Patients Matter

PA T I E N T S M AT T E R QUALITY YEAR IN REVIEW 2018/2019

15%

DECREASE IN

OVERALL RATING OF CARE

HOSPITAL ACQUIRED INFECTIONS

IMPROVEMENT OF INPATIENT

2.9

DECREASE IN

LEADING PRACTICE DESIGNATION FOR OUR WORKPLACE VIOLENCE PREVENTION SUBMISSION TITLED:

Embedding a Culture of Safety Via a Workplace Violence Prevention Program

PATIENTS SAID THEY WERE TREATED WITH

RESPECT

BY PHYSICIAN

WAIT TIME FOR AN INPATIENT BED 1 .4 DAYS

INCREASE OF 4% OVER LAST YEAR

WAIT TIME FOR OUTPATIENT REHAB 1 DAY (FROM 5 DAYS IN MARCH 2018)

PATIENT EXPERIENCE

ENGAGING FOR QUALITY The patient voice is important to everything we do at Hôtel-Dieu Grace Healthcare. Engaging patients with their care helps transform healthcare in general – it allows to shape and mold their experience to one of safety, satisfaction and improvements. To help promote and support the drive for active patient-engagement, HDGH has developed our own Patient Experience Framework. The Patient Experience Framework is designed to ensure patients are able to make and influence decisions that affect their lives and their health.

DISCHARGE TRANSITION AND CONTINUITY

COORDINATION OF CARE

INFORMATION SHARING

RESPECT & DIGNITY

PATIENTS FIRST

ACCESS TO CARE

ACCESS, CONNECT INFORM & PROTECT.

RESPONSIVENESS

PHYSICAL ENVIRONMENT

E X PA N D I N G

IN OUR SHARED GOVERNANCE MODEL

10 FUNCTIONING UNIT BASED COUNCILS ACROSS HDGH!

HDGH Unit Based Councils (UBC) continue to empower frontline staff to contribute and take ownership of decisions affecting their clinical practice, education, research, patient care, and their work environments. Today, HDGH Unit Based Councils have grown from six to ten across our organization. The chairs of each UBC continue to sit on the inter-professional quality council and report on their UBCs quality improvements monthly.

- Over 117 UBC Members Recruited - 132 UBC Meetings - 86% Meeting Participation Rate - 200 Opportunities for Improvement (OFIs) actioned by UBCs - The UBCs update the publically displayed Patient Safety Boards monthly using metrics from Unit Score Cards for patient safety indicators.

2018/2019 UBC ACCOMPLISHMENTS

TNI: Coping plan booklet for clients. These booklets help clients identify ways to cope and assists staff in helping them to use these strategies not only while in our care, but upon discharge.

2South: The team thought it would be great to ask their patients what they might be able to improve upon. Today, each patient receives a “Bright Idea” form in their welcome package.

3North: This UBC promoted the use of red slide sheets for their patients to help improve care and help prevent staff injury.

RH3: Investigated the cause of some medication errors to be due to “distraction” during their medication administration process. They did some health teaching with the care team and also placed these signs outside of the medication rooms.

RCC: Improved signage and way-finding for their clients and families.

They also started the “Breakfast Program” for Intensive Treatment Program children. The children LOVE their hot breakfast.

FAVOURITE PART OF BEING ON AN UBC – WHAT STAFF HAVE TO SAY...

Seeing changes happen that affect our day to day work Having a voice Getting to know my colleagues Feeling heard An excellent forum to propose change and work to make it happen

3N UBC

2S UBC

ES UBC

RCC UBC

3S UBC

FOOD & NUTRITION UBC

RH1 UBC

RH3 UBC

RH4 UBC

TNI UBC

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 & 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)

KEY

ACCOMPLISHMENTS Presenting at the International Safety Symposium

IMPROVING HANDOFFS BETWEEN ACUTE CARE AND HDGH:

- I n collaboration with HDGH’s acute care partners, a written handoff report form was developed to be used by both organizations along with establishing process to also incorporate a phone report.

- An escalation process was established for Manager to Manager follow-up with any identified concerns.

- Quarterly meetings between the two organizations were established to review process and discuss any process improvement opportunities.

On February 8th, two countries were bridged together through one common goal: keeping our patients, and thus, our communities, safe. The International Patient Safety Symposium welcomed a captive audience of over 100 to hear from healthcare, education, and business industry experts from Windsor and Detroit regions.

Hôtel-Dieu Grace Healthcare (HDGH) was proud to be an event partner for the Symposium, as we shared a number of organizational resources through information booths and speakers.

HDGH President and CEO, Janice Kaffer spoke on the need for staff safety and how HDGH has learned, improved, and continues to strive to uphold staff safety. Janice spoke on the ways staff safety impacts the safety of our patients.To conclude the event, HDGH’s Alison Murray, Director of Quality, Health Information Management, and Technology, along with Kathy Quinlan, Manager of Quality and Clinical Projects spoke about the voice of the patient and what our organization has done to improve the patient care journey. Some of these projects include our refreshed Strategic Plan that ensures our frontline staff see themselves in the plan, Unit Based Councils identifying areas for improvement on their unit, and real-time patient satisfaction surveys that ask for feedback from patients in order to make changes for the better.

Choosing wisely initiatives: - Tip of the month included in Medical Afffairs newsletters for physicians to review and institute in their practice.

Falls Committee Process Improvements - Standardized abbreviations on white boards to describe level of assistance for patient mobility.

- Updated the MORSE falls scale and interventions.

- Refined criteria for patients requiring direct observation and personal alarm use.

- Refined categories in Safety Reporting System on mobility status to improve data and trending.

- Purchased additional patient alarm systems for fall prevention.

- Standardized tool for fall investigation follow-up.

- Information for fall prevention on admission package and staff education during patient safety week.

FEBRUARY

2019

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PRESENTATION

Infection Prevention and Control Canada National Conference

In May of 2019, HDGH’s Infection Prevention and Control Practitioners, Lindsay Samoila and Ray Elwoord travelled to Quebec City to present on how HDGH solved common Personal Protective Equipment (PPE) challenges. A patient safety risk was identified as there was no standardized process for the storage of PPE at point-of-care to promote best practice donning and doffing techniques. An inter-professional working group composed of IPAC, Environmental Services, Materials Management, frontline staff, Ergonomist, Clinical Practice and Facilities was formed to review the situation using prospective analysis as the primary methodology. The team used a system-based approach to identify risk points and used current state analysis to focus on areas of improvement and determined risk reduction strategies.

HDGH IS IMPROVING PATIENT CARE THROUGH CHANGE DAY ONTARIO

As our tagline says, we’re changing lives together at HDGH, so when we heard about the opportunity to make change province-wide, we were eager to take part.

We knew, though, that we could not make a pledge that would speak to enhancing the experience of the patients in our care without actually consulting them, so as we do with the majority of our work, we brought our Change Day Ontario pledge ideas to our Patient and Family Advisory Council’s (PFAC) table.

Together, we finalized our Change Day Ontario pledge to involve patients/clients and families in their care.

“I pledge to involve patients/clients and families in their care by always listening to the patient when determining their goals of care.

Judy Simms, HDGH Clinical Practice Manager

QIP

QUALITY IMPROVEMENT PLAN

Quality improvement is an ongoing priority that helps us continually find new and better ways to enhance care for patients, increase satisfaction and achieve even better clinical outcomes. Our Quality Improvement Plan, or QIP, is one tool that we are using to help us document and review our current performance in a variety of areas. With this plan, we will be able to very clearly see our targeted areas for improvement and chart our progress.

The HDGH QIP Scorecard is updated quarterly to show how we are measuring against our key performance indicators relating back to the Annual Quality Improvement Plan.

Measure/Indicator from 18/19

17/18 Performance

18/19 Target

18/19 Q4 Performance

69%

71%

75%

82.9%

90%

78.6%

Did you receive enough information during the admission process (Definitely yes)

18%

23%

32%

Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital?

(Definitely yes)

31%

38%

34%

Medication reconciliation at admission

47%

95%

98.3%

95%

44.7%

Would you recommend this hospital to your friends and family?

(Inpatient care) (Definitely yes) Employee Workplace Violence Incidents without Injury

Medication reconciliation at discharge Rate of psychiatric (Mental Health and Addiction) discharges that are followed within 30 days by another Mental Health and Addiction admission

9.26%

6%

0%

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 postacute ALC information and monthly bed census data

15.43%

16.5%

13.4%

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 20192020 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 on all R 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 followup, 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

INVESTMENT IN

QUALITY Quality Improvement Advocates In 2019, the HDGH Quality Improvement Advocate team grew to a team of two. Sue Garbula joined Norma Mamaril in meeting with our patients and conducting real-time surveys on our patients’ experiences through admission, mid-stay and prior to discharge.

Both Sue and Norma are Registered Nurses which allows them the clinical expertise when meeting with patients and ability to identify and flag any patient safety risks IMMEDIATELY. Before introducing Sue and Norma and the real-time surveys, HDGH utilized NRC Picker’s Hospital Experience Survey to allow patients to provide feedback and help guide our practices. Since the introduction of Sue and Norma, our response rate has gone from 32% using NRC to 62% and now provides a more proactive approach. The information shared with Sue and Norma also allows us to act immediately and improve the patient’s experience while they are still receiving HDGH services – a great example of our HDGH commitment and investment in quality improvement!

SURVEY SAYS …..

-

Through January- December 2018 1235 patients were welcomed and surveyed 397 discharge surveys were completed 2019 – 66% said they received enough info on admission (42% in 2018) 9.2/10 Average rating of Treatment of Staff since arriving 96% of patients received a welcome package 100% said services were always sensitive to cultural needs 2019 – 99% would recommend HDGH (85% in 2018)

ACCREDITATION PREPARATION INVESTMENT:

- I n January of 2019, 25 members (23 Leadership and 2 PFAC members) received a 2-day training and education on how to conduct a Tracer for Quality Improvements. Standard Operating Practices were developed for conducting a Tracer. 46 HDGH Tracers were completed between February 2019 to May 2019.

- Simulated Mock Survey in March to assist in preparing organization.

- Communications strategy with weekly articles in Need to Know, poster boards on units and huddles. In addition, all staff and physicians received an Accreditation Handbook and were invited to particiapte in a Kick -off event and Accreditation Jeopardy Game - Frontline staff and PFAC involvement in Accreditation Working Groups

DAY MEDICATION REVIEWS: The Quarterly review (or 90-day Review) is an HDGH pharmacy led documented review of each patient’s medication conducted every three months. Medication reviews involve a comprehensive evaluation of each drug to check for appropriateness for the patient condition, its safety, effectiveness, and to avoid potential drug interactions and adverse drug effects. Medication reviews is an opportunity to reduce the potential harm of “polypharmacy” by deprescribing inappropriate medications and to optimize the treatment and therapeutic effect of each drug. Medication review is an important mechanism to educate and involve patients in decisions about their medications.

Current Metrics for 90 Day Medication Reviews completed in April 2019 are 100%. (30/30 patients had a 90-day medication review completed)

OPIOID STRATEGY:

- The Pharmacy team play a vital role to support the appropriate use and access of narcotic drugs.

- They collaborate with the inter-professional team to enhance patient safety by reviewing any patient orders with two or more narcotics to ensure appropriate utilization, duration of use, and potential alternative drugs for pain control.

- They developed process for pharmacy consults to review opioid needs and provide support and education around opioid issues.

NALOXONE STRATEGY: - N aloxone policy developed and Medical Directive.

- Training and education for staff and Board of Directors.

- Distribution kits to all high risk areas, WMS, ACT, TSC, RTF, WPEP as well as by our AED’s.

PATIENT CASE REVIEWS IN MQA:

-R eview of Difficult cases as well as Patients who return to acute care within 48 hours.

-M edical Quality Assurance Committee reviews difficult patient cases and all cases who return to acute care within 48 hours by conducting thorough chart reviews, investigation and discussion of findings for quality improvements.

-M QA also reviews physician score card data and real time survey data to identify areas for improvement.

PA T I E N T & F A M I LY

ADVISORY COUNCIL Our Patient & Family Advisory Council (PFAC) is at the center of all that we do here at HDGH. The group started as an “Engagement Council” when they were first established in 2015 but over the last year it was evident that this group was much more than that.

The name change to “Advisory Council” was warrented as the group has been instrumental in providing feedback on brochures, patient information, and on assisting to develop and monitor our Quality Improvement Plan.

This year, PFAC developed the benevolent fund with our staff to identify the needs of our patients to support financially. Many members of our PFAC are also involved in other committees to ensure that HDGH has a “patient voice” at the table. Some of these committees include: Strategic Advisory Committee, Mission Achievement, Accessibility committee, RCC, MHA, UBC’s, Ethics committee, Wound Care and French Language.

PFAC AND ACCREDITATION

Our PFAC were also directly involved in various working groups to help us prepare for the Accreditation in June 2019. They gave valuable input and suggestions on how we “involve or seek input” from our patients and families here at HDGH as over 40% of the Accreditation Standards were changed this year to include this language and philosophy. They received their own Accreditation Binder on the standards that they were reviewing and sat on the following working groups: Leadership, Rehabilitation, Mental Health inpatient and outpatient, Hospice and Palliative care. They also met with our surveyors during our accreditation cycle and were instrumental in helping us achieve our Exemplary Standing.

HDGH also requested a Patient Family Surveyor as part of our Survey Team.

Two of our PFAC members attended our training and education session through Accreditation Canada on how to use Tracers for Quality Improvement and were involved in completing over 20 HDGH Tracers for Quality Improvement with us.

PFAC AND REAL-TIME SURVEYS

Our PFAC team also developed their own “real time survey” that they complete with our patients and family members who are “mid stay” with us.

interview made this process so “I believe in having non-hospital people doing the their families spoke freekly. They authentic (no fear in answering.) Patients and and recommendations for imwere quick to give numerous positive comments HDGH allowed me to be a valid provement. For me personally, very pleased that in patient-care.” participant in a process that can make a difference Advisory Council Barb Masotti, Chair, Patient and Family p over the last five years “The commitment of HDGH senior leadershi advisors to share their to create opportunities for patient and family ms of care and in quality insights and perspectives in developing new syste inspire others.” improvement endeavors is impressive and will ident & CEO BEVERLY H. JOHNSON - IPFCC Pres

WHAT 'S TO COME

2019/2020 • Evolve: Clinical Transformation Project; GO LIVE June 2020.

• PFAC work plan: Orientation, Handbook, Tours, Presentations, and Annual Reports.

• PFAC revising their “real time survey” for patients in “mid-stay” at HDGH and also developing standard work around the quarterly completion of these.

• Add another PFAC member to the HDGH Board of Directors allowing them “voting membership.”

• PFAC involvement in the interview process.

• Further link the UBCs and PFAC in their efforts for Continuous Quality Improvement.

• HDGH Tracers for Quality Improvements.

• Indigenous Cultural and WeTrans training expansion to other leadership and frontline staff.

“I am so very proud that over the past 3 years, HDGH has developed and advanced throughout the entire organization an unwavering culture and commitment to quality care, service and patient safety, culminating in accreditation with Exemplary Standing, Accreditation Canada’s highest award. On behalf of the Quality Committee, I thank frontline staff, leadership, physicians and volunteers for their ongoing diligence and dedication throughout the process – all in pursuit of the highest level of care for patients.”

- John Clark – Chair of the Quality Committee of the Board -