Post on 31-Jul-2020
Runnymede Healthcare Centre 1 625 Runnymede Road, Toronto, ON M6S 3A3
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario
3/28/2017
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.
Runnymede Healthcare Centre 2 625 Runnymede Road, Toronto, ON M6S 3A3
Overview Runnymede Healthcare Centre (Runnymede) is pleased to share its seventh annual Quality Improvement Plan. This plan describes some of the hospital’s key priorities for quality improvement supporting our strategic plan of Vision 2020: Redefining Possible. This is Runnymede’s roadmap describing our vision to transform healthcare together and our mission to provide an exceptional patient experience by:
• Placing patients at the centre of their own care and decision-making • Driving innovation in rehabilitation and care for medically complex patients and • Continually raising the bar on quality and safety standards
Together, these have formed the basis for the key initiatives in our Quality Improvement Plan 2017/18, which outlines our commitment to quality, safety and patient experience. Dedication and focus on these important principles guide us in successfully attaining the targets for each of the six key improvement initiatives as outlined below. Our commitments to our patients and families are that: By March 31, 2018, we will be closer to achieving the aim of eliminating preventable harm caused by pressure injury and falls with harm by:
• Conducting regular skin integrity rounds with individualized patient assessments to strengthen care planning and education
• Engaging in international pressure ulcer prevalence survey to further inform pressure injury program • Improving communication and learning through implementation of patient safety huddles focusing on
falls and pressure injury. • Monitoring effectiveness of falls prevention strategies through semi-annual audits
By March 31, 2018, we will be closer to supporting an integrated and efficient health system by improving access and flow for complex continuing care and rehabilitation thereby reducing unnecessary time in acute care for patients with complex, chronic illness by:
• Implementing strategies aimed at reducing the number of long-stay Alternate level of Care (ALC) patients at Runnymede
• Engaging patients and families in discharge planning early in their inpatient stay • Providing important information to patients and families on programs and supports available in the
community to allow for better transition By March 31, 2018, we will be embracing the Patients First Act and putting people and patients first by improving their health care experience and their health outcomes by:
• Adopting a patient and family centred approach and input into quality improvement initiatives • Empowering the patient and family voice through technology and involvement
The priorities in Runnymede’s Quality Improvement Plan support the provision of high quality, patient-centred care. A complete description of these initiatives and how we will be successful can be found in the 2017/18 work plan.
Runnymede Healthcare Centre 3 625 Runnymede Road, Toronto, ON M6S 3A3
QI Achievements From the Past Year Our achievements over previous Quality Improvement Plans have demonstrated on-going and incremental improvements year over year. These results emphasize Runnymede’s commitment to quality improvement and our drive for excellence in the provision of safe, high quality care. This past year is no exception as Runnymede met or exceeded targets in the following 2016/17 Quality Improvement Plan initiatives: Medication Reconciliation at Admission and at Discharge: Runnymede continues to a provincial leader in medication reconciliation. We sustained performance at theoretical best of completing medication reconciliation for 100 percent of the time when a patient is admitted to Runnymede and when preparing to be discharged. It is well documented that when patients transition from hospital to home, medication discrepancies have been linked to increased acute hospital re-admissions. As part of our process, the pharmacist meets with the patient and family to review any changes in the medication regimen since admission. By performing complete, accurate medication reconciliations involving the patients and families, the Runnymede pharmacists eliminate an important source of potential harm, reduce system pressure through re-admission avoidance and help the patient transition to all care destinations safely and be informed about their care. Reducing Clostridium difficile Infection Rate: In addition to exceeding our target, Runnymede had no C. difficile outbreaks in 2016/17. Our success can be attributed to the adherence to recommended guidelines to reduce C. difficile infections with improved consistency of care across clinicians. Also, to ensure consistency and accountability, an independent audit of cleaning conducted by the infection prevention and control team was also implemented with the results shared to enhance understanding and focus education topics. Lastly, a comprehensive education program about hand hygiene and use of personal protective equipment for families and visitors was a powerful tool to emphasize that everyone has a role in reducing healthcare associated infections. Reducing falls in complex continuing care patients: This indicator is a top priority at Runnymede evidenced by the fact that our performance not only exceeded the TC LHIN average but also, our own stretch goal. This was achieved through clinicians working with patients to build strength and stamina to reduce falls and help in a safe transition home upon discharge. We also conduct proactive patient assessments and implement universal falls prevention precautions while employing a patient-centred approach. With a falls rate of 3.1% for 2016/17, we strongly outperformed the average rate of 9.4% in the Toronto Central Local Health Integration Network (TC LHIN) and of 10.6% in the province. Enhancing the patient experience: As we strive to deliver excellent patient-centred care, we are particularly proud of the success of our Quality Counts Survey program. Within two weeks of admission, activation therapy staff conducts a face-to-face meeting with patients and families. It is an invaluable opportunity to receive real-time feedback while establishing a relationship of trust and responsiveness. Survey results are also shared with referral hospitals so that together, we can improve transitions of care between organizations again to improve the experience for all of our patients.
Runnymede Healthcare Centre 4 625 Runnymede Road, Toronto, ON M6S 3A3
Population Health
As a leader in the provision of complex continuing care and rehabilitation, Runnymede understands its role and tailors resources and activities to improve the health of the population it serves. For example, patients frequently do not have a primary care clinician in their community. In these cases, we will work with local community health centres and clinics that are accepting patients to establish that linkage as well as arranging for the patients’ first visit following discharge. This is an important means to support the patient in their on-going health and well-being in the community while preventing hospital readmissions and emergency department visits in acute care. Chronic conditions such as, diabetes continue to be on the rise and Runnymede is addressing this trend through the development and work of its clinical nutrition team that are certified diabetes educators. This enables the Interprofessional team to critically assess patients with diabetes for optimal blood sugar control including other aspects of their care such as, medication management.
Equity
On an annual basis, a patient profile report is developed and reviewed to ensure that we continue to understand changing demographics of our patients. In addition, we complete the health equity survey in a face-to-face interaction with patients and families on admission. As a key dimension in providing quality care, the collection of data related to health equity enables and allows for informed decisions and actions to reduce inequities, and is an important provincial and LHIN level priority. We are proud to say that Runnymede is a leader in the TC LHIN for the collection of health equity data with a completion rate of over seventy percent. This information has been a catalyst in how we provide care and services. Two specific examples include the recent expansion of therapeutic diets to include halal and vegan choices but also finger food options to aid those with cognitive or physical impairments. To better assist patients who have limited socioeconomic resources, Runnymede has a dedicated staff member trained in social service who assists patients in understanding the various alternative income sources and community supports that can be accessed. This activity helps to ensure a successful transition back to the community and for on-going health and well-being of our patients upon discharge.
Integration and Continuity of Care
Runnymede views integration and continuity of care as paramount to improving the health of Ontarians with complex chronic disease. To this end, Runnymede collaborates with multiple system partners to integrate best practice guidelines for individuals with stroke and hip fractures. In collaboration with these partners and our patients, we provide seamless transitions across the continuum of care including from acute care to Runnymede back to the community. Some examples include:
• Partnering with St. Joseph’s Health Centre, Trillium Health Partners and the Greater Toronto Area (GTA) Rehabilitation network to standardize and enhance access to rehabilitation post- hip fracture.
Runnymede Healthcare Centre 5 625 Runnymede Road, Toronto, ON M6S 3A3
• Collaborating with Toronto Central Community Care Access Centre (TC CCAC) leadership to develop, review and implement strategies together to reduce the Alternative Level of Care (ALC) rate.
• Active participation in the West Toronto Health Links forum where we will continue to provide leadership and expertise in complex chronic disease management.
• Playing an integral role providing an option for the slow stream rehabilitation of patients who have suffered a severe stroke in collaboration with the West Greater Toronto Area Stroke Network and Trillium Health Partners prior to returning to Trillium Health Partners for active rehabilitation
The priorities identified in the Quality Improvement Plan support the provision of high quality and safe care from admission to Runnymede, through to discharge to home or the next care destination. A complete description of these priorities and how we will be successful can be found in the 2017/18 work plan.
Access to the Right Level of Care - Addressing ALC Issues
Our 2017-18 Quality Improvement Plan focuses on a number of change initiatives aimed at ensuring access and flow for all patients awaiting our services in acute care delivering strategies have been targeted at several phases of the care journey from referral and pre-admission to during the in-patient stay to and examples include:
• Attending ALC rounds of referring acute care centres to collaborate on and increase consistency of rehabilitation program goals and discharge expectations
• Early identification and proactive communication and engagement of patients and families to allow for better planning and understanding of what to expect after treatment at Runnymede concludes and community resources available post-discharge;
• Expanded membership for bi-weekly ALC rounds to include local leadership to strengthen consistency of communication with patient and family
• Systematic review with specialized expertise of Community Care Access Centre staff of all long-stay ALC patients including the development of individual action plans for transition to the most appropriate destination and identifying common barriers for discharge.
• Participation in ALC Avoidance and Management meetings at TC LHIN and West Toronto ALC strategy group where best practices and learnings are shared
• ALC Avoidance scorecards that are monitored monthly ensure that there is an organizational focus on the role that everyone has to play.
As this is a challenging problem across the healthcare system, we will also continue to work closely our acute care and community-based partners to enhance frequent communication and strive for seamless, safe and effective transitions from acute care to Runnymede and from Runnymede back to the community. Together, these initiatives will assist the delivery of the right care at the right time in the right place for all of our patients.
Runnymede Healthcare Centre 6 625 Runnymede Road, Toronto, ON M6S 3A3
Engagement of Clinicians, Leadership & Staff
At Runnymede, our annual Quality Improvement Plan is the result of a collaborative effort of administration and medical leaders within our organization. Additionally, we actively involve patients, families and system partners. This is done through an in-depth analysis of our progress on previous initiatives as well as opportunities for quality improvement feedback from patients, families, staff, physicians and system partners to optimize value for our patients and the broader health care system. More specifically, we use multiple forums that cascade information from the Board to bedside such as meetings of our Board of Directors, Quality Committee of the Board, Executive Advisory Committee, Operations Committee and Medical Advisory Committee. All these committees provide oversight to our quality operations across the hospital. Staff is actively involved at Interprofessional Care Committee, Safe Medication Practice Committee and regular staff meetings. Our results and performance are regularly shared at these forums through the Balanced Scorecard, Clinical Quality Indicator report and patient care area scorecards. To assist in fostering a culture of quality, patient safety and recognition, a comprehensive communication plan to launch the new Quality Improvement Plan and celebrate the success of the 2016/17 plan is in place.
Resident, Patient, Client Engagement
Patients and their families are engaged in the Quality Improvement Plan development process through our annual patient satisfaction survey and the compliment and concerns reporting process. In addition, the Patient Family Council continues to be a key venue to solicit feedback and insight. To generate continuous feedback, we actively meet with patients and families and ask questions on specific initiatives that have the greatest direct patient impact such as, pressure ulcers and patient experience. This approach has actively engaged our patients and families providing us with a more fulsome and rich source of considerations that matter most to our patients. This information has been embedded in the change ideas and action plan to foster a positive patient experience in 2017/18.
Staff Safety & Workplace Violence
Runnymede employs a number of strategies to monitor, reduce and prevent workplace violence to ensure compliance with Bill 168, the Occupational Health and Safety Amendment Act (Violence and Harassment in the Workplace 2000. Reporting and monitoring occurs through an internal online safety reporting system where employees submit reports of actual and potential physical, verbal or psychological threats. These are received, reviewed and acted upon by management as well as the Occupational Health and Safety department. Staff are supported through follow-up by the Occupational Health practitioner, their manager as well as through access to external professional and confidential counselling services through the Employee Assistance Program. Trending reports regarding incidents of workplace violence are monitored and shared at internal committees like the Joint Health and Safety Committee.
Runnymede Healthcare Centre 7 625 Runnymede Road, Toronto, ON M6S 3A3
In order to reduce and prevent workplace violence, Runnymede takes a proactive approach with staff education on Bill 168, the Respectful Workplace policy and Intimate Partner/domestic violence policy in addition to training on emergency codes specifically, Code White (violent situation), Code Purple (hostage taking) and Code Black (bomb threat) during general orientation which provide closer procedures for crisis intervention. Clinical staff attend educational sessions specific to management of aggressive/violent patients supported by internal policy. Educational material is available on the internal website and mock emergency drills are conducted monthly.
The prevention of workplace violence begins with early identification and awareness beginning when an application for admission is placed for an individual with documented behaviours from the referral site. The patient flow department reviews referrals from Resource Matching and Referral tool from the Toronto Central Local Health Integration Network to ensure that all admissions are appropriate and safe. During an inpatient stay, patients exhibiting signs and behaviours of potential aggression are identified and signage placed at the bedside to increase awareness and preparation for a potential threat.
Performance Based Compensation Subject to compliance with the Broader Public Sector Executive Compensation Act (BPSECA), 2014, 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 Quality Improvement Plan.
Sign-off It is recommended that the following individuals review and sign-off on your organization’s Quality Improvement Plan (where applicable): I have reviewed and approved our organization’s Quality Improvement Plan
_________________________
Mr. John O’Dwyer Board Chair
________________________
Ms. Susan Grant Quality Committee Chair
________________________
Ms. Connie Dejak Chief Executive Officer
625 Runnymede Road, Toronto, Ontario M6S 3A3
2017/18 Quality Improvement Plan"Improvement Targets and Initiatives"
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)Develop brochure for
Substitute Decision Makers
(SDM) regarding their role
in discharge planning.
Ensure roles, responsibilities & expectations of SDM
included in content
% of patients/SDM who receive brochure on admission 100% Increase
availability of
SDMs to
participate in
discharge 2)Standardize and
strengthen pre-admission
screening with referring
hospitals.
Patient Flow staff attend discharge rounds at referring
hospitals with targeted focus on potential barriers to
discharge.
% of external discharge rounds attended 80%
3)Develop information
packet for patients/families
outlining discharge
destination options e.g.
retirement home, long term
care and supports to assist
transition to community ,
activity of daily living (ADL)
community programs
New brochure developed and implemented. % of patients who receive discharge information
brochure
100% Goal is to provide
patients/families
with information
to allow for early
planning for care
and supports
available after
discharge from
Runnymede.
4)Cohorting ALC patients
with focus on long stay
patients i.e. greater than 40
days
Modify programming that is available to facilitate
transition to next discharge destination
Length of stay # of long stay patient discharges per
month
One patient per
month
1)Revise Patient Family
Advisory Committee
structure and mandate
adopting patient and family
centred approach including
input into quality initiatives.
Revise, implement and recruit for Patient Family
Advisory Committee (PFAC). Coordinate meaningful
meetings to engage PFAC members to provide input
into quality initiatives
1. # of meetings held per quarter 2. # of projects and
policies reviewed by patients and families in fiscal year
1. One meeting per
quarter 2. To have
all major policy
changes involve
patients and their
families to provide
the patient
experience
2)Implement Floor based
Patient/Family meetings
- Develop terms of reference, frequency - Develop
communication plan and engagement strategy
# of unit family councils per quarter One meeting per
floor per quarter
3)Implement nursing service
expectation standards
1. Online learning module 2. Incorporate into annual
performance evaluations
1. % of nursing staff who have completed service
standard training 2. % of staff to which enhancing
patient experience” is set as an objective
1. 80% 2. 100%
4)Implementation of online
patient feedback and safety
and risk learning system
including accessibility to
patients/families
-Broad stakeholder engagement -Technical build -
Training -Evaluation
1. % increase in reporting of compliments, concerns and
safety events 2. # of events submitted by patient/family
1. 10% 2. 2 per
month
5)Clinical operation audits
to address experience and
safety related concerns e.g.
medication safety,
environmental
clutter/cleanliness,
customer excellence tenets
Audit compliance with nursing staff completion # of audits completed per week - 2 audits per week
- Spread to Allied
Health and
Pharmacy
Items audited
identified from
patient
compliments/con
cerns and patient
safety reported
data
6)Video story-telling Adopt evidence informed process and structure for
video story-telling
1. # of patient stories videotaped/quarter 2. Percent of
corporate meetings where patient stories are shared
1. 1 2. 80%
7)Develop a Patient
Experience Framework
Framework developed in collaboration with patient
and/or family members of patients that have had care
in hospital in past year
Framework complete Developed and
implementation
begun by May 31,
2017
7.00 Considering the
high reliance on
external factors
for success
(CCAC resources,
patients’ LTC
selection,
supportive
housing) we
have set a target
to match 2016-
17 target.
Access to right level
of care
Efficient 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)
850* 10.37
83.10 Match Ontario
Hospital
Association
benchmark.
“Overall, how would
you rate the quality
of care and services
you receive here?”
(add together % of
those who responded
“Excellent, Good”)
% / Complex
continuing care
patients
NRC Picker /
Annual survey
850* 80.6Patient-centred Person experience
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)Revise Patient Family
Advisory Committee
structure and mandate
adopting patient and family
centred approach including
input into quality initiatives
Revise, implement and recruit for Patient Family
Advisory Committee (PFAC). Coordinate meaningful
meetings to engage PFAC members to provide input
into quality initiatives.
1. # of meetings held per quarter 2. # of projects and
policies reviewed by patients and families in fiscal year
1. One meeting per
quarter 2. To have
all major policy
changes involve
patients and their
families to provide
the patient
experience
2)Implement Floor based
Patient/Family meetings
- Develop terms of reference, frequency - Develop
communication plan and engagement strategy
# of unit family councils per quarter One meeting per
floor per quarter
3)Implement nursing service
expectation standards
1. Online learning module 2. Incorporate into annual
performance evaluations
1. % of nursing staff who have completed service
standard training 2. % of staff to which enhancing
patient experience” is set as an objective
1. 80% 2. 100%
4)Implementation of online
patient feedback and safety
and risk learning system
including accessibility to
patients/families
-Broad stakeholder engagement -Technical build -
Training -Evaluation
1. % increase in reporting of compliments, concerns and
safety events 2. # of events submitted by patient/family
1. 10% 2. 2 per
month
5)Clinical operation audits
to address experience and
safety related concerns e.g.
medication safety,
environmental
clutter/cleanliness,
customer excellence tenets
Audit compliance with nursing staff completion # of audits completed/week -2 per week -
Implemented in
Allied Health and
Pharmacy
department
Items audited
identified from
patient
compliments/con
cerns and patient
safety reported
data
6)Video story-telling Adopt evidence informed process and structure for
video story-telling
1. # of patient stories videotaped/quarter 2. Percent of
corporate meetings where patient stories are shared
1. 1 2. 80%
7)Develop a Patient
Experience Framework
Framework developed in collaboration with patient
and/or family members of patients that have had care
in hospital in past year
Framework complete Developed and
implementation
begun by May 31,
2017
1)Develop and initiate Skin
Injury Committee
Review and refine terms of reference and membership Frequency of meeting Monthly
2)Wound rounds Individualized patient assessment including discussion to
promote self management. Includes education,
development of care plans with patient, families and
staff
# of wound rounds/week 3 rounds per week
3)Engage in International
Pressure Ulcer Prevalence
Survey to monitor pressure
rates and practice
Data collection. Data analysis and reporting. Staff
education of prevalence outcomes. Interdisciplinary
discussion and improvement of practices.
1. % of chart reviews 2. % of staff informed and
educated on practice enhancement resulting from
prevalence study
1. 100% of in-
patients 2. 80%
1)Develop process to
improve presence of and
access to fall prevention
equipment e.g. lap tray,
chair alarms, floor mats
Inventory of existing stock Development of basic
minimum requirement Establish stocking, reordering
process Define centralized storage area
Audit that minimum equipment is ready to use 100% of time
equipment is
available to use
2)Modify the semi-annual
falls audit process to ensure
resulting data is relevant for
program evaluation
Educate new Falls Committee members on revised audit
process
1. Audit will be completed in Q1 & Q3 2. Gather
feedback from committee members on new audit
1. 100 %
completion of
audit in Q1 & Q3
for falls data in Q2
& Q4 2. Overall
positive feedback
3)Implement patient safety
huddles on each floor
focusing on falls prevention
Falls Committee will liaise with professional practice
leaders, Quality department to define a process that is
feasible & sustainable
Process is identified and trialed Implemented on all
patient care floors
by September 30,
2017
“Would you
recommend this
hospital to your
friends and family.
Positive response is
‘definitely yes.’
% / Rehab NRC Picker /
Quarterly
850* 77.3 70.00 Internal target as
insufficient data
collected to
establish
benchmark due
to new survey
questions, rating
through NRCC.
Safe Safe care Percentage of
patients receiving
complex continuing
care with a newly
occurring Stage 2 or
higher pressure ulcer
in the last three
months.
% / Complex
continuing care
patients
CIHI CCRS / July -
September 2016
(Q2 FY 2016/17
report)
850* 2.58 2.47 Five (5) percent
improvement,
well below
unadjusted rate
of 3.4% and
4.8% for Toronto
Central LHIN and
the province,
respectively for
same time
period.
0.65 5% improvementFalls with harm rate
per 1000 patient
days/All patients,
complex continuing
care patient
population
Rate per 1,000
patient days /
Complex
continuing care
patients
Hospital collected
data / Rolling 4
quarters
850* 0.68
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)Develop process to
improve presence of and
access to fall prevention
equipment e.g. lap tray,
chair alarms, floor mats
Inventory of existing stock Development of basic
minimum requirement Establish stocking, reordering
process Define centralized storage area
Audit that minimum equipment is ready to use 100% of time
equipment is
available to use
2)Modify the semi-annual
falls audit process to ensure
resulting data is relevant for
program evaluation
Educate new Falls Committee members on revised audit
process
1. Audit will be completed in Q1 & Q3 2. Gather
feedback from committee members on new audit
1. 100 %
completion of
audit in Q1 & Q3
for falls data in Q2
& Q4 2. Overall
Positive feedback
3)Implement patient safety
huddles on each floor
focusing on falls prevention
Falls Committee will liaise with professional practice
leaders, Quality department to define a process that is
feasible & sustainable
Process is identified and trialled Implemented on all
patient care floors
by September 30,
2017
Falls with harm rate
per 1000 patient
days/All patients, low
tolerance long
duration
rehabilitation patient
population
Rate per 1,000
patient days /
Rehab
Hospital collected
data / Rolling 4
quarters
850* 1.65 1.57 5% improvement