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2013/14 Quality Im
provement Plans for O
ntario Hospitals
Improvem
ent Targets and Initiatives
Please do not edit or modify provided text in Colum
ns A, B &
CA
IMM
EASU
RECH
AN
GE
Quality D
imension
Objective
Measure/Indicator
Current Perform
anceTarget for 2013/14
Target JustificationPriority
levelPlanned im
provement initiatives
(Change Ideas)M
ethods and process measures
Goal for change
ideas (2013/14)Com
ments
Safety1) M
onitor health care provider hand hygiene com
pliance with the
provision of timely feedback.
A) Conduct direct observations for hand hygiene com
pliance in selected areas. B) Create new
signage as reminders for good hand
hygiene practices. C) D
evelop recognition program to rew
ard areas that m
eet the target compliance rate quarterly.
Feedback to be provided w
ithin 30 days of availability
2) Educate health care providers and patients annually on hand hygiene indications, products, techniques and hand care
A) Completion of eLearning m
odules by staff Modules
include: Hand hygiene for Clinical and N
on-Clinical staff and Routine Practices and Additional Precautions B) Conduct short in-person education for new
em
ployees, medical/nursing students and for individual
departments upon request
75%
3) Ensure environmental controls
and systems support allow
for hand hygiene to be perform
ed
Perform w
orkflow pattern and risk assessm
ent to facilitate placem
ent of products and stationsBased on com
pletion
1)D
evelopprophylactic
antibioticcriteria-protocol
A) Order set established
B) Chart audits via PICIS data Monthly report
2) PQAC w
ill lead the initiativeA) Audit results B) M
onitor set guidelinesM
onthly reporting to PQ
AC or Com
mittee
3) Develop roll-out strategy
PQAC to review
rollout planRollout plan approved
Effectiveness1) M
onitor performance daily,
weekly, m
onthlyPerform
ance documented in PICIS
Reports completed
and reviewed
2) Monitor com
plianceD
ata presented regularly to OR Com
mittee
OR Com
mittee
reviews data
regularly
3) Monitor and evaluate outliers
Evaluate for ongoing improvem
ents Im
provements
made as necessary
1) Information gathering to
understand variables impacting
current rate
Review curent users ordering patterns and capacity of
systemClear understanding of current state
2) Improvem
ent strategy confirm
ed Stakeholder inform
ed improvem
ent strategy is critical to success
Improvem
ent strategy com
plete
3) Monitor im
plementation of
strategy M
onior utilization rates monthly as w
ell as user feedback
Monthly reports
reviewed
1) Complete a literature review
of existing benchm
arks for wait tim
es.Benchm
arks will be established based on literature
search findingsBenchm
arks determ
ined for Q1
2) Complete a process m
apping exercise to determ
ine areas that lead to long w
ait times (both
administrative processes and
provider scheduling)
Review current patient flow
patterns and capacity w
ithin the systemIm
provement
strategy complete
3) Implem
ent suggested im
provements
Identification of failure points and solutions for change to be established and im
plemented.
Changes monitored
routinely for impact
and revision
4) Continuously monitor and
improve.
Wait tim
es will be collected, m
onitored and reported.85%
of patients will
be seen within 20
mins
Majority of
Wom
en's College Hospital, 76 G
renville Street, Toronto, Ontario M
5S 1B2
Improve provider hand hygiene
compliance
Hand hygiene com
pliance before patient contact: The number of tim
es hand hygiene perform
ed before initial patient contact divided by number of observed hand hygiene
opportunities before initial patient contact, multiplied by 100. D
ata will be provided by a direct
observer.
Implem
entation of Antimicrobial
Stewardship Program
Antim
icrobial Stewardship: to m
onitor the appropriate administration of antim
icrobial therapy to achieve the best patient outcom
es, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and prom
ote patient safety. % of patients w
ho receive their appropriate antibiotic therapy w
ithin 45 minutes prior to incision for ACL reconstructions
100%99%
90%92%
3Increase hand hygiene
compliance to 92%
with the
longer term goal of reaching
100 %
A) Collect survey cards and calculate percentage of
2Increase com
pliance to 100%
Improve O
perating Room first
case start time accuracy
% First Case O
n-time (O
RBC): Percent of first OR cases that start on tim
e or early84.4%
90%Set target is sustainable
1
24%Im
prove procurement process: Im
prove the procurement process by increasing the percent of
requisitions submitted electronically. The percentage of e-requisitions divided by the total
number of requisitions that are subm
itted through the procurement process.
Improve procurem
ent processTarget has been set based on
current performance
50%
Improve patient engagem
ent in
Improve w
ait times in Specialized
Medicine Program
Access
1) Patients in FPHT w
ill be invited
Patient Engagement in FH
T: To increase patient engagement in the Fam
ily Health Team
by
75%1 1
78%Target has been set based on
Improve patient w
ait times from
arrival for appointment to provider contact: Im
prove wait
between patient scheduled appointm
ent time and the tim
e the first provider sees the patient: Percentage of patient (target 85%
) visits that meet w
ait time of 20 m
inutes benchmark.
Inclusion criteria: patients that arrived on time for their appointm
ent in a pilot project in Endocrine clinics.
76%85%
Target has been set based on evidence-based literature
1
Patient-centred
AIM
MEA
SURE
CHA
NG
E
2) Educate patients and staff about the initiative and the im
portance of hand hygiene
A) Conduct information session for staff at the
beginning of the project B) Share data, patient com
ments and progress w
ith staff and patients in various venues (i.e. staff m
eetings, patient education nights, etc.) C) Create signage to inform
/remind patients and staff of
hand hygiene initiative
Venues to share inform
ation TBD by
FPHT An increase
in return rate as a result of visual rem
inders
Monitor patient satisfaction
during transition to new facility
Patient Satisfaction : To monitor patients' perceptions of their care during the transition
"Overall how
would you rate the care and services you received at the hospital." Percent of
those who responded Excellent, Very G
ood and Good.
New
initative75%
Target has been set based on previous perform
ance through N
RC Picker
21) Patients receiving care in the new
facility will be invited to
provide feedback on their experience
A) Collect survey cards and calculate percentage of survey cards returned B) Collect feedback from
trained volunteers with
regards to experience interacting with patients in this
initiative
Majority of
feedback from
volunteers to be positive
Compliance w
ith TASHN
Research Q
ualifications Com
pliance with TA
HSN
Components: A) all individuals listed on an active research ethics
protocol will com
plete the "Responsible Conduct of Research" module and achieve a certificate
of completion, indicating a satisfactory m
ark on all required courses. B) All prinicpal investigators leading or are responsible for an active research ethics protocol w
ill complete the
"Responsible Conduct of Research" module and achieve a certificate of com
pletion, indicating a satisfactory m
ark on all required courses.
New
initiative - no m
odules completed
A) 50%
B) 65%Targets reflect the phased
approach to module
completion, coinciding w
ith protocol renew
als and subm
issions
31) Ensure inidividuals across the organization are aw
are of the new
educational opportunity and required courses.
A) Presentations to relevant hospital groups for team
dissemination
B) Individual notification from the research ethics boad
to principatl investigators with open research protocols
Online account
creation indicating the course m
odule has been started.
1) Work w
ith WCH
clinicians to identify key inform
ation-sharing requirem
ents for improved care
transitions between clinical
provider partners.
A) Tasks associated with developing the integration
approach for WCH
's aEPR will be reflected in the project
plan. B) Progress w
ill be tracked through project m
anagement structures and reported through project
governance structures.2) W
ork with W
CH's clinical
provider partners (e.g., UH
N, PM
H,
CCAC, SMH
, SHSC) and clinicians to
identify key information-sharing
requirements for im
proved care transitions w
ith WCH
Key information sharing requirem
ents will be identified
and documented
3) Confirm integration approach
for electronic exchange of key inform
ation identified.
Project plan will be developed inclusive of integration
approach for electronic exchange of key information
Confirmed aEPR
integration approach for electronic exchange of inform
ation with
clinical provider partners.
Integrated
Integration and implem
entation of an Am
bulatory Electronic Patient Record
Care Transitions: Defined integration requirem
ents for electronic exchange of information w
ith W
CH's clinical provider partners in support of im
proved care transitions (e.g., Virtual Ward,
After Cancer Treatment Clinic, Fam
ily Health Team
)
New
initiative By D
ec 31, 2013
integration requirem
ent defined
Target reflects required tim
ing 1
feedback from
volunteers to be positive
survey cards returned B) Collect feedback from
trained volunteers with
regards to experience interacting with patients in this
initiative
the Family H
ealth Team
to observe and provide feedback on health care provider hand hygiene com
pliance
involving them in providing hand hygiene com
pliance feedback. a) The num
ber of survey cards returned divided by the total number of survey cards
distributed.
current performance