP initiatives and performance occurs to the Board of Directors, Quality Committee of the Board, Executive, Management and staff on a quarterly basis via the Balanced Scorecard.

Performance Based Compensation [As part of Accountability Management] Subject to compliance with the Broader Public Sector Accountability Act (BPSAA), 2010, a percentage of an executive’s base salary is linked to the achievement of a defined number of performance improvement indicators set out in the QIP.

Health System Funding Reform (HSFR) Recognizing the importance of HSFR, we continually educate clinical staff and audit clinical activity to ensure that data is accurately captured so that we can benchmark our performance against peer hospitals. Functional Independence Measure (FIM) efficiency is a core indicator for measuring rehabilitation outcomes, rehabilitation quality of care and demonstrating excellent use of resources. During fiscal year 2015/16, we will be piloting the usage of the FIM tool to assess the effectiveness of our Low Tolerance Long Duration (LTLD) rehabilitation program, as well as the impact FIM efficiency may have on organizational funding. This patient group comprises over one-third of our patient population, therefore the opportunity to pilot the FIM tool will allow Runnymede to ensure that the care it provides to rehab patients continues to be effective, efficient and fiscally responsible. Although Quality Based Procedures (QBPs) are largely acute care focused, Runnymede is taking steps to understand the QBPs that impact complex continuing care such as, hip fractures and stroke rehabilitation in the post acute phase of illness.

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2015/16 Quality Improvement Plan for Ontario Hospitals"Improvement Targets and Initiatives"

AIM Measure Change

Quality dimension Objective Measure/IndicatorUnit / Population Source / Period Organization Id

Current performance Target Target justification

Planned improvement initiatives (Change Ideas) Methods Process measures Goal for change ideas Comments1) Develop and implement education program for nursing staff regarding the care and maintenance of Peripherally Inserted Central Catheter (PICC) lines.

Education to be developed and delivered by nurse educators self learning package.

Engaging Infectious Diseases physician in cases of managing suspected and confirmed infections.

Competency checklist to be developed.

Process for yearly competency testing to be developed.

Date of completion of education module.

Date of implementation of education module.

Percentage of staff educated on the policy.

Education developed by September 30, 2015.

Implemented by October 31, 2015.

80 % of nursing staff will receive education by December 31, 2015.

Teaching would include the use of the Situation Background Action Response (SBAR) communication tool using clinical example to demonstrate assessment and possible interventions.

2) Implement process for gathering, collating, and analyzing data to determine reasons for ED transfer.

Assigning a clinical lead to analyze data.

Review data quarterly and generate reports on trends. First review to be completed by May 2015.

Collaborate with acute care partner for insights, data and mitigation strategies.

Complete Pareto analysis. Identify the top 3 reasons for ED transfer and action plan for mitigation by May 2015.

3) Build on current nursing skills to improve physical assessment and documentation.

Implement Subjective Objective Analysis and Plan (SOAP) documentation.

Provide education on advanced physical assessment.

Percentage of staff educated on SOAP documentation.

Chart audits to determine if SOAP documentation is being used.

Percentage of nursing staff who have received advanced physical assessment skills.

100% clinical staff will use SOAP documentation by July 31, 2015.

100% Full-time nursing staff will have received the education by December 31, 2015.

4) Develop and implement medical directives for obtaining viral and bacterial respiratory specimens.

Develop order set for collecting specimens.

Develop criteria for when specimens are to be collected.

Date order set is developed.

Date order set is implemented.

Percentage of utilization of order set.

Developed July 30, 2015.

Implemented by October 1, 2015.

When indicated, the medical directive will be utilized 100% of the time.

5) Develop an ED transfer policy and procedure.

Checklist of steps to be completed prior to each transfer. Understand the role that patients and family play in decision making regarding ED transfer and provide education on the new policy and their role in decision making.

Education of policy to staff.

Communication of policy to patients, visitors and SDMs.

Date of implementation.

Percentage of staff educated on the policy.

Checklist will be implemented by November 30, 2015.

80% of staff will be educated on the policy.

This policy would include dealing with patient and family requests for transfer.

2.41 In absence of any provincial, national or relevant comparator for chronic care facilities the mean value of 2014 ED visit rate will serve as a good benchmark. This will enable Runnymede to revise targets moving forward and strive for continuous quality improvement.

Reduce the percent of Runnymede patients requiring transfer to Emergency Departments (ED)

Access Number of patients transferred to an acute care hospital Emergency Department divided by the total patient days x 1000

Rate per 1,000 / Complex continuing care residents

Hospital collected data / Q3 2014/15

850* 2.5

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1) Increase Ministry of Health & Long Term Care (MOHLTC)/ non MOHLTC revenue.

Understand the Rehab Care Alliance new definition framework and the reclassification of rehab/CCC bed impact and implications on Health System Funding Reform (HSFR).

Gain expertise and understanding of the National Rehabilitation Reporting System (NRS) through CIHI education by August 31, 2015.

Collect both Continuing Care Reporting System (CCRS) and NRS data for Slow Stream Rehab patients starting October 31, 2015.

Benchmark revenue opportunities with peer hospitals to identify opportunities by October 31, 2015.

Periodic audits of accommodation charges to maximize billing.

Projected MOHLTC revenue.

Percentage of sample population with CCRS and NRS data collected.

Percent of non-MOHLTC revenue.

Percentage of patients in preferred accommodation as requested.

MOHLTC revenues greater than or equal to expected cost per weighted day funding levels.

100% of sample population have NRS and CCRS data by December 31, 2015.

Non MOHLTC revenues greater than or equal to 14.5% (provincial benchmark) of total revenue by March 31, 2016.

100% of patients in preferred accommodation as requested by November 30, 2015.

2) Support reinvestment in Quality Improvement Measures to deliver better care more effectively.

Ensure funding of new programs and quality improvements are provided for in the budget.

Complete two (2) Quality Improvement Initiatives:

1. Product Standardization (ongoing to March 2016).

2. Decrease linen utilization and improve infection control through implementation of physical and system controls.

Dollars saved.

Cost of patient linen.

Save $100,000 by March 31, 2016.

Annual linen spend in line with mid range benchmarks by March 31, 2016.

3) Implementation of electronic management reports that meet the needs of the department heads for decision making purposes.

Statistical reporting and additional indicators to be developed to augment the financial reports.

Identify an internal Case Costing and Decision Support Expert that can marry finances with operations by July 31, 2015.

Develop quarterly management reports provided through the Ontario Case Costing Initiative.

Provide required training that will support the development of the various new reports by September 30, 2015.

Analyze the results of Health Based Allocation Model (HBAM) to identify where the hospital can focus on future efficiency opportunities by June 30, 2015.

Number of new electronic management reports.

Percent improvement in efficiency levels.

Complete three (3) new electronic Management Reports: 1. Operational indicators by November 30, 2015. 2. Payroll indicators by July 31, 2015. 3. Statistical indicators by September 30, 2015.

Improve efficiency levels by up to 2% if actual costs per weighted day exceed expected costs per weighted day as calculated by the MOHLTC based upon 2013/2014 results.

4) Update hospital investment policy to meet board objectives and achieve a higher rate of return.

Update current hospital investment objectives.

Meet with various investment advisors to determine investment vehicles available.

Review policy and objectives of similar organizations with similar strategies with investment advisor.

Present a revised policy to the subgroup of the Finance and Audit Committee by April 30, 2015.

Present a revised policy to the Finance and Audit Committee by May 31, 2015.

Rate of return on investments. Achieve rate of return greater than or equal to inflation and ahead of the approved and predetermined benchmark by March 31, 2016.

0 Ensures funds are spent on the provision of care to patients and meets government legislation of a balanced budget. It also ensures that the hospital has sufficient funds for capital renovation and equipment purchases.

Improve organizational financial health

Effectiveness Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year.

% / N/a OHRS, MOH / Q3 FY 2014/15 (cumulative from April 1, 2014 to December 31, 2014)

850* 6.11

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1) Enhance early discharge planning process.

Standardize application of ALC checklist at Interprofessional Rounds.

Incorporate into Rounds policy and procedure.

Develop procedure and communication plan regarding informing patients of expectations related to discharge to include implementation of letter to patients/SDM informing them of “Estimated Date of Discharge (EDD)”.

Number of staff educated on Rounds policy and procedure.

Number of patients through random chart audit who received letter within 7 days of admission.

80% of staff educated by September 30, 2015.

100% of patients audited that received EDD letter within 7 days of admission by September 30, 2015.

2) Launch awareness and education campaign related to updated ALC policy and procedure.

Working with system partners create a plan to support the roll-out, the updated ALC policy and procedure.

Utilize Patient Family Council to engage patients and families.

Percentage of staff receiving education on newly revised ALC policy and procedure.

80% of staff educated on updated ALC policy and procedure by September 30, 2015.

3) Introduce patient Functional Independence Measure (FIM) score as screening tool for discharge predictability.

Create interprofessional working group to develop procedure.

Pilot FIM application on small sample of patients.

Percentage of sample patients will have FIM completed on admission and discharge.

100% of sample patients will be screened using FIM tool by December 31, 2015.

1) Focus on customer service initiatives interacting with patients and families.

Implement Hospital Wide NOD: state Name, Occupation and what is to be Done with the patient.

Communicate the NOD strategy hospital wide: Executive Meetings, Operations Committee, Staff Meetings.

Provide customer service education sessions through Employment Assistant Program.

Incorporate the patient’s experience “Day in the Life of A Runnymede Patient “ as part of staff orientation/ training.

Percentage of managers who incorporate the use of NOD into performance evaluations.

Percentage of staff who attend education sessions.

Percentage of new staff who receive patient experience education.

100% of managers incorporate the use of NOD as part of staff performance evaluation by March 31, 2016.

80% attendance by March 31, 2016.

100% of new staff receive patient experience education through orientation by March 31, 2016.

2) Post Discharge Phone call. Develop policy and procedure regarding post discharge phone calls.

Percentage of post discharge calls completed. Year 1 – at minimum 60% of patients discharged will be called (percentage as high as possible) by March 31, 2016.

3) Survey Postcards. Survey postcards with questions pertaining to quality, patient safety and patient experience can be distributed to patients to collect real time data about their experience at Runnymede by August 31, 2015.

Percentage of post cards returned to patient relations. Year 1 – 15% of postcards returned by December 2015.

1) Maintain current performance.

Continue with current practice. Percentage of patients with Medication Reconciliation completed.

100%Safety Increase proportion of patients receiving medication reconciliation upon admission

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.

% / All patients Hospital collected data / most recent quarter available

850* 100

82.4 Average of 4 years and adding 5%

850* 80.4

100 Theoretical Best.

Improve patient satisfaction

Patient-centred From NRC Canada: "Overall, how would you rate the care and services you received at the hospital (inpatient care)?" (add together % of those who responded "Excellent, Very Good and Good").

% / All patients NRC Picker / October 2013 - September 2014

7 Target set to align with Hospital Service Accountability Agreement (H-SAA) Performance Target. In Q3 2015/16,Runnymede’s patient population changed resulting in an increase in ALC rate such that 7.0% will be an improvement in performance.

Reduce the percent of patients who are waiting at Runnymede for an alternate level of care (ALC).

Integrated ALC Rate: Total number of inpatient days designated as ALC, divided by the total number of inpatient days.

% / Complex continuing care residents

CCO iPort / (Q3 2013/14 to Q2 2014/15)

850* 4.37

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1) Focus medication reconciliation on discharge to sub-population of patients with complex medication regimens.

Conduct medication reconciliation on discharge as per policy.

Number of patients where medication reconciliation (Best Possible Medication Discharge Plans) was completed.

100% of patients in recently opened LTLD Rehab beds will have medication reconciliation completed on discharge by July 31, 2015.

94% of all other patients will have medication reconciliation completed on discharge by July 31, 2015.

1) Implement component of Antimicrobial Stewardship Program (ASP).

Implement Clostridium difficile Infection (CDI) treatment Order Sets for managing patients with CDI by May 2015.

Infectious Disease grand rounds for clinicians to be planned in collaboration with infectious diseases physician.

Monitor percentage of patients with CDI receiving treatment as per Order Set.

Completion of Grand Rounds pertaining to infectious diseases.

100% of patients are being treated for CDI using the Order Sets by July 31, 2015.

1 completed by September 30, 2015.

2) Ensure compliance with best practices regarding the cleaning, disinfection and storage of commodes.

Develop and implement commode cleaning, disinfection and storage policy and procedure.

Percentage of staff attendance at education. 80% of staff educated by August 31, 2015.

3) Infection Prevention and Control (IPAC) team to independently audit CDI room cleaning practices and report results monthly to housekeeping supervisor.

Use luminescent pen to audit effectiveness of cleaning of patient rooms as well as high touch surfaces in all clinical areas.

Using CDI room cleaning audit tool to observe room being cleaned.

Number of luminesce pen audits/month.

Number of observational CDI room cleaning audits/month.

10 audits per month beginning in April 2015.

1 observation per day per patient isolated for CDI (suspected or confirmed cases) beginning by April 2015.

4) Sustain gains made since hand hygiene program began in 2008.

Observational audit using Ministry of Health audit tool. Moment 1: Before initial contact with patient and/or environment.

Maintain current performance of 90% for 2015 calendar year.

Sustainability plan will be key to maintain current performance.

5) Implement a family and visitor hand hygiene campaign: “Ask me”.

Date of completion to celebrate World Hand Hygiene Day.

Number of Awareness Campaigns completed.

Celebrate World Hand Hygiene Day on May 5, 2015.

2 Awareness Campaigns completed before March 2016.

Visitors and staff will be engaged and have an open dialogue about hand hygiene.

1) Evaluate compliance with:

1.Quarterly Braden Pressure Ulcer Risk Assessment completion.

2. Pressure Ulcer Prevention Clinical Protocol completion for patients that meet the criteria for pressure ulcer development.

Advance Practice Leader Nursing will complete quarterly audit:

1.Quarterly completed Braden Pressure Ulcer Risk Assessment.

2.Pressure Ulcer Prevention Clinical Protocol completed for patients that meet the criteria for pressure ulcer development.

Percentage of Health Records audited that have:

1.Braden Pressure Ulcer Risk Assessment completed.

2.Pressure Ulcer Prevention Clinical Protocol completed for patients that meet the criteria for pressure ulcer development.

100% of records audited have specified documents in place each quarter (July, October, January, April).

2) Ensure that Occupational Therapist (OT), Physiotherapist (PT) and Clinical Registered Dietitian (CRD) are considering patient’s risk for pressure ulcers in creation of their treatment plans.

Addition of Braden risk score to objective section of OT, PT, CRD assessments.

Revised assessment approved and implemented. 100% of OT, PT and CRD educated on new assessment process by June 30, 2015.

0.09 Represents a 10% improvement in performance.

Reduce hospital acquired infection rates

Percent of complex continuing care (CCC) residents with a new pressure ulcer in the last three months (stage 2 or higher).

% / Complex continuing care residents

Reduce incidence of new pressure ulcers

CDI rate per 1,000 patient days: Number of patients newly diagnosed with hospital-acquired CDI, divided by the number of patient days in that month, multiplied by 1,000 - Average for Jan-Dec. 2014, consistent with HQO's Patient Safety public reporting website.

Rate per 1,000 patient days / All patients

Publicly Reported, MOH / Jan 1, 2014 - Dec 31, 2014

850* 0.1

CCRS, CIHI (eReports) / Oct 1, 2013 - Sep 30, 2014 -Q2 FY 2014/15 rolling 4 quarter ave

850* 1.62 1.6 Maintain target. Improvement efforts will continue however, we are strong performers against the provincial unadjusted average of 4.2%).

94 95 Represents 100% performance for Low Tolerance Long Duration Rehabilitation (LTLD Rehab) beds opened October 1, 2015 and maintenance of performance on all other units.

Increase proportion of patients receiving medication reconciliation upon 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.

% / All patients Hospital collected data / Most recent quarter available

850*

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3) Develop and implement procedure for local unit Interprofessional Skin and Wound Team (SWAT) to support the management of all patients that have been identified by the BUM (Braden Scale, Unknown, Measurable), at risk for wound development or identified wound concerns.

Skin and Wound Committee to draft policy and procedure for inclusion in Skin and Wound program.

Complete education on new procedure.

Skin and Wound Committee to develop evaluation criteria and report format.

Roll-out education.

Evaluation of program.

Policy and procedure approved and implemented.

Evaluation and report to Executive Sponsor(s).

80% of staff educated on new policy and procedure by May 31, 2015.

Evaluation report completed by December 31, 2015.

4) Reduce occurrence of new pressure ulcers through Root Cause Analysis (RCA).

Complete an RCA on patients that develop a pressure ulcer and identify opportunities for improvement on a quarterly basis.

Number of RCA reports completed.

Percentage of approved recommendations implemented.

1 RCA completed each quarter.

100% of approved recommendations implemented.

5) Reduce occurrence of pressure ulcers related to seating systems incorrectly reassembled post cleaning.

System implemented to facilitate correct reassembly of seating systems using icons.

Evaluation and monitoring.

Percentage of wheelchairs with new system in place.

Percentage of wheelchairs with seating system correctly reassembled post cleaning.

100% of wheelchairs will have new system in place by April 30, 2015.

100% will be correctly assembled on quarterly audit.

1) Minimize occurrence of patients falling while attempting to mobilize to the washroom.

Continence program refresher training. Percentage of participation in education. 80% education participation by June 2015.

2) Ensure clinical staff have working knowledge of the Falls Prevention Program.

Share key learnings from falls audit in a timely way with opportunity for direct care providers to provide input and ask questions of the Falls Committee.

Education department in collaboration with Falls Committee to update and refresh: falls curriculum and falls competency quiz.

Falls Committee to share quarterly falls data and “messages” with clinical staff and solicit their input and identified opportunities to reduce falls.

Percentage of clinical staff who have received updated Falls Prevention Program by June 30, 2015.

Number of reports from the Falls Committee.

80% of clinical staff have received updated Falls Prevention Program education.

Four/year by March 31, 2016.

3) Improve accuracy of data from internal Incident Reporting System (IRS).

Clarify definitions in IRS: Degree of harm and actual fall versus good catch.

Education to be provided to all clinical staff.

Percentage of clinical staff accurately categorizing falls in the IRS system.

Percentage of Falls events correctly categorized in the IRS.

Greater than 90% by September 30, 2015.

95% of incidents are accurately inputted into IRS by clinical staff by December 31, 2015.

4) Add `Degree of Harm from Falls` to Clinical Quality Indicator Report.

Monitor effectiveness of Falls Prevention Program at injury prevention.

Add aggregate data of severe and critical injury from falls on Clinical Quality Indicator Report.

Presence of aggregate data on Clinical Quality Indicator Report.

Data will be present on the Quarter 1 2015/2016 Clinical Quality Indicator Report.

With an increasing proportion of LTLD Rehab patients more falls are expected. We need to ensure that our Falls Prevention Program effectively minimizes harm as well as reduces falls.

5) Effective and timely Implementation of Falls Prevention Program audit recommendations

Interprofessional Care Committee will adopt a template to track implementation of recommendations including identification of initiative lead, who will develop a detailed action plan and timeline. Falls Committee to submit summary report to executive lead regarding improvement opportunities and progress

Percentage of approved recommendations implemented.

Number of progress reports to executive lead

100% of approved recommendations implemented by March 31, 2016.

2/year.

3.9 Maintain target. Improvement efforts will continue however, we are strong performers against the provincial unadjusted average of 7.6%).

Avoid Patient falls Percent of complex continuing care (CCC) residents who fell in the last 30 days.

% / Complex continuing care residents

CCRS, CIHI (eReports) / Q2 FY 2014/15 rolling 4 quarter average (October 1, 2013 - September 30, 2014)

850* 3.87

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