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2019-2020

PAT I E N T Safety Plan


INFECTION CONTROL

RISK ASSESSMENT

WORKLIFE WORKFORCE

MEDICATION USE

SAFETY CULTURE

COMMUNICATION

THE SIX PATIENT SAFETY AREAS


PAT I E N T SAFETY PLAN KEY REQUIRED ORGANIZATIONAL PRACTICES

SAFETY CULTURE Create a culture of safety within the organization

COMMUNICATIONS Promote effective communication transfer with patients, families and the healthcare team across the continuum of care

MEDICATION USE Ensure the safe use of high risk medications

- Measuring various quality indicators via score cards at different levels throughout the organization - P ublicly displayed Patient Safety Boards updated monthly by Unit Based Councils (UBC) from scorecard & real time patient experience surveys - Use of Safety Reporting system to monitor and track incidents for our patients and staff - U se of an Integrated Risk Management system to assess risk in the organization Health Insurance Reciprocal of Canada (HIROC Q3 years)

- S ustainment of Medication Reconciliation on Admission, Transfer & Discharge (inpatient and outpatient) via monthly HDGH Tracers - Monthly HDGH Tracers to sustain safe med practice (two patient identif ier) - Monitor Real Time Patient Experience surveys to ensure communication at all transition points are effective - A udits of Emergency Department (ED) and SBAR Transfer tools

-

9 0 Day medication reviews on long term patients A udits of Pyxis reports for narcotic usage A udits of safety reports for medication incidents and do not use abbreviations Yearly infusion pump training, evaluation of competence, and monitoring of reports.

INFECTION CONTROL Reduce the risk of health care associated infections and their impact across the continuum of care

- O ur goal is to be the “Cleanest Hospital in Ontario” - O rientation and education of staff, patients and families on hand hygiene practices - E nforce standard accepted hand hygiene protocols and monitor compliance via Mariner System - H ospital Acquired Infections (HAI) investigation tool used for investigating, monitoring and reporting to staff and patients.

RISK ASSESSMENT Identify and mitigate safety risks in the organization

- R  educe hospital injuries related to falls - Avoid facility acquired pressure injuries, multi-disciplinary group creating standard work to assist in prevention of mechanical device related pressure injuries - R oll out of zero suicide initiative and Columbia Risk Screening tool

WORKLIFE/ WORKFORCE Create a work-life and physical environment that supports our patients and our people

- O  ur goal is to be the “Safest Hospital in Ontario” - Education and Communication plan for our zero tolerance for violence and roll out of our “Awareness Keeps you Safe” video series - Non violent crisis intervention training program for all staff (orientation and ongoing) - I mplementation of chart flagging process


ANNUAL HDGH

QUALITY IMPROVEMENT PLAN 2019-2020 HĂ´tel-Dieu Grace Healthcare (HDGH) is committed to improving the health and well-being of the Windsor-Essex community through the delivery of patient-centered, valued-based care. Our 2019-2020 Quality Improvement Plan(QIP) continues to be driven by our three strategic drivers: Our Patients; Our People; and Our Identity. Our goals and improvement plans for our 2019-2020 QIP were co-developed by staff, and our Patient Family Advisory Council.

HDGH believes strongly that excellence in patient/client care starts with employees working in a safe environment when providing care to patients and clients. The safety of our people is foundational and our Workplace Violence Prevention Program is a foundational element of our efforts. This includes providing education to our patients, clients, families and community about ways we can work together to keep everyone safe and encouraging individuals to report all incidents. Safety upon discharge is paramount in continuing a patient/client’s journey. At HDGH, improving hospital discharge experiences is a vital step in helping our patients and clients lead healthier lives. HDGH partners with patients, families and caregivers to ensure all changes to medications are resolved prior to discharge and increase patients' understanding of their medications. Partner with home care and our community partners to ensure the facilitation of appropriate and timely discharges to an Alternate Level of Care (ALC). Improving hospital discharge experience by making sure patients have the information they need when they leave our sites so they can stay healthy and well.  educe re-admission rates for our mental health patients with full case reviews R on all re-admissions. We will ensure gaps in the system are identif ied as they relate to access/intake and discharge to prevent the need to return to acute care. Improve timely access to information to our primary care providers so on patient follow-up, primary care providers have the information they need for continuity of care. Improve early identif ication of palliative care patients and ensure that those with a progressive, life-limiting illness have their palliative care needs identif ied early through a comprehensive and holistic assessment.

For more information about Quality Improvement Plan for HDGH, go to

WWW.HDGH.ORG/QIP


HÔTEL-DIEU GRACE HEALTHCARE’S COMMITMENT TO

At Hôtel-Dieu Grace Healthcare (HDGH) patient safety and quality improvements are key strategic priorities. The importance of patient safety is reflected in our vision and strategic plan and is embedded into the job descriptions of everyone employed by the hospital. The HDGH Board of Directors has established a Quality Committee of the Board that ensures that requirements from the Hospital Management Regulation as it relates to quality are met. This committee meets monthly, and reviews patient

safety related indicators and issues as well as oversees the preparation of our annual Quality Improvement Plan (QIP). Our Quality and Patient Safety Plan is designed to improve patient safety, reduce risk and respect the dignity of those we serve by assuring a safe environment. Recognizing that effective medical/ health care error reduction requires an integrated and coordinated approach, the following plan specif ically relates to a systematic

hospital-wide program to minimize physical injury, accidents and undue psychological stress during hospitalization. The organizationwide safety program will include all activities contributing to the maintenance and improvement of patient safety. Over the last few years, HDGH has focused on a number of initiatives that have created positive change for quality and patient safety at HDGH.

Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives. - William A. Foster -


ONGOING

PAT I E N T Safety Initiatives

PAT I E N T CA S E R EVI EWS

- M  edical Quality Assurance Committee (MQA) reviews diff icult patient cases and all cases who return to acute care within 48 hours by conducting chart reviews, investigation and discussion of f indings for quality improvements. - M QA also reviews physician scorecard data and real time survey data to identify areas for improvement.

PAT I E N T H A N D O F F B E TWE E N ACUT E - CA R E A N D H D G H

- P  rocess improvements to improve handoff reports from acute care and HDGH, utilizing written and verbal reports as well as an escalation process if follow-up required for any concerns. - E stablished quarterly meetings to review process and discuss any process improvements.

SUSTAINING A L E A R N I N G C U LT U R E -

LEADs framework training for all leaders. Emerging Leaders course for frontline staff. 360 performance evaluations and feedback for leaders. Tuition reimbursement and conference reimbursement.

CHOOSING W I S E LY ACCREDITATION CANADA SURVEY

Accreditation Canada will be onsite the week of June 3rd, 2019 for our onsite survey. Stay tuned for more information in upcoming editions of our newsletter!

FEBRUARY 2019

NOVEMBER 2018

eason’s Greetings to All the Professional Staff at Hôtel-Dieu Grace Healthcare. Over the last two months we have hosted two excellent speakers for Grand Rounds, Dr. Vasudev from London Schulich and Dr. Jouney from Michigan. They brought information about Non-Pharmaceutical treatment for Depression and a great primer on Addiction Medicine. The plan is to offer another Grand Rounds in the New Year. These programs are accredited and free of charge and we encourage everyone to take advantage of the learnings.

site (hopefully in February). We will be keeping you informed as events happen and training begins. Dr. Vince Ruisi will be leading us in this major change in our work life at the hospital.

Don’t forget the Professional Staff Quarterly meeting with Hot Breakfast on December 14th at 8am in the Chrysler Room, we hope to see you there!

As the holidays approach, we would like to wish everyone a safe and festive season with your friends and family.

H D G H PR O F E S S I O N A L STA F F Q UA RT E R LY A reminder that our next HDGH Professional Staff Quarterly Meeting will take place on Friday, March 8th at 8am in the Chrysler Room in the Emara Building. Beverages and a continental breakfast will be provided. We will be holding our annual voting for the Professional Staff Association at the March 8th Professional Staff Quarterly Meeting. On that date, Dr. Deb Hellyer will be passing the torch to Dr. Harman Virk for the position as President. Dr. Pat Montaleone is our upcoming nominee for the Vice President position. We will also have a representative from Ellis Graphics in attendance at our March Staff Quarterly Meeting with samples of white coats for physicians to order. The Medical Affairs Department will be covering the cost of embroidery for any purchases.

The HIS-Cerner project-Evolve, is still underway, though quiet at the moment as we wait for the arrival of Cerner on

PLEASE VISIT THE

for details on upcoming events.

DR.COLIN MASCARO Dr. Colin Mascaro, a PGY5 Resident in Physical Medicine & Rehabilitation from Queen’s University in Kingston, will be completing a Physical Medicine & Rehabilitation elective at HDGH under the supervision of Dr. Nathania Liem, Clinical Lead. We wish him a great experience during his time on our campus from December 18, 2018 – January 14, 2019.

Welcome aboard!

- T  ip of the month included in Medical Affairs newsletters for physicians to review and institute in their practice. - Prevention of Urosepsis/ PHYSICIAN ASSISTANT - Palliative Antimicrobial stewardship working ANNOUNCEM group to look at The Medical Affairs Teams i best practice and new additions to our membe prevention strategies.

elcome to the Mid-Winter Newsletter. We have some good news to share about new add additions to our physician families! Congratulations to all the new parents and grandpar project with Cerner we are happy to report that Cerner will be coming on site to start the real wo March 2019. We will start to see what our new world is going to look like as they roll out their pro

In addition, a reminder for all staff to watch their emails for the 2019/20 re-application forms wh through the CMARS portal. The deadline for all applications for Windsor Regional Hospital an (HDGH) is March 31st, 2019. Hope to see many of you at the upcoming Geriatric Conference o

We are currently recruiting to fill a Temporary Replacement (approx.1 the Palliative Care Unit. We have several interested and qualified physi

Dr. Jeff Cohen officially became a proud gran Dr. Ryan Mills welcomed a baby girl, Selah M Dr. Priya Sharma welcomed a baby girl, Jiya G

PROFESSIONAL STAFF BY-LAWS

Our Board of Directors approved the Professional Staff By-Laws on January 30th, immediately and will be posted on our intranet on the Medical Affairs Department physicians for their review and feedback!


PAT I E N T SAFETY BOARDS

- P  ublicly displayed patient safety boards located on all patient care areas. - HDGH Unit Based Councils update these boards monthly by reviewing their scorecards and realtime surveys to update metrics and populate information on the board. - T hey highlight areas of strength and identify quality improvements from trends as well as post a “patient safety tip of the month”.

PHARMACY

- T hird party training completed for supervisor and two champions on sterile non-hazardous compounding to ensure continued education and training for new staff. - S upervisor/champions trained all the pharmacy staff to meet standards for compounding of non-hazardous drugs (NAPRA standards).

ENVIRONMENTAL SERVICES (ES) AND INFECTION CONTROL RELATIONSHIP – CLEANEST HOSPITAL IN ONTARIO

- B  oth teams work closely together with a common goal preventing the spread of infection and are members of our Infection Prevention and Control Committee (IPAC). - Monthly meetings to discuss any learnings, needs and areas for improvement. - P resenting at IPAC Canada in May 2019.

PA T I E N T & F A M I LY A D V I S O R Y C O U N C I L ( P F A C )

- P  FAC members involved in several committees throughout the organization; Board and Quality Board, Strategic Advisory Council, Accessibility Committee, Creating Tomorrow Together, IPAC, Unit Based Councils, Mental Health and Addictions Council, and Regional Children’s Centre Family Council. - A  ssisted to revise the HDGH “Family Presence and Visiting policy”, website design and review all our program brochures receiving the “PFAC Checkmark” of approval. - A nnually assist in developing the HDGH QIP (with special attention to our patient sensitive indicators) monitor quarterly results and assist with identifying action plans. - Monitor real-time patient experience surveys (admission and discharge). - Developed the PFAC survey completed monthly with our patients. - Two PFAC members were trained by Accreditation Canada along with 23 other leaders in the organization on how to use Tracers for Quality improvement.


OUR MISSION The mission of Hôtel-Dieu Grace is to serve the healthcare needs of our community including those who are vulnerable and/or marginalized in any way be it, physically, socially, or mentally. As a Catholic sponsored healthcare organization, we provide patient-centred care treating the body, mind, and spirit. We do this by providing holistic, compassionate and innovative care to those we serve.

OUR VISION A trusted leader transforming healthcare and cultivating a healthier community.

OUR VALUES Respect • Teamwork Compassion • Social Responsibility


PATIENT EXPERIENCE

DISCHARGE TRANSITION AND CONTINUITY

COORDINATION OF CARE

INFORMATION SHARING

RESPECT & DIGNITY

PATIENTS FIRST

ACCESS TO CARE

ACCESS, CONNECT INFORM & PROTECT.

RESPONSIVENESS

PHYSICAL ENVIRONMENT

Our Patient Experience Framework is based on the key dimensions that are measured in our Patient Experience Surveys. Our patients are at the center of all that we do and our focus is on improving access, connections, information and safety. The HDGH Patient Safety Plan, Strategic Indicators and Quality Framework are reviewed routinely to ensure continued alignment to the organization’s vision and mission and continuous commitment to improvement and quality of care.


QUALITY FRAMEWORK To show how quality flows through our organization, HDGH has created the Quality Committee Framework as a visual representation. It serves as the foundation for quality improvement throughout the organization. It is specif ic to each one of our strategic drivers: Our Patients, Our People, and Our Identity.

QUALITY COMMITTEE

PARTNERING WITH OUR PATIENTS AND FAMILIES IN THEIR CARE

PARTNERING WITH OUR STAFF IN CONTINUOUS QUALITY IMPROVEMENT

PARTNERING WITH OUR COMMUNITY TO MEET THE NEEDS OF OUR PATIENTS

Keep me safe Listen to me

OUR PATIENTS SERVICE EXCELLENCE

Be kind to me Explain things to me

I am safe I am respected I am engaged

OUR PEOPLE BEST PLACE TO WORK

I am heard I can reach my full potential

Help me find my way

OUR IDENTITY CENTRE OF EXCELLENCE

Take my hand and guide me through my journey Provide access to services in the community


The Quality Committee Framework Is a series of linked committees that coordinate and provide a connection from the Board of Directors to the frontline staff. At the centre of this framework sits the HDGH Patient & Family Advisory Council (PFAC) because the patient and family are at the centre of everything done at HDGH. It is important that patients and their families have a voice and are involved in direct decision making about their care. Each committee or group around PFAC makes decisions about how quality and safety are executed throughout HDGH. There is continuous monitoring and reporting of metrics through the various committees from frontline to Board of Director level. The HDGH Research and Evaluation Department works with each of the councils and committees with program planning and evaluation as well as knowledge transfer and education opportunities.

EXECUTIVE LEADERSHIP COUNCIL • Strategic and Operation Plan • Senior Management Council

BOARD QUALITY •

MEDICAL QUALITY ASSURANCE

Monitor Quality of Service within HDGH Oversee preparation of Quality Improvement Plan oversight Ensure Regulations met (ECFAA, Hospital Management Regulations, 965)

• •

• • •

MEDICAL ADVISORY COMMITTEE

UNIT BASED COUNCILS • • • • •

PATIENT FAMILY ADVISORY COUNCIL

Unit Based Quality and Safety Clinical Work Environment Clinical Practice Monitors Unit Scorecards Updates Patient Safety Boards

• •

Develops Program Goals and Objectives Monitors Program Scorecards and Indicators Develops Program plans and integrates quality improvement and safety

RESEARCH AND EVALUATION • • •

Research Program Planning & Evaluation Knowledge Transfer & Education

• • • •

Quality of Medical Care Credentialing & Re-Appointment Professional Staff Matters Professional Staff Policies

DIRECTORS COUNCIL

PROGRAM QUALITY COUNCILS •

Morbidity and Mortality Review Quality of Care Information Protection Act (QCIPA) Competence and Quality Assurance

• • • • •

INTER-PROFESSIONAL QUALITY COUNCIL • • • • • • •

Utilize Evidence Based Practice Quality Improvement Education/Innovation/Research Professional College Regulations Clinical Policies Infection Prevention and Control Monitoring of quality trends, safety metrics and patient experience data

• •

Patient Surveys Accreditation Oversite Risk Management Hospital Policies Joint Occupational Health & Safety Committee Privacy Oversite Financial /Decision Support /Performance Oversite (sustainment)


PAT I E N T S A F E PATIENT SAFETY GOAL

OBJECTIVE

PLANNED INITIATIVES

Create an environment that supports safe care and services

Reduce the time patients designated for Alternate Level of Care (ALC) spend in hospital

1. Standardized Discharge Rounds 2. Development of supporting Policies and Screening Tools to support appropriate admission 3. Review Role of Assertive Community Treatment (ACT) services to support

Reduce total overall # of work place violence incidents

1. Completion of communications plan roll out 2. Development of work group to research best practice and create chart flagging process that focuses on patients and staff 3. Review of Violence Risk Assessment tool with input from Joint Health and Safety Committee, managers, frontline staff and patients 4. Review of education/training for staff to determine any enhancements that should be introduced.

Develop an overall Harm Indicator Metric

1. Establish a high level Harm Indicator that includes key harm indicators for sub-acute care (will be internal number as provincial Harm Indicator is for Acute care only). This is meant to assist board level. All Harm metrics are currently monitored on the Interprofessional Practice Quality Council (IPQC) and Board Safety/Quality quarterly report . Establish baseline for new high level indicator and set target for annual reduction based on indicators selected. (to be determined by September 2019)

Reduce hospital injuries related to falls

1. Evaluate and monitor compliance of falls prevention program through chart audits, falls risk screening compliance 2. Conduct post fall debriefings/huddles 3. Provide education to patients and family members about how to prevent falls, monthly report out to IPQC and summary of falls committee reporting

Avoid facility acquired pressure ulcers

1. C  omplete annual hospital-wide pressure ulcer prevalence audit 2. Develop multi-disciplinary team to review wounds related to medical devices

Avoid hospital readmission rate for Mental Health & Addictions (MH & A)

1. C  ombine Toldo Neurobehavioural Institute (TNI) intake with ACT so there is single point, coordinated access to tertiary and ACT services using a standardized process for program acceptance. Denial and appeal 2. Wait list management to help improve efficiencies and facilitate access for clients that need ACT support to prevent acute care readmission

Identify and mitigate safety risks inherent in specific patient populations


TY WORKPLAN MEASURE(S)

TARGET

TIMEFRAME

LEAD

RESPONSIBILITY

QIP

1. A  LC patients have Complex Discharge Rounds (CDR) /ALC review 2. P  atients considered for admission have screening tool completed

1. 100% 2. 100%

2019-2020

Director , Rehabilitation

Vice President Mental Health /Vice-President Rehabilitation

x

1. C  ommunications Plan 1. 100% rollout completed - 100% of 2. Collecting tasks identified for 19/2020 Baseline (CB) 2. # work place incidents (current YTD 3. % incidents without injury : 40 ) 3. 85%

2019-2020

Director Occupational Health & Safety (OH & S)

Chief Human Resource Officer (CHRO)

x

# I ncidents of Harm (with injury )

Collecting Baseline (CB)

2019-2020

Director Quality / CNE

Vice President Quality

1. % falls rate overall 2. % falls with injury

1. < 12.5% 2. < 2%

2019-2020

CNE

VP Rehabilitation / MH & A

1. %  of inpatients with facility acquired pressure ulcer (stage two or higher) 2. D  ecrease # of wounds related to medical device

1. < 4% 2. 10% decrease

2019-2020

CNE

VP Rehabilitation

1. S tandard process established 1. 95% meeting 2. W  ait list management target (< 2 process established $ % days) meeting target to admission 2. 90% meeting 3. M  onitor patient experience wait time/ metric related to access: access Access/Entry to Services experience dimension

2019-2020

Director , MH & Addictions

VP MH & Addictions

x


PAT I E N T S A F E PATIENT SAFETY GOAL Promote Effective Information transfer with patients and team members across the continuum of care

OBJECTIVE

PLANNED INITIATIVES

Integration of patients into the care planning process and documentation

1. RH4 trial/pilot on care plan integration/documentation improvement project 2. Continued education to staff on including patients in decision making 3. Monitor survey question results from patients related to integration into planning and decision making

Medication Reconciliation on discharge

1. Standardize discharge Med Rec process and forms throughout organization (inpatient and outpatient clinic areas) 2. Develop training strategies and roll out plans to inter-professional team 3. Complete software development to support and capture reporting and data for completed discharge Med Recs in electronic system

Reduction of Medication Incidents

1. Monthly monitoring of Medication Incidents thorough RL6 and develop improvement strategies through Medication Management Team. 2. Continue with weekly reports and monthly review by programs/units 3. Continue to encourage reporting by staff - learning environment 4. Roll out RH3 pilot/Unit Based Council (UBC) "quiet zone" - spread to other units

Implement Palliative Care standards

1. Establish baseline through review of current state analysis. Develop Plan for non-palliative care unit trigger process /Palliative Care Documentation and chart review. 2. Review Health Quality Ontario (HQO) Palliative Care standards and identify processes and supporting documentation tools and create a best practice work plan

Implementation of Expected Discharge Date on admission

Identification of Expected Discharge Date on Admission to drive care planning and patient planning and involvement in discharge planning and goals

Discharge Summaries to primary care within 48 hours

1. Review current state process and map out future state (including with HIS implementation) to identify gaps from physician perspective and develop work plan 2. Work with vendor to improve reporting to monitor and flag transcription times. Establish baseline dictation to transcription times. 3. Work with vendor to address number of transcribed reports going to the review queue and being delayed Currently 46% (estimated)


TY WORKPLAN MEASURE(S)

TIMEFRAME

LEAD

RESPONSIBILITY

1. # units implemented 1. 100% post pilot. 2. 85% 2. M  onitor impact on Patient Experience - I feel involved as much as I would like to be in decisions about my goals and care plan (Rehab / COMPLEX )

2019-2020

Director, Rehabilitation

VP , Rehabilitation

1. I mplementation completed in 100% of areas identified. 2. E  ducation /training completed in all areas 3. S oftware and report requirement identified are 100% completed

1. 100% 2. 100%

2018/2019 2019-2020

CNE

VP Rehabilitation / MH & A

1. # medication incidents with breakdown by type and severity. Target to increase reporting 2. # of incidents as result of omission (due to staff distractions)

1. increase by 10% (education on increasing reporting) 2. 10% decrease from 18-19

2019-2020

CNE

VP Clinical

1. R  eview documentation on all flagged palliative patients identified as at risk of dying and in need of palliative care. 2. V  erify palliative documentation on medical record

1. 100% reviewed 2. 100% of records reviewed

2019-2020

Director, Rehabilitation

VP Rehabilitation / Director Rehabilitation

% of admissions have Estimated Date of Discharge (EDD) on record within 72 hours of admission

75%

2019-2020

Director, Rehabilitation

VP Rehabilitation

1. %  sent to primary care within 48 hours (Rehab) 2. %  sent to primary care within 48 hours (TNI) 3. %  sent to primary care within 48 hours (Complex) 4. R  eduction in reports going to the review queue for resolution

1. 2. 3. 4.

2019-2020

Director Health Information Management (HIM)/Medical Director Rehabilitation

VP Quality/medical

TARGET

80% 80% 60% 60%

QIP

x

x

x


PAT I E N T S A F E PATIENT SAFETY GOAL

OBJECTIVE

PLANNED INITIATIVES

Reduce the risk of healthcare associated infections and their impact across the continuum of care

Enforce standard accepted hand hygiene (HH) protocols and monitor compliance

1. Conduct monthly audits to ensure compliance (target) 2. Implement educational opportunities to promote effective hand hygiene practices for staff, physicians and patients

Improve overall quality of care for patient journey

Improve patient experience and enough information at discharge

1. Create discharge package with input from patients/families and real time survey feedback 2. Creation of Caring About Your Discharge brochure 3. Creation of Discharge Sheet for Patients with all follow-up information (based on feedback from real time surveys) 4. Monitor impacts of Medication Reconciliation improvements on patient experience 5. Review planning opportunity for follow-up discharge call process

Improve overall and would you recommend patient experience

1. Implement Quarterly NRC /Benchmarking Experience Scorecards to Programs (in alignment with Experience Framework) -indicators already on program scorecards & Executive Council (EC) Scorecard 2. Monthly updates from real time surveys and themes to Programs /units and UBC and track and monitor improvement initiatives from real time survey results and actions 3. Q  uarterly reports to Patient Family Advisory Council (PFAC) 4. Communication Plan - to support quarterly updates in Newsletter/Need to Know highlighting quality improvements 5. Highlight themes and improvement activities in Quality Matters Infographic (quarterly) 6. Increase patient /family representation on key committees and initiatives


TY WORKPLAN MEASURE(S)

TARGET

TIMEFRAME

LEAD

RESPONSIBILITY

1. O  verall rate - before and 1. 95% for all after contact intervals moments 2. M  onitor Hospital Acquired 2. Reduce to Infections (HAI) rates <30 HAI cases (MRSA/VRE/Cdiff annually rates) through IPQC and Infection Control Committee (reduce to 33 cases from 56 over past year)

2019-2020

CNE

CNE

1. %  positive /excellent /top box score (yes, definitely) for enough information at discharge 2. %  positive /excellent /top box score (yes, definitely) on understanding of medications (current state J-D 2018 - 69%)

1. 62% 2. 75%

2019-2020

Director Quality /Director Rehabilitation

VP Quality /VP Rehabilitation

1. M  onitor the seven dimensions of care. Target 2-5% improvement in each element 2. M  onthly surveys sent out to units/UBC (target : 12) 3. Q  uarterly reports and feedback opportunity at PFAC (target : 4) 4. # committees with patient /family representation (identify committees to add pt./family representative)

1. 2-5% 2019-2020 improvement in each dimension 2. 100% surveys sent out 3. 100% PFAC engagement sessions 4. Track # of committees pt. rep is on

Director, Quality

VP Quality

QIP

x


PAT I E N T S A F E PATIENT SAFETY GOAL Improve overall quality of care for patient journey

Digital Health Strategy

OBJECTIVE

PLANNED INITIATIVES

Apply Tracer Methodology

Conduct a minimum of one tracer monthly and share learning's at IPQC

Expand Shared Governance Model

1. Expand UBC to Outpatient (OP) area and Pharmacy (this will also assist with HIS implementation /planning) 2. Improve communication of performance metrics and results to the UBC level - revise intranet site for Quality to include all scorecard links and increase communication related to scorecard. Review role of leadership in review of performance accountabilities in their areas.

Implementation of new regional HIS Implementation of CERNER Health Information System (HIS) - Registration /Scheduling /Electronic Documentation, Computerized Physician Order Entry (CPOE), Closed Loop Medication, Electronic scheduling etc.

Implementation of Patient Portal /My Chart - post HIS implementation Implementation of Self Scheduling (Patient) Development of Benefits Risk Analysis Plan Expansion of OTN Services - focus on providing psychiatry care to those in the community, specifically rest homes via OTN Regional Initiatives

Continued adoption of Clinical Connect. Currently we have 268 users. CO HEALTH - patient discharge instructions and resources regional project


TY WORKPLAN MEASURE(S)

TARGET

TIMEFRAME

LEAD

RESPONSIBILITY

% completed (target : minimum 10 annually)

100%

2019-2020

Director Quality / CNE

VP Quality

1. I ncrease UBC in 2-3 out patient areas and Pharmacy 2. M  onthly posting on intranet of all scorecards and by managers.

1. 3 additional UBCs implemented 2. 100% of scorecards posted monthly

2019-2020

Director Quality

VP Quality

Evolve Project Work plan - 20 work groups in place : July 2019 - May 2020

2020-2021

Director Quality / HIM /Technology & CNE

Executive Leadership Team

20-21

2020-2021

CFO /Director Technology/CNE

CFO /Director Technology/CNE

21-22

2020-2021

CFO /Director Technology/CNE

CFO /Director Technology/CNE

19-20

2019-2020

Director , Quality / HIM/Technology/ CNE

VP Quality /CFO

# of additional clients served # o f rest homes served through expansion

2019-2020

Director MH & A /Director Rehabilitation

VP Rehabilitation /MH &A

2019-2020

Director Quality / HIM /Technology

VP Quality

2020-2021

Director Quality / HIM /Technology

VP Quality

# Clinical Connect Users HDGH to set date for implementation

Increase user by 10%

QIP


PATIENT & FAMILY ADVISORY COUNCIL

Profile for HDGH

Patient Safety Plan  

Our Patient Safety Plan is designed to improve patient safety, reduce risk and respect the dignity of those we serve by assuring a safe envi...

Patient Safety Plan  

Our Patient Safety Plan is designed to improve patient safety, reduce risk and respect the dignity of those we serve by assuring a safe envi...

Profile for hdgh