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2012/13 Quality Improvement Plans: An Analysis for Improvement

2012/13 Quality improvement plans: an analysis for improvement

Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Progress Achieved Over 2011/12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Overview: Priority Setting, Target Setting and Change Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Quality Improvement by Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Safety: Clostridium Difficile Infection (CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Safety: Ventilator-Associated Pneumonia (VAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Safety: Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Safety: Central Line Associated Blood Stream Infection (CLI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Safety: Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Safety: Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Safety: Surgical Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Safety: Physical Restraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Effectiveness: Hospital Standardized Mortality Ratio (HSMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Effectiveness: Hospital – Total Margin (OHRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Access: 90th Percentile ED Length of Stay for Admitted Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Patient-Centred: Patient Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Integrated: 30-Day Readmission Rate to Any Facility (Specific Case Mix Groups) . . . . . . . . . . . . . . . . . . . . . . . 61

Integrated: Percentage of Alternate Level of Care (ALC) Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Appendix A: Suite of Capacity-Building Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Appendix B: Technical Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

2 2012/13 Quality improvement plans: an analysis for improvement

Executive Summary

In April 2012, Ontario hospitals submitted their Quality

Improvement Plans (QIPs) for 2012/13, the second year

of provincially mandated QIPs under the Excellent Care

for All Act (ECFAA), 2010 . It was recommended that

hospitals focus on five key attributes of quality care —

safety, effectiveness, access, patient-centred and

integrated — and to include at least one core recom-

mended indicator from each of these attributes .

Indicators were to be assigned a priority of 1, 2 or 3 .

Hospitals’ executive compensation is linked to the

achievement of quality improvement goals . This

requirement drives both improvement and accountability

for the delivery of QIPs, and increases motivation at

all levels of the organization to achieve agrressive, but

realizable, targets . Hospitals were also asked to provide

a report on the progress made since the 2011/12 QIPs .

This analysis of the 143 QIPs submitted includes the

background to QIPs under ECFAA, looks at the progress

achieved over 2011/12 and outlines key findings regarding

priority setting, detailing how many hospitals selected

each indicator and how targets were set as compared

to current performance . A selection of good change

ideas is provided for four of the most selected indicators .

In 2012, Health Quality Ontario (HQO) put forward a new

Strategic Plan, or roadmap, to guide the agency as it

works to achieve an overarching quality aim in Ontario’s

healthcare system — better outcomes, better experience,

better value for money . Analysis and feedback on QIPs

are key ways that HQO can assist individual hospitals

to achieve and exceed their improvement targets: If the

majority of hospitals meet or exceed targets in key

areas, there is an opportunity to push the provincial

average to new (and better) levels of performance . For

patients and staff, this means better patient outcomes

and more reliable care delivery .

This analysis also serves as a learning tool for hospitals

going forward: It will help them share innovative change

ideas, effective strategies and success stories; commu-

nicate progress achieved; and highlight continued areas

for improvement . The appendices include a summary

of the suite of supports available to hospitals as they

complete their QIPs, and a technical report .

Overall, hospitals made progress since the initial year

for submitting QIPs under ECFAA, 2011/12 . Three key

areas of progress include:

• A perfect compliance rate with submitting QIPs and

progress reports, as well as more consistency in

completing specific elements of the QIPs .

• Clear aims aligned with hospitals’ strategic priorities,

which were identified by a number of hospitals and

included appropriate measures and motivational

targets, and change plans that the hospitals intend

to implement to achieve their aims .

• Innovative and thought-provoking change ideas,

which were submitted by a number of hospitals .

While the completeness of QIPs has improved this year,

there were still gaps in some plans, including targets

that did not appear to be stretch targets and instances

where little or no detail was provided about change

ideas . In the spirit of quality improvement, hospitals are

encouraged to review their existing plans and compare

them to the exemplary plans identified in this document,

and to look for opportunities to adopt the best practices

for QIP development that their peers are using .

2012/13 Quality improvement plans: an analysis for improvement 3

Background

Quality improvement plans (Qips): What

they are, Why they matter and hQo’s role

Under the Excellent Care for All Act (ECFAA), 2010,

every hospital in Ontario (as defined in the Public

Hospitals Act) must submit an annual QIP . The QIP

is a tool that enables hospitals to identify, report on

and achieve QI objectives in a structured way . The

improvement attained by hospitals is the result of

clearly and consistently focusing on the principles

outlined in the Model for Improvement (see page 4) .

Each hospital’s Quality Committee oversees the

preparation of the QIP, which must be certified by the

Board Chair and the Chief Executive Officer, submitted

to HQO and made available to the public . The Ministry

of Health and Long-Term Care (MOHLTC) has compiled

a number of resources to support Quality Committees

(see http://www .health .gov .on .ca/en/ms/ecfa/pro/

updates/qualitycommittee/bp_resources .aspx) .

In 2012, HQO set in place a new Strategic Plan, or

roadmap, for moving ahead with our mandate . This plan

is a transformative document for HQO . It consolidates

and makes explicit the agency’s raison d’être: to work

with others to drive a quality agenda for Ontario that

is provincial in scope, rooted in collaboration and

supportive of integrated and coordinated efforts

across all segments of the healthcare system .

Hospital QIPs are the key way in which HQO works

with its hospital partners to drive improvement in the

system and to help hospitals measure success, introduce

innovative change ideas and reach excellence in care .

The transformative objectives outlined in the Strategic

Plan include an overarching quality aim in Ontario’s

healthcare system — better outcomes, better experience,

better value for money .

Health Quality Ontario, together with its partners

across the system, has been the driving force behind

making the quality of healthcare in Ontario an explicit

and shared priority supported by system leaders,

providers and patients . QIPs are one important

component of change, but they are by no means

the only one: HQO is a key catalyst of system-wide

change . Moving forward, HQO will:

• Focus the system on a common quality agenda

(establish priorities, goals and targets and mobilize

system leadership around a common agenda) .

• Build evidence and knowledge (generate or access

the evidence and knowledge needed to provide

quality care and improve population health) .

• Broker improvement (develop the tools and supports

needed to accelerate the adoption of evidence-

based best practice, and foster the development of

quality improvement capacity in the system) .

• Catalyze spread (guide, support and collaborate

within the system to spread knowledge about best

practices, measurement tools and implementation

strategies) .

• Evaluate progress (provide timely and relevant health

system monitoring, measurement and reporting, and

assess progress and report to the public) .

ECFAA lays the groundwork for a significant cultural

shift in Ontario’s healthcare system . Excellent QIPs and

well-executed improvement plans will strengthen the

hospital sector’s ability to deliver high-quality patient

care . The goal of the legislation is to blend quality and

value in such a way that patients move to the centre of

the healthcare system – their needs are prioritized and

services are designed to meet these needs . Ontarians

should expect high-quality, person-centred care now,

and in the future . Patient outcomes, patient experiences

and the quality of care delivered will drive the way

services are delivered, the way the system plans

services and how it is held accountable .

http://www.health.gov.on.ca/en/ms/ecfa/pro/updates/qualitycommittee/bp_resources.aspx

http://www.health.gov.on.ca/en/ms/ecfa/pro/updates/qualitycommittee/bp_resources.aspx


Developing and implementing QIPs should ultimately

help create a healthcare system that focuses on keeping

Ontarians healthy, provides appropriate and timely

access to excellent primary healthcare, and provides

the right care at the right time in the right place, all the

while promoting focused improvement, building capacity

to deliver person-centred care, and striving to meet

theoretical best .

Quality improvement plans and the model

for improvement

The concept and format of Ontario’s QIPs are based

on the Model for Improvement framework for quality

initiatives originally developed by thought leaders at the

Institute for Healthcare Improvement (IHI) . The Model

asks three simple questions . The first two questions —

“What are we trying to accomplish?” and, “How will

we know if a change is an improvement?” — are

embodied in ECFAA . Hospitals are required to set

clear aims: a specific numeric target for improvement

to be accomplished by a specific time frame in the

fiscal year . Hospitals are also required to select process

and outcome indicators to help them measure progress

towards their aims and targets .

The answer to the third question — “What changes can

we make that will result in improvement?” — describes

the organization’s change strategy . When developing

their change strategies, hospitals should consider two

change dimensions:

• Specific changes to clinical practices or activities that,

according to scientific evidence, will lead to improve-

ment (e .g ., ordering the right drug or performing a test

at the right time for a patient) .

• Specific changes to organizational practices that will

ensure best clinical practices are adopted not just some

of the time but all of the time (e .g ., ensuring that people

have the right skills to perform a task or redesigning the

way care is delivered to ensure that key information is

always passed from one person to the next) .

setting targets

Target setting is an important part of every hospital’s QIP .

Part of HQO’s role is to provide guidance for hospitals

on how they can set “stretch” targets — challenging,

forward-thinking but achievable results that surpass

a hospital’s past performance and set the stage for

achieving their best possible performance in their

priority areas for improvement .

Although HQO works with hospitals to challenge them

to meet excellent stretch targets, we do not decide what

those targets should be . Every hospital must decide the

stretch targets it will set for each fiscal year, according

to the hospital’s strategic vision and the level of perfor-

mance it currently sits at and chooses to aspire to,

or to attain .

STUDY DO

ACT PLAN

Model for Improvement

What are we trying to accomplish?

How will we know if a change is an improvement?

What changes can we make that will result in improvement?


Health Quality Ontario encourages hospitals to consider

what level of performance is acceptable to them and to

their patients, and what it will take to achieve this level .

Hospitals need to ask themselves if maintaining the

same level of performance from one year to the next is

good enough: Is being at or below the provincial average

acceptable to the patients they serve and the staff

who provide these services? Hospitals will be asked to

include their rationale for selecting targets on priority

indicators . (Note: some thought-provoking questions

can be found in the charts that are included for each

of the indicators, beginning on page 31 .)

For a more detailed understanding of stretch targets,

and why they are important, see page 24 .

analysis of 2012/13 Qips: year-tWo successes

and challenges

In this second year of ECFAA implementation, hospitals

were asked to focus on five key attributes of quality

care: safety, effectiveness, access, patient-centred and

integrated . It was recommended that at least one core

indicator be included from each of these attributes and

that indicators be assigned a priority of 1, 2 or 3 . Hospitals’

executive compensation is linked to the achievement of

quality improvement goals . This requirement drives both

improvement and accountability for the delivery of QIPs,

and increases motivation at all levels of the organization

to achieve agrressive, but realizable, targets . A description

of planned improvement initiatives (change ideas) was

requested for objectives where hospitals intended to

improve quality . Hospitals were also asked to provide a

report on the progress made since their 2011/12 QIPs .

Health Quality Ontario received and reviewed the QIPs

and progress reports submitted by 143 hospitals this

year,i which provided a snapshot of hospital activity

and performance across the province .

This year’s plans were stronger overall than last year’s

in terms of their completeness and the robustness of

change plans; a selection of change ideas has been

shared within this report . In the spirit of quality improve-

ment, we have also identified areas for improvement

that could increase the impact of the QIP as a QI tool .

purpose of the analysis for improvement

This analysis of the 2012/13 QIPs is designed to be

a learning tool . Its purpose is to:

• Disseminate innovative change ideas, and highlight

strong improvement plans and success stories from

the field .

• Communicate progress achieved from year one

(2011/12) .

• Highlight examples of plans that fulfill the Model

for Improvement’s components and adhere to quality

improvement science .

• Highlight continued areas for improvement in QIPs .

The analysis examines the following aspects of quality

improvement plans:

• progress achieved: What improvements were

sustained over 2011/12? What changes led to

improvement?

• priority setting: How many priorities did hospitals

typically choose in their QIPs, and what topics did

they choose?

• target setting: What types of targets did hospitals

set? Are there examples of well-articulated “stretch”

targets? How can hospitals improve their target

setting?

• change plans: What types of change ideas do

hospitals describe? How can hospitals strengthen

their change ideas?

i This number is lower than last year’s 152 plans due to a number of mergers in the hospital sector.

hospital

Baseline

(Jan.–dec.

2010)

target for

2011/2012

change ideas

result

(Jan.–dec.

2011)

The Scarborough

Hospital*

(large community)

1 .93 0 .75 • Ongoing monitoring of Safer

Healthcare Now! insertion and

maintenance bundle .

• Chlohexidine dressings to help

prevent CLIs .

• Chlorhexidine baths for high-risk

patients and those with central

lines in situ .

• Establish percentage of infected

central lines by line type .

• Establish percentage of infected

central lines by patient type .

1 .14

taBle 1: success example† — central line associated Blood stream infection


Progress Achieved Over 2011/12

Hospitals made progress this year . In April 2012,

hospitals reported interim results on indicators chosen

in their 2011/12 QIPs . The tables below highlight examples

from those progress reports, where hospitals had

clear strategies for change and achieved important

improvements . Given that the reporting periods for

some indicators fell within 2010/11 or Q1 2011/12 and

would not have reflected changes implemented in 2011/12,

some indicators — pressure ulcers, falls, HSMR and

readmission — have not been included within this section

of the report . A complete analysis of the progress

achieved will be possible once end-of-fiscal-year data

become available, and will be shared with hospitals in

next year’s analysis . The final results will likely be even

better than these interim results .

central line associated Blood stream

infection and ventilator associated

pneumonia rates improvement

Improvement in central line blood stream infection (CLI)

and ventilator associated pneumonia (VAP) rates were

noted when the best practice Safer Healthcare Now!

bundles were applied consistently . Implementation

challenges were overcome by providing ongoing

practice evaluations, visual cues and frequent feedback

to point-of-care staff (see Tables 1 and 2) . Plans for

improvement include change ideas that include the

use of visual cues .

† Success examples were derived from the reports on progress that hospitals submitted on April 1, 2012. Success was acknowledged when significant progress against the targets set out in the 2011/12 QIPs had been achieved.* Further details on change initiatives and contact information can be found at the HQO Quality Improvement Map(www.hqontario.ca/en/ecfaa.html).


* Further details on change initiatives and contact information can be found at the HQO Quality Improvement Map (www.hqontario.ca/en/ecfaa.html).

hospital

Baseline

(Jan.–dec.

2010)

target for

2011/2012

change ideas

result

(Jan.–dec.

2011)

Kingston General

Hospital*

(acute teaching)

2 .02 1 .82 • Consistent application of VAP

prevention bundle .

• Checklist placed at every bedside

and discussed on multidisciplinary

rounds .

• Daily physician champion assigned .

• Preprinted admission order set

developed .

• Oversight of data/trends by patient

safety coordinator .

• Review on quarterly basis by critical

care program, QI and safety

committee .

• Celebration held during patient

safety week

1

London Health

Sciences Centre

(acute teaching)

1 .6 0 .99 • Full implementation of the Safer

Healthcare Now! bundle .

• Statistics, checklists and case

reviews by critical care staff and

physicians .

0 .31

Toronto East

General Hospital

(large community)

4 .47 4 .25 • Publicly post hand hygiene audit

rates in the ICU .

• Develop a strategy to identify points

of transmission .

• Develop a strategy to standardize

knowledge about and implementation

of the sedation vacation protocol .

• Investigate the feasibility of using

subglottic trach tubes .

• Determine incidence of ICU patients

without oral gastric tubes .

1 .96

taBle 2: success examples — ventilator associated pneumonia


At times, significant change occurs as a result of

a crisis, which generates the need for improvement;

this is often the case with hospital-acquired infections .

Muskoka Algonquin Healthcare, for example, success-

fully reduced its CDI rate (after experiencing its first

outbreak in 2010) by undertaking major infrastructure

changes and implementing the changes summarized

in Table 3 . Additionally, strategies employed to reduce

one hospital-acquired infection will often result in

improvements in all hospital-acquired infections, as was

the case at Chatham-Kent Health Alliance . Chatham-Kent

improved its CDI rate by investigating and acting on

the root cause of the high rate of VRE . Chatham-Kent

determined that the hospital’s bedpan management

practices were contributing to higher infection rates,

and put strategies in place to address the issue, resulting

in a reduction in rates of both CDI and VRE (see “CDI

Case Study: Chatham-Kent Health Alliance,” page 10) .

(Note: Case studies included in this analysis were gath-

ered by HQO from hospitals that were asked to complete

success story templates and clarifying information based

on those template submissions, when necessary .)


hospital

Baseline

(Jan.–dec.

2010)

target for

2011/2012

change ideas

result

(Jan.–dec.

2011)

Muskoka Algonquin Healthcare* (large community)

0 .51 Equal to or better than provincial rate (0 .34 per 1,000 patient days for 2011)

• Improve compliance with high-touch surface cleaning .

• Improve turnaround times for lab results .

• Consistent utilization of standard orders for the management of confirmed CDI patients .

• Monthly performance reviewed across the organization as a key corporate indicator linked to executive compensation .

• Updates on progress shared with all staff via an internal newsletter .

0 .31

Chatham-Kent Health Alliance* (large community)

Chatham: 0 .62;Sydenham: 0 .81


• Use best practices for treatment when C. difficile is suspected by having the C. difficile order set print automatically in the ED every time an order is entered for a C. difficile specimen .

• Initiate UV marker audits of patient room cleaning as a measure to ensure improved and appropriate cleaning in patient rooms .

• Increase bedpan flusher units across hospital by seven units .

• Staff engagement for development of safer bedpan management methods .


Royal Victoria Regional Health Centre (large community)

0 .52 0 .35–0 .49 per 1,000 patient days

• Awareness: CDI rate reported publicly every month on website and annually on QIP .

• Screening: daily (Monday–Friday) review of IPAC admission screening tool completion on selected inpatient charts by IPAC practitioners .

• Surveillance: inpatient unit-specific rates posted monthly .

• Corporate rate posted monthly on website . Quarterly rate shared with Board .

• Prevention: annual required hand hygiene and PPE education completed by direct care staff .

• Process: implementation of Infection Control Resource Team recommen-dations wherever possible .

0 .18

taBle 3: success examples — Clostridium diffiCile infection

* Further details on change initiatives and contact information can be found at the HQO Quality Improvement Map(www.hqontario.ca/en/ecfaa.html).


cdi case study: chatham-Kent health alliance

Chatham-Kent Health Alliance (CKHA) is a large community hospital operating through three hospital sites . The

Alliance serves the residents of Chatham-Kent, South Lambton and Walpole Island in Southwestern Ontario .

Chatham-Kent’s battle against CDI began in 2009-10, when an investigation into high rates of hospital-acquired

vancomycin-resistant enterococcus colonization led to the discovery of problematic bedpan management

practices . It is well understood that the patient care environment can become contaminated during routine

activities, and so a second focus — on environmental cleaning — became part of CKHA’s 2011/12 QIP .

challenges and strategies

environmental: The 60-bed patient care unit had only one bedpan flusher, and it was located quite far from many

of the patient rooms . A multi-disciplinary team was formed to address bedpan management practices . After

conducting a staff survey on infection prevention practices, and a literature review, a safer method of automated

washer-disinfectors was adopted in 2010 . Because of the prohibitive cost of adding washer-disinfectors in all

patient care areas, a second, interim method — using bedpan liners — was also used over the 2–3-year period

it took to purchase all of the capital equipment .

Behavioural: Many staff did not like the idea of walking down the hall with a full bedpan . Staff were shown

videos outlining current bedpan management practices, in order to garner their support for change and to

identify educational needs related to best practice bedpan management . Subsequently, 90% of the nurses

stated that they wanted a safer, less time-consuming approach to managing bedpans . Complete removal of spray

wands and bedpan holders from patient bathrooms also helped ensure the unsafe practice did not continue .

Knowledge: Personal protective equipment was not being used consistently . All units were provided education

on the appropriate use of personal protective equipment, and a safe human waste-management policy has

been developed . A UV marker auditing system was used to educate housecleaning staff, and to help improve

the percentage of high-touch surfaces cleaned on a regular basis .

mechanical: Many staff noted that the flusher was often out of service for maintenance and repair; this was

mainly due to user error, however .

resources: The cost of additional washer-disinfectors was substantial . To secure leadership support for the

capital equipment, a cost–benefit analysis was conducted, examining the cost of continuing to manually wash

bedpans (while wearing personal protective equipment) versus the cost of purchasing washer-disinfectors .

hand hygiene improvement

Hospitals with demonstrated success in improved hand

hygiene had a strong organizational commitment to

improvement . Characteristics of these hospitals included

accountability for results at each level of the hospital,

constant monitoring of their tests of change and

accompanying results, and immediate and individualized

feedback to staff (see Table 4) .

Bluewater Health’s change plan for improving compliance

with hand hygiene protocol included the use of champions

from nursing, physician and support services staff . These

leaders were given formal hand hygiene auditor training —

peers audited peers — and immediate feedback was

given to the individual who may have missed one of

the “Four Moments .” Including hand hygiene within

the Most Responsible Physician (MRP) collaborative

provided funding for additional handwash stations and

facilitated physician participation (see “Hand Hygiene

Case Study: Bluewater Health,” page 12) .


hospital

Baseline

(Jan.–dec.

2010, unless

otherwise

indicated)

target for

2011/2012

change ideas

result

(Jan.–dec.

2011)

Baycrest

(CCC & rehab)

30 .67%

(2009/10)

70% • Implement patient empowerment on

all patient care units .

• Unit-specific hand hygiene results

posted on patient care units .

75 .70%

Bluewater Health*

(small community)

45% (2009/10) Increase

compliance

amongst

nurses,

support staff

and physi-

cians within

two targeted

areas to 75%

or better

• Increase rates through the imple-

mentation of a detailed action plan

and campaign specific to each

target group (nurses, physicians

and support staff) . This plan

includes job-specific education

and intervention auditing, in addition

to other actions .

• Linked with the MRP physician

collaborative for focused physician

compliance .

82 .76%

Grand River

Hospital

(large community)

45%

(2009/10)

Improve by

5% per

quarter

• Hand hygiene audits with “real time”

educational moments, publication of

results by clinical program/service .

• Develop marketing plan to increase

awareness and compliance .

• Implement hospital lead for hand

hygiene .

• Develop sustainability plan for

late-career nurses’ engagement as

champions .

• Develop interactive hand hygiene

education series .

79 .78%

Holland Bloorview

Kids Rehabilitation

Hospital* (CCC &

rehab)

53 .6%

(2009/10)

80% • Board-driven initiative after increased

nosocomial outbreak episodes .

• Observation audits using MOHLTC

“Just Clean Your Hands” protocols .

• Audits of completion of e-learning

module, Hand Hygiene Awareness

Day .

• All staff and families included in the

hand hygiene strategy .

• Process control charts used to moni-

tor changes with results cascaded

through all levels of the hospital .

• Initiative tied to the strategic plan .

• Dedicated auditor added to staffing .

90 .75%

taBle 4: success examples — hand hygiene



hand hygiene case study: Bluewater health

Bluewater Health is a small community hospital comprising Bluewater Health in Sarnia and Charlotte Eleanor

Englehart Hospital in Petrolia .

Despite intensive efforts, year after year, Bluewater’s annual overall hand hygiene compliance rates remained

stubbornly low . While numerous strategies to influence compliance had resulted in small gains, Bluewater was

struggling to sustain those successes and achieve further improvements, including hand hygiene within the

Most Responsible Physician (MRP) collaborative facilitated physician participation .

challenges and strategies

Behavioural: It was difficult to change employees’ habits . The plan implemented in 2011/12 was different from

previous approaches in that it had three distinct yet coordinated streams of focus, targeting the different employee

groups — nursing, physician and support service staff . The hand hygiene initiative partnered with the MRP

collaborative and developed a focused action plan to improve physician compliance . To test intensive actions

across all three streams, Bluewater further focused on the rehab and surgical in-patient units . Hand hygiene

champions were identified within each stream and provided with formal hand hygiene auditor training — peers

audited peers, and immediate feedback was given to the individual who may have missed an opportunity .

Leaders within the targeted areas were given specialized education on how to model the right behaviours,

and a checklist was provided to the leaders to remind them of key activities . Hand hygiene reminders on the

“Four Moments” were added to existing safety briefings, and the briefings’ data sheets were monitored to

ensure hand hygiene was listed as a topic for discussion . A Pin Campaign was also added, to recognize good

hand hygiene practices .

environmental: The number and location of handwash stations were insufficient . Approximately 200 alcohol

hand-rub stations were added throughout the organization . The locations of these stations were based on

physician input, for improved visibility and ease of use .

Knowledge: Many staff were unaware of their lack of compliance with the Four Moments . The infection

prevention and control team (IPAC) provided targeted education for each stream on the importance and

expectations for hand hygiene compliance . They also shared stories, to help convey why staff should

be concerned . IPAC addressed specific questions pertinent to the staff group — for example, What are the

hand hygiene expectations during delivery of meal trays? Education packages about hand hygiene were

delivered to each physician . A new Winning with Hand Hygiene contest ran every three months; it drove

staff to the Intranet, where they received information on the Four Moments before accessing and printing

ballots . A standardized quarterly report detailing major activities and a summary of the compliance results

by employee stream were broadly shared across the organization .

resources: The cost of developing and implementing the QI project was re-examined . CEO and executive

compensation was tied to improving hand hygiene compliance, which helped garner leadership support and

interest in the progress of the initiative, including hand hygiene within the Most Responsible Physician (MRP)

collaborative facilitated physician participation .


emergency department Waits improvement

Many emergency departments (EDs) in Ontario are

challenged by wait times, with the lack of available

beds for admitted patients playing a significant role

in prolonged waits . Cambridge Memorial Hospital

improved its wait times for admitted patients by imple-

menting a “pull philosophy” (in which the inpatient unit

“pulls” the patient from ED by ensuring that his or her

bed is ready exactly when needed), using flow coaches

on patient units monitoring emergency patients . Cornwall

Community Hospital invested in process improvement

and project manager training for its middle managers,

and Hawkesbury and District General Hospital encour-

aged teamwork between services (see Table 5) .

hospital

Baseline

(Jan.–dec.

2010)

target for

2011/2012

change ideas

result

(Jan.–dec.

2011)

Cambridge

Memorial Hospital

(large community)

42 .9 hours 30 hours • Implement process to ensure

discharge plan is completed for

each patient on the medical unit

within 48 hours of admission .

• Conduct a focused review of

hospitals with leading performance

to identify strategies for CMH .

• “Pull philosophy” implementing flow

coaches and unit managers to moni-

tor emergency department patients .

• Email sent to flow coach automati-

cally when an inpatient is discharged .

• Weekly flow-operations meeting to

review and resolve placement delays .

26 .3 hours

Cornwall

Community

Hospital*

(large community)

72 .9 hours 65 .6 hours • CCH is a successful applicant to the

Emergency Department Process

Improvement Program (ED PIP)

Wave IV Full Program (2011/12) .

ED PIP provides hospitals with an

intensive structured approach and

resources to improve patient flow

from the point at which patients

arrive in the ED through to discharge

from inpatient units .

• Implementation of a rapid assess-

ment zone and daily access

reporting tool .

• Manager training in Lean process

improvement, project management

and change management strategies .

• Emergency department waiting

room rounds every hour .

42 .2 hours

taBle 5: success examples — emergency department Waits


alternative level of care days improvement

Many hospitals in Ontario are struggling to place people

who no longer require acute care into community-based

or long-term care . Beginning at admission, planning for

discharge using individualized care plans and involve-

ment of patient families has demonstrated success .

For continued improvement, integration across the

healthcare system is essential (see Table 6) .

hospital

Baseline

(Jan.–dec.

2010)

target for

2011/2012

change ideas

result

(Jan.–dec.

2011)

Hawkesbury &

District General

Hospital

(large community)

57 .4 hours 37 hours • Assisted-living initiative with LHIN .

• Bed-management meetings twice

daily at change of shift to optimize

bed utilization .

• Meet LOS benchmarks .

• Establish hospital avoidance initiative

for the patients of FHT .

• Participate in ED/ALC LHIN steering

committee .

• Ongoing GEM initiative with RGP,

monitor and review ALC .

• Ongoing review of patient satisfac-

tion survey results for a patient

perspective .

• Development of general clinical

pathways for patients meeting

CDU inclusion criteria .

• Organizational priority; leadership

including MAC representation on

the improvement committee .

36 .7 hours

taBle 5: success examples — emergency department Waits (CONTINUED)


hospital

Baseline

(Q2 2010/11)

target for

2011/2012

change ideas

result

(Q2 2011/12,

unless

otherwise

indicated)

Leamington

District Memorial

Hospital

(small community)

31 .60% 20% • Continue to implement flow initiatives

on inpatient units .

• Focus the organization on discharges

before 11 a .m .

• Implement regional utilization

management system .

10 .90%

North Wellington

Health Care

(small community)

21 .70% 15% • Participation in Home First program .

• Partnership with CCAC for all

discharge planning .

• Continue to support GEM Nurses in

the ED .

• Advocate for continuity in rural

community services .

11 .80%

Northumberland

Hills Hospital*

(large community)

17 .50% 16 .80% • Implement a restorative care

program .

• Enhance staffing to enable seven-

day-a-week rehabilitation services .

• Implement the Hospital Elder Life

Program (HELP) .

• Implement the Home First philosophy

hospital-wide .

• Develop and implement a formal

discharge planning framework and

processes .

5 .00%

Royal Victoria

Regional Health

Centre

(large community)

17 .07% 13 .8–16 .3% • Admission management: partner-

ship with NSM CCAC for ED Client

Care Coordinator seven days/week

to reduce percentage of ED patients

admitted primarily due to ALC status .

• Discharge management: partner-

ship with NSM CCAC to implement

Home First approach to support

discharge homes with community

support where appropriate, to await

choice of long-term care bed in the

community .

• Appropriateness: work with regional

partners to facilitate timely transition

of CC patients at RVH to regional

CCC beds .

11 .88%

taBle 6: success examples — percentage of alternate level of care days



patient experience improvement

In order to achieve significant improvement in patient

experience, hospitals are encouraged to focus on

a handful of specific areas that correlate with the

complaints and compliments they have received,

as well as feedback from patient satisfaction surveys .

There were several good examples where hospitals raised

patient satisfaction scores by improving communication

and coordination at discharge (see Table 7) .

hospital

Baseline

(Q2 2010/11)

target for

2011/2012

change ideas

result

(Q2 2011/12,

unless

otherwise

indicated)

West Lincoln

Memorial Hospital*

(small community)

15 .40% 11% • Bed Management/Patient Flow

Team implemented to enhance flow

through entire hospital .

• Close collaboration with CCAC

partners to assist the Home First

process .

7 .8%

(April 2011–

Feb . 2012)

Woodstock

General Hospital

(large community)

18% 15% • Continue to participate in FLO project

in all acute in-patient units .

• Maintain regular meetings with CCAC

to investigate barriers to discharge

of ALC patients .

• Develop education for ED physicians

and nurses to increase knowledge

of CCAC services and role within

the hospital .

• Develop liaison role at WGH to liaise

with CCAC to review patients

who are waiting for admission in

the community and to consider

augmentation of CCAC services

or geriatric assessment .

13 .60%

taBle 6: success examples — percentage of alternate level of care days (CONTINUED)



hospital

Baseline

(most recent

12-month

period, unless

otherwise

indicated)

target for

2011/2012

change ideas

result

(most recent

12-month

period, unless

otherwise

indicated)

North Bay Regional

Health Centre

(large community);

ED: “Would you

recommend…?”

ED, Q2 2010/11:

54 .1%

55 .20% • Staff education on requirement of

verbal/written patient safety teachings

before discharge to home .

• Update and make easily available

to staff discharge instruction sheets

and provide to patients at discharge .

• Revisit/research software programs

for discharge instruction sheets .

• Develop “drill-down” questions from

the “discussed danger signals to

watch for” survey question and

add to NRC Picker ER survey to

identify gaps .

• Develop action plan to address any

identified gaps and implement .

65 .2%

(Oct . 2010–

Sept . 2011)

Peterborough

Regional Health

Centre

(large community);

“overall care

received”

93 .60% ≥96% • Implement strategies to improve

satisfaction with access to services

and responsiveness . 2011/12

initiatives include: (a) implementing

new services such as the radiation

bunker and cancer care navigator;

and (b) regular rounding by staff and

leaders in acute care patient areas .

• Implement post-discharge phone

calls in surgical services . 2011/12

initiatives include implementing

post-discharge phone calls with

script for same-day surgery patients

identified as high risk for admission

and spread to inpatient area as

appropriate .

• Implement improved pre-admission

and pre-discharge patient education

and communication processes in

Maternal Child Services . 2011/12

initiatives include: (a) “Purple Crying”

and (b) pre-admission education

and electronic resources .

98 .5%

(Q1 2011/12)

taBle 7: success examples — patient satisfaction


hospital

Baseline

(most recent

12-month

period, unless

otherwise

indicated)

target for

2011/2012

change ideas

result

(most recent

12-month

period, unless

otherwise

indicated)

St . Francis

Memorial Hospital

(small community);

“Would you

recommend…?”

80% (Q3

2010/11)

≥80% • Promote a positive, patient-centred

environment .

• Improve signage for patient instruc-

tions, wait times, etc .

• Develop educational material for

patients on discharge .

90 .1%

St . John’s Rehab

Hospital

(CCC & rehab);

“Would you

recommend…?”

94 .7% >92% • Focus on three dimensions of care:

participation in decision-making

and goal setting; coordination; and

continuity and transitions using a

variety of written and verbal tools,

e .g ., whiteboards, documented

explanation of meds, written med side

effects, discharge checklist, etc .

• Implement integrated goal sheet .

98 .9%

(March–Sept .

2011)

taBle 7: success examples — patient satisfaction (CONTINUED)


Overview: Priority Setting, Target Setting and Change Plans

priority setting

A QIP is an important place to identify key priorities for

improvement . Priorities help organizations focus on what

they want to accomplish . Hospitals have the option of

designating a priority level of 1, 2 or 3 to the objectives

identified in their QIPs . It is recommended that indicators

where performance has been below organizational goals

be given the strongest consideration as Priority 1 or 2 .

Priority 1 indicators must be closely aligned with orga-

nizational strategic priorities, and will receive a greater

emphasis in terms of change plans and resources for

implementation than lower-priority indicators . When

results have been sustained at rates that are consistent

with organizational goals, or performance is at or near

theoretical best, a Priority 3 rating should be considered .

considerations When setting priorities

Priority setting can be a complex process that requires

organizations to consider and balance a number of

different factors . Organizations often consider the

following issues when choosing topic areas as priorities:

• How does the proposed topic align with our strategic

objectives?

• In which areas are we currently performing below

desired performance?

• Which quality problems are occurring most frequently,

and what are the most serious consequences when

they do occur?

Many hospitals did a good job explaining how their QIPs

aligned with their strategic priorities within the Part A

Short Form, including Lady Minto Hospital, Lake of the

Woods District Hospital, The Royal Ottawa Health Care

Group, St . Joseph’s Continuing Care Centre of Sudbury,

Listowel Memorial Hospital and Providence Care . (This

is not a comprehensive list, but rather a selection of

good narratives .)

excerpts from Qip part a short forms

The Quality Improvement Plan and selected

indicators are aligned with the NELHIN [North

East Local Health Integration Network]

Integrated Health Services Plan, Hospital

Service Accountability Agreement, Network

13 Strategic Plan, our community partners’

strategic plans, Accreditation Canada and the

MIC Group of Health Services Strategic Plan.

– Lady Minto Hospital

The LWDH Quality Improvement Plan for

2012/13 is in alignment with LHIN objectives

and the H-SAA agreement with the MOHLTC.

It is coordinated with organizational strategic

goals, the mission/vision/values of the organi-

zation and the LWDH Integrated Quality/Risk

Framework. It is also aligned with governance

policies and ends of the Board of Directors.

The Quality Improvement Plan supports best

practices as defined by Accreditation Canada.

The plan incorporates consultation with and

participation by our health care partners to

achieve the planned objectives.

– Lake of the Woods District Hospital

Quality attributes core indicators

safety Clostridium difficile infection (CDI)

Ventilator-associated pneumonia (VAP)

Hand hygiene compliance before patient contact

Central line associated blood stream Infection (CLI)

Pressure ulcers

Falls

Surgical safety checklist

Restraints

effectiveness Hospital standardized mortality ratio (HSMR)

Hospital – total margin

access 90th percentile ED length of stay for admitted patients

patient-centred Patient satisfaction

integrated 30-day readmission rate to any facility (specific case mix groups)

Percentage of alternative level of care (ALC) days

taBle 8: core indicators for 2012/13


Most Common Priorities for ImprovementFor 2012/13, it was recommended that hospitals include

in their QIPs selections from a core set of indicators, with

at least one indicator in each of the five quality attributes:

safety, effectiveness, access, patient-centred and

integrated (see Table 8) .

Figure 1 shows how often hospitals chose each core

indicator as Priority 1, 2 or 3 in 2012 . There was little

variation in the choice of core indicators between

acute care hospitals of different sizes . The most

common topics were hand hygiene, total margin,

patient satisfaction, emergency department (ED) waits

and percentage of alternate level of care (ALC) beds .

Among mental health hospitals, restraint use was one

of the most common indicators . Falls and pressure

ulcers were common topics among rehabilitation and

complex continuing-care (CCC) facilities .

In general, topics that hospitals can focus on

independently (e .g ., hand hygiene) were much more

popular than topics that require coordination between

hospitals and community-based services (e .g ., ALC

and readmissions) . Hospitals have been working hard

to improve outcomes and performance in these areas .

In the future, it will be important for hospitals to work

closely together, to develop community-wide quality

improvement plans with these external partners if

Ontario is to make progress on the most important

challenges facing the healthcare system .


0

20

40

60

80

100

120

140

Patie

nt Sa

tisfac

tion

Total

Margin

Hand H

ygien

e AL

C

ED W

ait Ti

me (Ad

mitted P

atien

ts) CDI

Readm

ission

s

Surgi

cal S

afety

Check

list

Press

ure Ulce

rs

HSMR

Falls

VA

P CLI

Phys

ical R

estra

ints

Core Recommended Indicators

Num

ber o

f Hos

pita

ls T

hat C

hose

Eac

h Co

re R

ecom

men

ded

Indi

cato

r

Quality Attributes for Core Recommended Indicators

Safety

Effectiveness

Access

Patient-Centred

Integrated

Quality Attributes for Core Recommended Indicators — Priority 1

■ Safety

■ Effectiveness

■ Access

■ Patient-Centred

■ Integrated

Quality Attributes for Core Recommended Indicators — Priority 2 or 3

■ Safety

■ Effectiveness

■ Access

■ Patient-Centred

■ Integrated

Pri 2 or 3 ■ ■ Pri 1

figure 1: freQuency of indicators chosen as priority 1, 2 or 3 in 2012/13 ontario hospital

Quality improvement plans (n = 143)

Among Priority 1 indicators chosen by hospitals, 57%

were core indicators and 43% were additional indicators

representing local priorities (see Table 9) . The most

frequently chosen additional indicator was medication

reconciliation . Because medication management is a

critical area of patient safety, HQO recommends that a

core indicator for medication reconciliation be added for

selection within the Quality Improvement Plan Guidance

Document for 2013/14 (see http://www .health .gov .on .ca/

en/pro/programs/ecfa/legislation/qualityimprove/up-

date .aspx) . Standardizing the definition of this

indicator will be important, because hospitals used

many different methods this year for tracking progress

on medication reconciliation .

http://www.health.gov.on.ca/en/pro/programs/ecfa/legislation/qualityimprove/update.aspx



safety Medication reconciliation (29)

Medication incidents/errors (14)

Falls (14)*

Hospital-acquired infections (12)

VTE prevention (8)

Safe work environment (6)

Patient safety (8)

Pressure ulcers (5)*

Hand hygiene (4)*

Restraint (2)*

integrated Improve discharge and transitions (13)

effectiveness Increase efficiency and effectiveness (25)

Reduce non-value-added work in process (13)

Staff satisfaction (9)

Compliance with established guidelines (9)

Overtime pay, sick time, vacancy (7)

Length of stay (3)

access Wait times (15)

Access to specialized services (16)

patient-centred Patient satisfaction (17)*

taBle 9: additional indicators selected By hospitals for 2012/13 (grouped By

Quality attriBute)


Notes: Figures in parentheses indicate frequency. *These definitions differed from the definitions used for the core recommended indicator: e.g., falls — falls with injury; patient satisfaction — improve pain management.

Number of Priorities SelectedThis year, Ontario hospitals selected a similar number of

indicators as they did in 2011/12 — on average, between

four and five Priority 1 indicators, four Priority 2 indicators

and three Priority 3 indicators . The number selected did

not differ significantly across different hospital types .

Although the guidance document encourages hospitals

to select at least one core indicator from each dimension,

seven hospitals chose just one Priority 1 indicator,

11 hospitals chose nine or more Priority 1 indicators and

two hospitals chose no Priority 1 indicators . Some

(but not all) of these hospitals have multiple sites,

with priorities set across the sites .

We do not yet know if there is an “ideal” number of

priorities for organizations to set . Future analyses could

examine whether there is a relationship between the

number of different priorities and success in implementing

changes that have demonstrated improvement .


target setting

Target setting is an important component of QIPs:

Organizations are more likely to achieve major

improvement when they set a stretch target — that is,

one that is challenging but achievable . Stretch targets

can be inspirational . They motivate staff and, when

accomplished, can engender confidence in staff’s

ability to tackle the next major challenge .

Determining an appropriate stretch target is a challenging

exercise: What constitutes significant change, but not

so much change that it will be impossible to implement?

Hospitals are encouraged to develop target setting

processes that engage all stakeholders, including

front-line staff . Modelling of different scenarios may be

helpful for hospitals to project the impact of planned

changes, allowing hospitals to set targets with greater

confidence .

The relentless pursuit of excellence underpins the

Excellent Care for All Act and is a central tenet of quality

improvement . Setting aspirational improvement and/or

performance targets is a critical first step . Excellence can

only occur when hospitals are fully accountable — to

the public, their staff, their boards and their peers —

to achieve the targets articulated in their QIPs and

continually strive to achieve higher levels of performance .

Hospitals should distinguish target setting for

accountability agreements from target setting for

quality improvement . Targets contained in accountability

agreements represent the basic level of quality for an

organization that must be achieved . Setting targets for

quality improvement is about challenging providers and

staff, your organization as a whole and eventually the

system to achieve higher levels of performance and to

reliably deliver high-quality care .

areas for improvement identified in target setting

for Qips

The careful consideration that went into target setting

in many hospitals was evident within the 2012/13 QIPs .

Some suggestions are offered for hospitals with plans

that had missing baseline measures or targets, missing

or unclear target justification or targets set at or below

baseline performance .

1. missing Baseline measures or targets

In some cases, hospitals did not provide a figure for

baseline performance . This occurred most commonly

when a hospital was aiming to improve in an area where

no data had previously been collected . Lack of baseline

data makes it difficult to set a realistic target .

In other cases, hospitals did not set a specific numeric

target . Instead, they stated that the target was to be

“better,” “meet the average” or, “reduce by X cases .”

In most cases, the hospitals did not provide a clear

justification for the lack of a numeric target .

SuggestionsIf a hospital does not have baseline data, it could

consider including a data collection plan in its QIP

along with specific timelines pinpointing when it will

finish collecting the baseline data, and make an updated

plan with a numeric target available to the public and

to staff .

Having a clear, numeric target and setting a specific time

frame within which to reach that target are essential to

success . When the target is vague (e .g ., “just do your

best” or, “do better”), there is no shared understanding

amongst staff of what success means .

2. missing or unclear target Justification

For some targets, hospitals did not provide a clear

indication of how their target was selected . In some

cases hospitals stated what target was selected but did

not reflect on why the target was selected . For example,

“We have set a target of 5% improvement” provides

no information about how this target was selected .

A well-written target justification might read as follows:

“Given current performance of 60% for hand hygiene,

we are targeting 80%, in order to cut our defect rate

in half . We believe this is an aspirational target that

can be achieved through concerted effort to implement

our change plan .”


SuggestionsIt is recommended that hospitals clearly describe the

rationale for the targets set in the target justification

component of their QIPs, in order to ensure a consistent

process for target setting .

3. targets set at or Below Baseline performance

As Table 10 illustrates, several hospitals set targets

for Priority 1 indicators that were below their baseline

performance .

Hospitals provided a variety of different justifications for

these targets:

• Some are anticipating that changing circumstances

will make it more challenging to achieve a given

performance, compared to the previous year .

• Some are in a “monitoring stage” after concerted

QI effort, and are focused on sustaining their

changes and improvement .

• Some have set targets based on the Ontario or LHIN

average, even though their performance was already

better than average .

SuggestionsIn the spirit of improvement, it is suggested that indicators

for Priority 1 should generally have stretch targets

associated with them . Where performance is already

better than average, organizations are encouraged to

set targets that represent at least maintaining results,

rather than accepting the average as a target .

When hospitals believe that maintaining current

performance will be a significant stretch due to

changing circumstances, and they choose to target

below baseline performance, is it particularly important

to substantiate the target with a clear target justification .

This will avoid sending an unintentional message to the

public or to hospital staff about the hospital’s quality

improvement goals .

HQO has developed six guidelines for hospitals to

consider when setting stretch targets (see page 25),

and has identified several examples chosen from the

2012/13 QIPs of hospitals that appeared to follow

these guidelines .

indicator

direction

Better

hospital

type

current

value

target

target Justification

Hand

hygieneh

Large

community

84%

80% Exceed provincial rate of 72%

ED waitsi

Acute

teaching

21 .0 23 .0

Maintain achievement of Toronto Central

LHIN target

ED waitsi

Large

community

10 .6 23 .0

LHIN goal has increased over the past

year from 9 .3 to 23 hours

ALCi

Small

community

11% 21 .64%

Comparison with North West LHIN

hospitals

taBle 10: examples of targets set BeloW Baseline performance


1: aim for the theoretical Best

application examples from 2012/13 Qips

The theoretical best represents the maximum or optimal

performance . It is most applicable in areas that measure

defects, wait times or use of a best practice (e .g ., aim

for zero defects, zero wait time or 100% compliance

with best practice bundle) .

• Stevenson Memorial Hospital set a target of 100% for

hand hygiene compliance (baseline = 84%) .

• Carleton Place & District Memorial Hospital set a target

of 100% for surgical safety checklist compliance

(baseline = 97%) .

2: aim for Best achieved elsewhere


Any organization may seek to match the best achieved

elsewhere, but this may be of particular relevance to

those organizations that already have above-average

performance and still wish to do better .

• Weeneebayko Area Health Authority, Moose Factory

site, set a target of 92% for hand hygiene compliance,

the best achieved to date in Ontario (baseline = 87%) .

• Kingston General Hospital set a target of 99% for the

patient satisfaction indicator, the best achieved to date

in an Ontario academic hospital (baseline = 94%) .

3: aim for 90th percentile among peers


The Centres for Medicare and Medicaid suggest aiming

to be in the 90th percentile among peers as a stretch

goal .ii This could be appropriate if the hospital’s baseline

falls well short of this level; otherwise, a target of best

achieved elsewhere or theoretical best may be a more

appropriate stretch target .

• There are no examples of this approach to date;

examples may appear in the future as these data

are not yet available to hospitals .

4: aim to cut a defect or Waste in half in the current planning cycle


An organization may decide that the theoretical best is

not achievable in this year and so may target to reduce

the gap between baseline and theoretical best by half

(e .g ., baseline = 90%, or a defect rate of 10%; target to

improve by 5%) . Mainly used with indicators for which

the theoretical maximum can be readily defined, such

as zero defects, zero wait times or 100% adoption of a

best practice .

• West Lincoln Memorial Hospital has a baseline

of 79 .3% for the surgical safety checklist, and is

targeting to improve by 10% (half of the approximate

20% room for improvement towards 100%) .

ii U.S. Department of Health and Human Services. Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program. http://www.cms.gov/AcuteInpatientPPS/downloads/HospitalVBPPlanRTCFINALSUBMITTED2007.pdf. Accessed October 17, 2011.


5: aim to match the rate of improvement achieved by other organizations


Looking at the best rates of improvement achieved by

high-achieving organizations is useful when it is hard to

compare performance to peers because of differences

in case mix or where, historically, it has been difficult

for organizations to achieve large improvements in a

given year .

• There are precedents in Canada and abroad of

hospitals that have been able to achieve a 5- to

10-point-per-year reduction in HSMR .

• Rouge Valley Health System is aiming to reduce

HSMR from 102 to 90 by focusing on improving

patient outcomes for CHF and COPD through

standardized order sets and by developing a

standard process for documenting and validating

palliative status .

6: aim to match the average (only in situations Where an organization is far Below average)


Average or median performance in the sector may be

an appropriate stretch when an organization’s baseline

falls well below this figure . In most instances, however,

average quality is not desirable and is far from the

optimal or best demonstrated elsewhere

• One hospital set its target for hand hygiene at the

provincial average of 72 .1% (baseline = 57 .7% .)

change plans

Hospitals were asked to identify change ideas for all

Priority 1 indicators in their QIPs . These change ideas

are important, because they represent an organization’s

strategy for improvement . There are many sources of

change ideas, including:

• Evidence-based best practices;

• Creative thinking by front-line staff, providers and

patients;

• Learning from others; and

• Using change concepts, which are general approaches

that must be adapted according to circumstances in

order to result in a situation-appropriate change idea .

One of the most important steps in choosing the right

change strategy is to first understand the root causes of

quality problems . There are many tools available to assist

with examining the root causes, including fishbone (cause

and effect) diagrams or the “Five Whys” technique (see

www .hqontario .ca/en/analysing_system .html) .

Once the root causes of quality problems have been

identified, change ideas that correspond with the most

important root causes should be selected . This is

a logical approach to strategy development: linking

specific system problems with targeted solutions .

Table 11 lists some common generic root causes of

quality problems and the change concepts associated

with each root cause .


For more information on chance concepts, see The

Improvement Guide: A Practical Approach to Enhancing

Organizational Performance .iii

areas for improvement identified in change plans

The 2012/13 QIPs included a wide variety of change

ideas that demonstrated the ways in which a number

of hospitals have carefully examined their systems and

processes and developed change plans that reflect both

best practices and creative innovation . Some QIPs were

not complete for reasons that include absent or limited

change ideas, a lack of corresponding process measures

and root cause analysis as the change strategy .

The following suggestions are offered to assist hospitals

with strengthening their QIP change plans .

1. inclusion of strong change ideas

Some hospitals did not provide change plans for all

of their Priority 1 indicators, or provided little detail .

Specific examples include:

• Repeating the aim in the change section instead of

a specific idea for improvement: e .g ., “Maintain 0%

CLI rate .”

• Including only one change idea or providing sparse

detail on the change idea: e .g ., “Processes to analyze

and reduce readmission rates .”

Over-reliance on staff training as the sole change

strategy deserves particular mention . Staff training, while

important, does not necessarily lead to improvement .

Not all staff will attend the training and, once the training

is over, they may not necessarily implement the new

skill or carry it out in the way it was intended . If staff

skills are included in the change plan, it may be helpful

to describe the methods that are in place to verify that

the skill has been learned and applied consistently

(see Table 12) .

In most instances, there is more than one root cause

of a quality problem (see Table 11) . The likelihood of an

organization achieving breakthrough improvements is

greatly increased when a clear strategy to address the

most important root causes is well articulated .

Health Quality Ontario strongly encourages hospitals

to include more detail about their change ideas . This

makes change plans more transparent to staff and

to the public, and allows HQO to share knowledge

between hospitals about what strategies other

organizations are using; this facilitates peer-to-peer

learning .

taBle 11: root causes and corresponding change concepts

root cause change concepts

Providers unaware of how poor performance actually is Measurement and feedback systems

Easy to forget, busy, too complicated, unaware of best practice

Reminder systems, clinical decision supports

Poor processes, non-standardized Redesigned processes

Lack of skill to perform best practice, or deterioration over time

Training and skills verification, “on-boarding” of new

staff or creation of specialized staff or teams

Wrong, or lack of, resources or capacity Targeted investments or shifting of capacity to where it

is needed

Patients unaware of their role or options, not engaged Patient engagement — education, involvement in design

No incentive or motivation to change Recognition, rewards, inspiring leadership, account-

ability, executive compensation tied to quality

iii Gerald R. Langley et al. (2009), San Fransisco: John Wiley & Sons.


See the “Quality Improvement by Indicator” section

for examples of good change ideas submitted in this

year’s QIPs for four of the most selected indicators:

hand hygiene, patient satisfaction, ALC and ED waits .

2. root cause analysis as a Key part of the change

strategy

In some QIPs, hospitals did not specify any change

ideas . Instead, they set out a plan to collect data, do a

root cause analysis and then identify change ideas — for

example, “Analyze data from client experience survey .”

While it is good practice to identify root causes before

specifying a change strategy, we recommend that this

process be done before hospitals complete their QIPs .

If this is not possible, then hospitals may consider

specifying a target date for when specific change ideas

will be put forward, and then commit to making them

public at that time .

3. inclusion of process measures to support

implementation of change ideas

The Model for Improvement’s second question, “How

will we know if a change is an improvement?” can be

answered through measurement . There are two main

types of measures for quality improvement: outcomes

and process . An outcome measure is the measure of

overall performance . It looks at high-level results: the

effect of a number of things that have happened — e .g .,

patient satisfaction, hand hygiene rates or CDI rates .

Isolated activities influence the outcome measure .

A process measure describes how well an organization

is executing a particular action or best practice that is

known to have a positive impact on improving outcomes .

In many instances, hospitals identified a change idea

but did not link it to a process measure or a target

that could measure success . Some hospitals listed

a change idea instead of a process measure in the

process measure column . This may have occurred

because:

• Organizations may not be clear what information

belongs in this column, or what a process measure is;

or

• It may be difficult for hospitals to define these measures

for their change ideas .

Process indicators are important for monitoring whether

the change strategy is implemented according to plan,

and whether a course correction in the middle of the

year is needed . For example, an organization might

decide to conduct staff training on “teach back,” a

method of verifying that patients understand discharge

instructions . A process measure might include the number

of staff that have been observed to be using the method

correctly, or an audit on a sample of patients, asking

them if the teach-back method was actually used .

Without such a process measure, a hospital will never

know whether the staff training was effective or not .

Table 12 lists some specific examples of process

measures that organizations can consider .


taBle 12: examples of potential process measures per change concept

change concepts example of process measure

Measurement and feedback

systems

Number of leadership walkabouts per month, number of audits performed

per month, number of on-the-spot feedbacks provided per month

Reminder systems, clinical

decision supports

Percentage of time reminder system was used, number of times

decision-support system used per day

Redesigned processes Percentage of time the “new” process was used appropriately, or

implemented correctly the first time (i .e ., first-time pass)

Training and skills verification,

“on-boarding” of new staff or

creation of specialized staff

or teams

Percentage of staff that attend training, percentage of staff that pass

the quiz/test, percentage of staff observed performing skill correctly

“on the job”

Targeted investments or shifting

of capacity to where it is needed

Percentage of patients admitted with assessments complete, percentage

of patients seen by appropriate triage team, number of appropriate referrals

received per month

Patient engagement —

education, involvement

in design

Percentage of patients that can “teach back” to healthcare provider,

percentage of patients/families that receive educational brochure, number

of outreach sessions provided per month

Recognition, rewards,

inspiring leadership,

accountability, executive

compensation tied to quality

Number of rewards distributed quarterly, number of success stories printed

in hospital newsletter per month, number of champion roles developed


Quality Improvement by Indicator

This section provides an overview of how many hospitals

selected each indicator and how targets were set as

compared to current performance .

For each indicator, we have included the following

information to assist hospitals in their target setting

process:

• How many hospitals chose the indicator as Priority 1,

and as any other priority;

• A definition of the indicator;

• A target setting table that includes best achieved

performance to date (if available), the theoretical best,

provincial average and relative improvement targets

by hospitals (including the average target submitted,

and the highest and lowest target submitted); and

• A graph that allows hospitals to compare their

current performance to their peers and to the

provincial average, and to set targets that meet or

exceed their peers’ performance or the provincial

average .

Examples of change ideas provided within 2012/13

QIPs have been included for four of the most-selected

indicators: hand hygiene, patient satisfaction, ALC and

ED waits . North Bay Regional Health Centre produced

an excellent QIP in support of ALC reduction, which has

been included in its entirety (see Table 31) . These tables

outline key change ideas proposed by different hospitals,

and therefore illuminate how, by pooling ideas from

different hospitals, we can see the full range of ideas

that are available — an important way for hospitals to

learn from their peers . See the HQO Quality Improvement

Map (www .ohqc .ca/en/ecfaa .html) for further change

ideas and links to useful tools and resources .

Some things to look for and consider when examining

the tables and charts for each indicator include:

• Whether targets were set above current performance;

• How stretch targets were set (e .g ., best achieved in

Ontario, theoretical best, provincial average);

• The relative improvement values that were set (i .e ., the

percentage increase/decrease that target represents

relative to current performance);

• Where your hospital sits in comparison to your peers;

and

• If your target is below current performance, or below

the provincial average, whether this is an acceptable

level of performance .

For every indicator, each hospital’s current performance

and target are identified, as well as the provincial average

and benchmark (where they exist) . Note that the number

of hospitals that chose each indicator as a Priority 1 and

the number of hospitals included in the graphs may

differ slightly . This is due to insufficient data submitted

by hospitals (missing or unclear data, or different

reporting periods than what was recommended in the

instructions outlined in the Quality Improvement Plan

Guidance Document for 2012/13 .) You will also note

that the graphs contain guidance about how to interpret

the information provided, as well as some thought-

provoking questions to consider .


Safety: Clostridium Difficile Infection (CDI)Thirty hospitals chose CDI as Priority 1 and 91 hospitals

chose it as any priority .

definition

The CDI rate is defined as the number of patients newly

diagnosed with hospital-acquired CDI, divided by the

number of patient days in that month, multiplied by 1,000,

consistent with publicly reportable patient safety data .

Best achieved to date

in ontario

theoretical

Best

provincial

average

relative improvement targets by

hospitals that selected as priority 1average

target

lowest

target

highest

target

Benchmarks under developmentApproaching

zero

0 .36

(Dec . 2011)24% -88%* 100%*

*Negative values reflect the fact that some hospitals set targets that were lower than baseline performance.

taBle 13: cdi target setting, 2012/13 Qips

figure 2: cdi rate — current performance and targets Within 2012/13 Qips

A B C D A B C A B C D E F G H I J K L M N O A B C D E F G H

Acute Teaching CCC and

Rehab Large Community Small Community

Current Value 0.54 0.54 0.56 0.97 0.21 0.26 0.37 0.18 0.30 0.31 0.32 0.37 0.41 0.41 0.46 0.56 0.61 0.68 0.69 0.76 0.81 0.95 0.00 0.00 0.06 0.19 0.22 0.46 0.48 0.52

Target 0.54 0.45 0.39 0.30 0.00 0.26 0.30 0.23 0.34 0.36 0.30 0.27 0.34 0.77 0.20 0.52 0.43 0.34 0.45 0.60 0.60 0.72 0.25 0.00 0.00 0.20 0.00 0.00 0.48 0.52

0.00

0.50

1.00

Rate

CDI Rate Per 1,000 Patient Days (by Hospital), 2012/13 QIPs

BETTER

Provincial Average = 0.36

Theoretical Best = Approaching 0

HQO recognizes that hospitals have worked hard to decrease infection rates and that these multi-faceted problems are very dif�cult to address. Ontario could eliminate CDIs if hospitals made it a Priority 1, set aggressive targets and dedicated suf�cient resources to eliminate these infections.


Safety: Ventilator-Associated Pneumonia (VAP)One hospital chose VAP as Priority 1 and 38 hospitals


definition

The VAP rate is defined as the total number of newly

diagnosed VAP cases in the ICU after at least 48 hours

of mechanical ventilation, divided by the number of

ventilator days in that reporting period, multiplied

by 1,000, consistent with publicly reportable patient

safety data .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

Zero for teaching, large, and

small hospitals; not applicable

for CCC & rehab and mental

health

Zero1 .26

(Q3 2011/12)19% 19% 19%

taBle 14: vap target setting, 2012/13 Qips

figure 3: vap — current performance and targets Within 2012/13 Qips

A Large Community

Current Value 1.23

Target 1.00

0.6

1.4

1.2

1

0.8

0.4

0.2

0

Rate

VAP Rate Per 1,000 Ventilator Days (by Hospital), 2012/13 QIPs

Provincial Average = 1.26

Theoretical Best = 0

BETTER

HQO recognizes that hospitals have worked hard to decrease infection rates and that these multi-faceted problems are very dif�cult to address. Ontario could eliminate VAPs if hospitals made it a Priority 1, set aggressive targets and dedicated suf�cient resources to eliminate these infections. Only one hospital selected VAP as Priority 1, despite performing better than the provincial average.


Safety: Hand HygieneEighty-five hospitals chose hand hygiene as Priority 1

and 119 hospitals chose it as any priority .

definition

The hand hygiene compliance rate is defined as the

number of times that hand hygiene was performed

before initial patient contact divided by the number of

observed hand hygiene indications before initial patient

contact, multiplied by 100, consistent with publicly

reportable patient safety data .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

92% for teaching, large

community, CCC, mental

health hospitals; 100% for

small hospitals .

100%72%

(FY 2010/11)9% -19%* 40%


taBle 15: hand hygiene target setting, 2012/13 Qips

figure 4: hand hygiene — current performance and targets Within 2012/13 Qips

A B C D E F A B C D E F G H A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI AJ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI AJ AK AL AM AN AO AP AQ

Acute Teaching CCC and Rehab Large Community Small Community

Current Value 71 75 76 80 83 85 58 61 65 69 73 74 75 84 51 55 56 56 59 64 65 65 66 67 68 68 68 69 69 70 71 74 74 77 79 80 80 82 82 82 82 83 83 84 84 84 85 86 87 91 46 50 57 57 60 63 64 65 66 66 68 71 72 72 73 74 74 75 75 75 77 77 78 80 80 81 81 81 81 81 83 83 83 83 84 84 86 88 88 89 89 90 95

Target 75 85 83 86 90 88 72 72 70 80 80 78 80 88 56 70 70 70 80 77 85 80 80 75 80 80 80 75 80 80 80 86 85 80 84 85 84 80 90 80 90 85 90 88 89 80 85 89 92 92 75 60 80 70 75 75 75 80 70 80 75 75 76 75 76 80 79 70 80 80 80 72 80 82 72 81 72 81 85 84 90 72 85 85 95 100 90 92 90 72 75 95 100

0%

50%

100%

Rate

Hand Hygiene Compliance Rate (by Hospital), 2012/13 QIPs

Provincial Average = 72%

Theoretical Best = 100%

BETTER

The most common indicator chosen, hand hygiene, was selected by 85 hospitals. Many organizations set stretch goals that either matched the best results (between 92% and 100%) or moved halfway towards the goal of 100% compliance. Some organizations set minimal or even negative goals, or goals that were still well below the provincial average of 72%. If their target was described as a rate of defects (e.g., we are willing to accept a failure rate of 28%), organizations should ask themselves whether this reality is good enough for their patients and staff.


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hy

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(CO

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ED

)


Safety: Central Line Associated Blood Stream Infection (CLI)One hospital chose CLI as Priority 1 and 38 hospitals


definition

The CLI rate is defined as the total number of newly

diagnosed CLI cases in the ICU after at least 48 hours

of being placed on a central line, divided by the number

of central line days in that reporting period, multiplied

by 1,000, consistent with publicly reportable patient

safety data .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

Zero for teaching, large, and

small hospitals; not applicable

for CCC & rehab, and mental

health

Zero0 .48

(Q3 2011/12)25% 25% 25%

taBle 17: cli target setting, 2012/13 Qips

figure 5: cli — current performance and targets Within 2012/13 Qips

A Large Community

Current Value 0.4

Target 0.3

0

0.25

0.5

Rate

Rate of Central Line Blood Stream Infections (by Hospital), 2012/13 QIPs

BETTER

Provincial Average = 48% (Q3)


HQO recognizes that hospitals have worked hard to decrease infection rates and that these multi-faceted problems are very dif�cult to address. Ontario could eliminate CLIs if hospitals made it a Priority 1, set aggressive targets and dedicated suf�cient resources needed to eliminate these infections, as achieved by some hospitals already. This year, only one hospital selected CLI as a Priority 1 indicator, despite performing better than the provincial average.


Safety: Pressure UlcersTen hospitals chose pressure ulcers as Priority 1 and

44 hospitals chose it as any priority . This indicator was

most selected by CCC and rehab hospitals .

definition

The pressure ulcer rate is defined as the percentage of

complex continuing care residents with a new pressure

ulcer in the last three months (stage 2 or higher) .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

Benchmarks under development2 .0%

(Q2 2011/12)20% 0% 49%

taBle 18: pressure ulcers target setting, 2012/13 Qips

figure 6: pressure ulcers — current performance and targets Within 2012/13 Qips

A B A B A B C D

CCC and Rehab Large Community Small Community

Current Value 2.1% 4.9% 4.4% 5.1% 0 0 2.6% 12.0%

Target 1.1% 3.8% 3.6% 2.6% 0 0 2.4% 10.0%

0%

7%

14%

Perc

enta

ge

Pressure Ulcers (by Hospital), 2012/13 QIPs

Provincial Average = 2% (Q2)

Although 10 hospitals chose pressure ulcers as Priority 1, only eight provided current performance and/or target data that can be included in this analysis. When developing their QIPs, hospitals should remember that, “You cannot manage what you cannot measure.” Two small community hospitals that achieved a current theoretical best value of zero still prioritized pressure ulcers as a Priority 1. Once the theoretical best has been achieved, an objective often can be monitored as a lower priority. It is recommended that hospitals explain their rationale in the comments section of the QIP. BETTER

Benchmarks are under development


Safety: FallsTwelve hospitals chose falls as Priority 1 and 40 hospitals

chose it as any priority . This indicator was most selected

by CCC and rehab hospitals .

definition

The falls rate is defined as the percentage of complex

continuing care residents who fell in the last 30 days .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

Benchmarks under development8 .4%

(Q2, 2011/12)14% 2% 29%

taBle 19: falls target setting, 2012/13 Qips

figure 7: falls — current performance and targets Within 2012/13 Qips

A B C A B A B

CCC and Rehab Large Community Small Community

Current Value 4.6% 6.0% 6.5% 4.3% 6.3% 6.0% 14.0%

Target 3.7% 5.5% 5.3% 4.0% 5.4% 5.9% 10.0%

0.0%

7.5%

15.0%

Perc

enta

ge

Falls (by Hospital), 2012/13 QIPs

BETTERAlthough 12 hospitals chose falls as Priority 1, only seven included performance and/or target data that can be included in this analysis. When developing their QIPs, hospitals should remember that, “You cannot manage what you cannot measure.”

Benchmarks are under development

Provincial Average = 8.4% (Q2)


Safety: Surgical Safety ChecklistEight hospitals chose surgical safety checklist as

Priority 1 and 60 hospitals chose it as any priority .

definition

The surgical safety checklist rate is defined as the

number of times all three phases of the surgical safety

checklist were performed (“briefing,” “time out” and

“debriefing”) divided by the total number of surgeries

performed, multiplied by 100, Jan .–Dec . 2011, consistent

with publicly reportable patient safety data .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

100% 100%99 .2% (Q2 to

Q3 2011/12)5% 0% 13%

taBle 20: surgical safety checKlist target setting, 2012/13 Qips

figure 8: surgical safety checKlist — current performance and targets Within 2012/13 Qips

Current Value 88.7% 97.7% 100% 100% 100% 79.3% 87.7% 97.7% 100%

Target 99% 99% 100% 100% 100% 90% 90% 95% 100%

A B A B C A B C DAcute Teaching Large Community Small Community

0%

50%

100% Provincial Average = 99.2% (Q2–Q3)

Theoretical Best and Best Achieved = 100%

BETTER

Most Ontario hospitals have already achieved 99–100% compliance; any hospital that has not achieved this yet should be aiming for full (100%) compliance.

Surgical Safety Checklist (by Hospital), 2012/13 QIPs

Perc

enta

ge


Safety: Physical RestraintsEight hospitals chose physical restraints as a Priority 1

and 30 hospitals chose it as any priority . This indicator

was most selected by mental health hospitals .

definition

The physical restraints rate is defined as the number of

patients who are physically restrained at least once in

the three days prior to a full admission, divided by all

cases with a full admission assessment .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

Approaching zeroNo data

available3% -25%* 20%


taBle 21: physical restraints target setting, 2012/13 Qips

figure 9: physical restraints — current performance and targets Within 2012/13 Qips

A A B C

Large Community Mental Health

Current Value 14% 2.8% 3.4% 6.8%

Target 11% 3.5% 3.2% 6.0%

0%

8%

16%

Perc

enta

ge

Physical Restraints (by Hospital), 2012/13 QIPs

BETTER

No provincial average data are currently available.

Best Achieved to Date = Approaching 0%

While there may be reasons for setting the target below current performance, hospitals should include that rationale in their QIPs.

Although eight hospitals chose physical restraints as Priority 1, only four included performance and/or target data that can be included in this analysis. One organization (Baycrest) has achieved near-zero restraint use.


Effectiveness: Hospital Standardized Mortality Ratio (HSMR)Six hospitals chose HSMR as Priority 1 and 41 hospitals


definition

The HSMR is defined as the number of observed

deaths/number of expected deaths, multiplied by 100 .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

n/a n/a100% (this is

baseline)5% 1% 12%

taBle 22: hsmr target setting, 2012/13 Qips

figure 10: hsmr — current performance and targets Within 2012/13 Qips

A B A B C D E

Acute Teaching Large Community

Current Value 101 101 84 90 101 101 102

Target 100 97 94 81 100 98 90

0

60

120

Ratio

HSMR (by Hospital), 2012/13 QIPs


BETTER

About half of organizations set reasonable improvement targets of between 4 and 11 points. Others, however, set very small improvement targets — so small that they are within the statistical margin of error.

One hospital set an HSMR target that indicates an increased mortality rate. When setting targets, ensure that the indicator components and the direction of improvement are clearly understood.


Effectiveness: Hospital — Total Margin (OHRS)Sixty-two hospitals chose total margin as Priority 1 and

121 hospitals chose it as any priority .

definition

The total margin is defined as the percentage by which

total corporate (consolidated) revenues exceed or fall

short of total corporate (consolidated) expenses, excluding

the impact of facility amortization, in a given year .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

0 .7%–1 .7% for teaching;

0 .1%–1 .6% for CCC; 0%–1 .6%

for large; 0%–1 .8% for small;

1 .9% for mental

0%–2%Data not

available*n/a n/a n/a

*Data available on MOHLTC website; HQO cannot access this data, however.

taBle 23: total margin target setting, 2012/13 Qips

figure 11: total margin — current performance and targets Within 2012/13 Qips

A B C A B C D E F A B C D E F G H I J K L M N O A B C D E F G H I J K L M N O P Q R S


Current Value -0.2 0.06 0.16 0% 0% 0.93 1.78 3.60 4.88 -2.3 -1.8 -1.7 -1.5 -1.2 -1.1 -1.0 -0.0 -0.0 0% 0% 0.50 0.90 1.01 2.29 -5.7 -3.3 -1.0 -0.4 -0.3 -0.1 0% 0.04 0.71 0.76 0.78 0.78 0.81 1.00 1.30 1.91 2.00 2.07 3.43

Target 0% 0% 0% 0% 0% 0.50 0% 0% 0% -2.5 0.50 0.01 0% 0% 0% 0% 0% 0.00 0% 0.80 0% 0% 0% 0% -3.4 -3.0 -1.0 0% 0% 1.00 0.67 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1.00

-8.00%

0.00%

8.00%

Tota

l Mar

gin

Total Margin (by Hospital), 2012/13 QIPs

No provincial average data are currently available.

Most organizations set a target of between 0% and 2%, which is within suggested guidelines.

Theoretical Best = 0%-2%

BETTER

BETTER


Access: 90th Percentile ED Length of Stay for Admitted Patients Fifty-four hospitals chose 90th percentile ED length of

stay for admitted patients as Priority 1 and 94 hospitals


definition

The ED length of stay for admitted patients is defined

as the time from triage or registration, whichever comes

first, to the time the patient leaves the ED .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

Data not availableApproaching

zero

11 .5 hours

(FY 2010/11)11% -117%* 68%


taBle 24: 90th percentile ed length of stay for admitted patients target setting,

2012/13 Qips

figure 12: 90th percentile length of stay for admitted patients — current performance

and targets Within 2012/13 Qips

A B C D E F G H A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI AJ AK A B C D E F G H

Acute Teaching Large Community Small Community

Current Value 21.0 23.6 26.3 27.0 27.9 28.2 31.0 39.8 9.2 10.6 11.2 14.3 17.1 17.5 18.9 20.1 20.6 22.6 22.9 23.2 23.4 23.9 24.1 24.8 25.0 25.8 26.3 28.4 28.5 29.3 30.9 30.9 32.2 36.4 36.7 37.5 39.4 42.2 44.0 45.8 48.1 49.8 55.2 69.4 70.6 7.1 8.5 8.9 11.1 12.2 12.3 21.8 33.3

Target 23.0 22.0 25.0 25.0 25.1 25.0 29.0 36.0 8.0 23.0 19.8 8.0 12.2 15.9 18.0 19.0 18.5 20.4 19.0 21.0 20.0 20.8 21.9 22.0 8.0 23.2 20.0 25.0 24.0 25.0 27.8 29.0 29.0 34.0 36.0 37.4 23.0 40.1 42.0 34.4 35.2 39.0 40.3 45.0 47.0 6.0 7.5 6.0 10.0 11.0 14.2 18.9 22.5

0

40

80

Leng

th o

f Sta

y (H

ours

)

90th Percentile ED Length of Stay for Admitted Patients (by Hospital), 2012/13 QIPs

BETTER

Provincial Average = 11.5 hours

Theoretical Best = Approaching 0

ED length of stay continues to affect most hospitals. Hospitals that had the longest waits had the biggest targets for improvement, which is encouraging. Some organizations, however, set very small improvement targets despite being far worse than average.


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orts

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the

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ake

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h

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tha

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ve o

ptim

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phy

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taffi

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rovi

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add

ition

al

phy

sici

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over

age

for

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igh-

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and

per

iod

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the

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sep

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ilto

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cute

teac

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)

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ving

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float

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nviro

n-

men

tal S

ervi

ce W

ork

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osi

tion

dur

ing

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k ad

mis

sion

per

iod

to

red

uce

time

wai

ting

for

a ro

om t

o b

e

clea

ned

and

pre

par

ed fo

r ad

mis

sion

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ted

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emen

ted

pro

cess

mea

sure

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pec

ted

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e of

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rven

tion

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ctiv

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r if

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cove

ry p

lan

req

uire

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u-

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ls

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and

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ient

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e C

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ittee

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he

boa

rd, E

mer

genc

y C

linic

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eam

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ical

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viso

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ittee

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l has

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nt fl

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y fis

cal

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ckvi

lle

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eral

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spita

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read

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to

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surg

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om t

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s th

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ort

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rter

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ualit

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e C

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mer

genc

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ical

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l has

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tern

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nt fl

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y fis

cal

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ckvi

lle

Gen

eral

Ho

spita

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rge

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mun

ity)

taB

le

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ch

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ge

ide

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ro

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Wa

it t

ime

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or

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mit

te

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at

ien

ts

(CO

NTI

NU

ED

)


ch

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e

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nce

pt

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ateg

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ate

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.g.,

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men

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lem

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rap

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s-

men

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pat

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pro

vem

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wai

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pb

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spita

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ater

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ro

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(CO

NTI

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et

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rove

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(con

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with

in 2

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sure

s ex

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y

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s

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ry p

lan

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ired

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rnw

all

Co

mm

unity

Ho

spita

l (la

rge

com

mun

ity)

imp

rove

acc

ess

to c

omm

unity

serv

ices

to

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vent

ret

urns

to e

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Max

imiz

e re

ferr

als

to t

he G

ener

al

Inte

rnal

Med

icin

e R

apid

Acc

ess

Out

pat

ient

Clin

ic (G

IMR

AO

C) b

y

pro

vid

ing

qua

rter

ly d

ata

to G

IM a

nd

ED

phy

sici

ans

rega

rdin

g th

eir

refe

rral

rate

to

the

GIM

RA

OC

Per

cent

age

incr

ease

in t

he n

umb

er

of n

ew v

isits

to

GIM

RA

OC

ove

r

2011

/12

5% im

pro

vem

ent

over

201

1/12

Ham

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n H

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ence

s (a

cute

teac

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ldin

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the

succ

ess

of th

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apid

Ref

erra

l Clin

ic fo

r as

sess

men

t an

d

man

agem

ent

of m

edic

al p

atie

nts

to a

void

inp

atie

nt a

dm

issi

ons,

a

feas

ibili

ty s

tud

y w

ill b

e in

itiat

ed fo

r

add

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al c

linic

s fo

r ca

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and

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pat

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Trac

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the

num

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Med

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Rap

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linic

Co

mp

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feas

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Cen

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)

inp

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nt b

ed

man

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Med

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pat

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jour

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iden

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key

bar

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to

pat

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n b

ed

man

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es t

o b

est

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e an

d p

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mes

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rele

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cap

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dem

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dem

and

with

cap

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)

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d le

ngth

of s

tay

vs . a

vera

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leng

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f sta

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D le

ngth

of s

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for

adm

itted

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8 ho

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LOS

varia

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osp

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taB

le

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ch

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ge

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imp

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ve

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Wa

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NTI

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ED

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et

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Imp

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to t

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the

right

tim

e th

roug

h a

sim

ulat

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info

rmed

bed

map

1 . A

pp

licat

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of S

urgi

cal P

red

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e

Bed

Mo

del

2 . D

evel

opm

ent o

f Med

ical

Pre

dic

tive

Bed

Mo

del

1 . S

urgi

cal P

red

ictiv

e

Mod

el: a

pp

licat

ion

com

plet

e at

iden

tified

HH

S s

ites

by O

ctob

er

2012

2 . M

edic

al P

redi

ctiv

e

Mod

el: p

ilot m

odel

deve

lop

ed A

pril

201

3

Ham

ilto

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ealth

Sci

ence

s (A

cute

Teac

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Ens

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phy

sici

an r

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acu

te

care

are

com

ple

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ord

er t

o en

sure

pat

ient

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char

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uni

t b

efo

re

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urs

Rep

ort

qua

rter

ly t

o th

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ualit

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and

Pat

ient

Car

e C

omm

ittee

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boa

rd, E

mer

genc

y C

linic

al T

eam

and

Med

ical

Ad

viso

ry C

omm

ittee

Goa

l has

bee

n se

t

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tern

ally

man

age

pat

ient

flow

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fisca

l

year

Bro

ckvi

lle

Gen

eral

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spita

l (la

rge

com

mun

ity)

imp

rove

hand

off

s fr

om

eD

to

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atie

nt

war

d

Imp

lem

enta

tion

of a

mul

tidis

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plin

ary

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issi

on te

am in

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ED

to c

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inat

e th

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re o

f pat

ient

s

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ting

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sfer

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pat

ient

bed

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r p

atie

nts

adm

itted

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ough

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and

car

ed

for

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on t

eam

Dec

reas

e th

e av

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e

acut

e le

ngth

of s

tay

for

patie

nts

adm

itted

thro

ugh

ED

fro

m

5 .9

day

s (2

011/

12

YT

D Q

3) b

y 10

%,

to 5

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ays

Mar

kham

Sto

uffv

ille

Ho

spita

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com

mun

ity)

Tran

sitio

n te

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pla

ce a

nd t

estin

g

star

ted

on

imp

rovi

ng t

he p

roce

ss

of t

rans

ition

ing

the

pat

ient

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m t

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ED

to

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in a

mo

re t

imel

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whi

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leng

th o

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pro

ve t

rans

ition

pro

cess

to

inp

atie

nt u

nit,

red

uce

time

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pat

ient

uni

t

Bed

rea

dy

for

pat

ient

in 3

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es,

volu

me

of a

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itted

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ient

s se

en b

y

tran

sitio

n te

am

Per

cent

age

mee

ting

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e ta

rget

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el D

ieu

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ce

Ho

spita

l (la

rge

com

mun

ity)

taB

le

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ch

an

ge

ide

as

to

imp

ro

ve

ed

Wa

it t

ime

s f

or

ad

mit

te

d p

at

ien

ts

(CO

NTI

NU

ED

)


ch

ang

e

co

nce

pt

ch

ang

e

su

b-c

ateg

ory

ch

ang

e id

ea

pro

cess

mea

sure

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targ

et

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e)

dec

isio

n

su

pp

ort

s

pat

ient

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er

sets

Intr

oduc

e pa

tient

ord

er s

ets,

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udin

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adm

issi

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dize

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ecte

d da

te o

f dis

char

ge, e

nsur

e

early

dis

char

ge p

lann

ing

and

enga

ge-

men

t of c

omm

unity

pro

vide

rs a

s

need

ed

Per

cent

age

of p

atie

nts

adm

itted

with

a c

omp

lete

d a

dm

issi

on o

rder

set

on c

hart

Low

acu

ity: 4

;

high

acu

ity: 8

Jose

ph

Bra

nt

Mem

oria

l

Ho

spita

l (la

rge

com

mun

ity)

pat

ien

t

en

gag

emen

t

info

rm p

atie

nts

abo

ut w

ait

times

Be

tran

spar

ent

with

cur

rent

wai

t

times

. Use

tec

hnol

og

y to

let

the

pub

lic k

now

wha

t th

e w

ait

time

is

Non

e lis

ted

Low

acu

ity: 4

;

high

acu

ity: 8

Bro

ckvi

lle

Gen

eral

Ho

spita

l

(larg

e co

mm

u-

nity

)

info

rm p

atie

nts

abo

ut t

heir

care

Util

ize

whi

teb

oard

s in

eac

h p

atie

nts

room

; id

entif

y d

isch

arge

pla

nnin

g

for

fam

ilies

and

pat

ient

s to

vie

w

Ran

dom

aud

its p

erfo

rmed

to

ensu

re

that

sta

ff u

pd

ate

whi

teb

oard

s on

dai

ly b

asis

to

refle

ct p

lan

of c

are

and

dis

char

ge p

lan

dev

elop

ed in

colla

bo

ratio

n w

ith p

hysi

cian

s

100%

co

mp

lianc

e

with

whi

teb

oard

utili

zatio

n

Ste

vens

on

Mem

oria

l (sm

all

com

mun

ity)

res

ou

rces

Ded

icat

ed s

taff

to m

anag

e e

D

flow

Use

a P

atie

nt F

low

Co

ord

inat

or

po

sitio

n to

gui

de

pro

cess

imp

rove

men

ts in

the

ED

for

CTA

S

1-3

pat

ient

s . T

he C

oo

rdin

ato

r w

ill

help

the

ED

tea

m t

o us

e E

D b

eds

mo

re e

ffici

ently

so

that

the

y ca

n

red

uce

the

wai

t tim

e fo

r p

atie

nts

Use

ED

tra

ckin

g b

oard

dat

a to

map

the

flow

of p

atie

nts

thro

ugh

the

ED

,

and

use

thi

s d

ata

to e

xam

ine

and

imp

rove

bed

util

izat

ion

Non

e lis

ted

St

Jose

ph’

s

Hea

lth C

entr

e—

Ham

ilto

n (a

cute

teac

hing

)

taB

le

25:

ch

an

ge

ide

as

to

imp

ro

ve

ed

Wa

it t

ime

s f

or

ad

mit

te

d p

at

ien

ts

(CO

NTI

NU

ED

)


ch

ang

e

co

nce

pt

ch

ang

e

su

b-c

ateg

ory

ch

ang

e id

ea

pro

cess

mea

sure

pro

cess

targ

et

ho

spit

al (

typ

e)

res

ou

rces

(con

tinue

d)

Pilo

t an

d e

valu

ate

Bed

Co

ord

inat

or

role

to

sup

po

rt b

ed m

anag

emen

t

bes

t p

ract

ices

, e .g

., p

red

ictiv

e

dis

char

ge p

roce

ss, b

ed m

anag

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men

t m

eetin

gs

twic

e d

aily

at

chan

ge

of s

hift

to

optim

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util

izat

ion,

early

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rnin

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atie

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rans

fers

fro

m

ED

-IP

ser

vice

s, 1

0 am

dis

char

ge,

etc .

Qua

rter

ly Q

IP2

sco

reca

rd p

rese

nted

to s

enio

r le

ader

ship

tea

m, M

edic

al

Qua

lity

Com

mitt

ee a

nd Q

ualit

y an

d

Per

form

ance

Mon

itorin

g C

omm

ittee

Non

e lis

ted

Co

rnw

all

Co

mm

unity

Ho

spita

l (la

rge

com

mun

ity)

red

eplo

y

reso

urce

s to

bo

ttle

neck

s

Con

tinue

with

“ho

t sp

ot”

stra

tegi

es,

e .g .

, nur

se p

ract

ition

er in

fast

-tra

ck

area

, flow

coa

ches

and

ad

mis

sion

/

dis

char

ge u

nit

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e lis

ted

Non

e lis

ted

Cam

brid

ge

Mem

oria

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Ho

spita

l (la

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ity)

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ff s

kill

ss

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gC

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atio

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ols:

intr

od

uce

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ch b

ack”

tra

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d c

omm

unic

atio

n

trai

ning

to

all f

ront

-lin

e H

CP

Per

cent

age

trai

ned

90%

of f

ront

line

HC

P (e

xclu

din

g M

D

are

trai

ned

in t

each

bac

k (F

T an

d P

T)

Red

Lak

e

Mar

gar

et

Co

chen

our

Mem

oria

l

Ho

spita

l (sm

all

com

mun

ity)

taB

le

25:

ch

an

ge

ide

as

to

imp

ro

ve

ed

Wa

it t

ime

s f

or

ad

mit

te

d p

at

ien

ts

(CO

NTI

NU

ED

)


Patient-Centred: Patient Satisfaction Fifty-nine hospitals chose patient satisfaction as


definition

Improving patient satisfaction involves asking patients

questions about the care and services they have

received at a hospital, and/or whether they would

recommend the hospital to others . Most hospitals

use NRC Picker Canada questions for both hospital

in-patients and ED patients, but an in-house survey

may also be administered .

indicatorBest achieved to

date in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

percentage

who would

definitely

recommend

to others —

inpatients

Benchmarks under

development

Approaching

100%

73 .1%

FY 20103% -20%* 23 .0%

percentage

who would

definitely

recommend

to others —

eds

Benchmarks under

development

Approaching

100%

58 .2%

FY 201011% 2% 20%

percentage

who rate the

care they

received as

excellent,

very good

or good —

inpatients

Benchmarks under

development

Approaching

100%

93 .2%

FY 20102% -15%* 15%*

percentage

who rate the

care they

received as

excellent,

very good

or good —

eds

Benchmarks under

development

Approaching

100%

85 .1%

FY 20102% 0% 5%


taBle 26: patient satisfaction target setting, 2012/13 Qips


figure 13: patient satisfaction — current performance and targets Within 2012/13 Qips

A A B C A B C D E F G H I J K L M N O A B C D E F G H I


Current Value 78% 82% 89% 98% 60% 61% 62% 63% 64% 68% 69% 71% 73% 75% 77% 82% 84% 86% 99% 52% 80% 85% 90% 92% 93% 94% 100%100%

Target 80% 85% 90% 100% 69% 75% 67% 67% 76% 75% 74% 74% 75% 77% 80% 85% 75% 87% 95% 63% 81% 88% 90% 92% 85% 85% 90% 80%

0%

50%

100% Pe

rcen

tage

Percentage of Patients Who Would De�nitely Recommend This Hospital to Friends and Family (by Hospital), 2012/13 QIPs

Provincial Average = 73.1%

Theoretical Best = Approaching 100%

The majority of hospitals want to improve patient satisfaction, and have set stretch targets above current performance and the provincial average. Most hospitals set targets of approximately three percentage points; many organizations with lower baselines set more aggressive targets, and high performers had smaller targets. These targets appear to be appropriate and reasonable. Organizations that had set out to achieve zero or negative improvement, or minimal improvement despite being well below average, should ask themselves if their targets should be strengthened.

BETTER

A B A B A B C D E F G H I J K A B C A B C D E F G H

Acute teaching

CCC and

Rehab Large Community

Mental Health

Small Community

Current Value 94% 94% 71% 89% 79% 89% 89% 89% 90% 91% 91% 91% 92% 93% 94% 60% 80% 80% 61% 90% 92% 92% 94% 94% 96% 96%

Target 95% 99% 80% 89% 81% 92% 92% 94% 90% 93% 92% 95% 93% 84% 97% 65% 80% 85% 70% 93% 97% 80% 96% 80% 96% 98%

0%

50%

100%

Perc

enta

ge

Percentage of Patients Who Rate the Care They Received as Excellent, Very Good or Good (by Hospital), 2012/13 QIPs

Hospitals generally achieve high satisfaction ratings on the overall care received. Most hospitals set targets of approximately three percentage points; many organizations with lower baselines set more aggressive targets, and high performers had smaller targets. These targets appear to be appropriate and reasonable. Organizations that had set out to achieve zero or negative improvement, or minimal improvement despite being well below average, should ask themselves if their targets should be strengthened.



BETTER


figure 13: patient satisfaction — current performance and targets Within 2012/13 Qips

(CONTINUED)

A B C D A B

Large Community Small Community

Current Value 42% 47% 51% 50% 54% 60%

Target 47% 54% 55% 57% 55% 72%

0%

50%

100% Pe

rcen

tage

Percentage of Patients Who Would Recommend This Emergency Department to Friends and Family (by Hospital), 2012/13 QIPs

BETTER

All but one hospital that chose this indicator as Priority 1 are currently below the provincial average of 58.2%. Each has set a target (in red) above current performance. These efforts are encouraging, and HQO recommends that hospitals continue working towards the theoretical best.



A B C A


Current Value 80% 81% 81% 90%

Target 80% 85% 85% 90%

0%

50%

100%

Perc

enta

ge

Percentage Who Rate the Care They Received as Excellent, Very Good or Good(by Hospital), 2012/13 QIPs

BETTER



Of the four hospitals that selected overall satisfaction with the ED as Priority 1, two hospitals elected to remain at their current level of performance. Maintaining the same level of current performance suggests that this indicator is not a Priority 1, so providing a rationale for this choice is imperative.


ch

ang

e

co

nce

pt

ch

ang

e

su

b-c

ateg

ory

ch

ang

e id

ea

pro

cess

mea

sure

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cess

targ

et

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t

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db

ack

feed

bac

k to

ind

ivid

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nits

Hig

hlig

ht p

osi

tive

sco

res

rece

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from

sur

vey

resu

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o st

aff

Ana

lyze

sur

vey

resu

lts f

rom

Jan

uary

2012

sur

vey

and

dev

elop

qua

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imp

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t in

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ives

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uire

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ded

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al O

ttaw

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lth C

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r C

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yste

m

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plim

ents

, sug

gest

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and

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pla

ints

are

rec

eive

d f

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y

sour

ces

and

find

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s w

ill b

e tr

end

ed

and

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red

with

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ager

s

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rovi

ded

Roy

al O

ttaw

a

Hea

lth C

are

Gro

up (m

enta

l

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th)

freq

uent

min

i-su

rvey

s

No

hosp

itals

men

tione

d m

ini-

surv

eys

spec

ifica

lly, b

ut th

is b

est p

ract

ice

shou

ld b

e co

nsid

ered

by

orga

niza

tiona

l lea

der

s

to h

elp

the

m g

ain

timel

y an

d v

alua

ble

insi

ghts

into

the

del

iver

y of

hea

lthca

re s

ervi

ces

that

pat

ient

s re

ceiv

e, in

ord

er t

o

bet

ter

mee

t th

eir

need

s an

d e

xpec

tatio

ns . F

or

mo

re in

form

atio

n on

po

sitiv

e p

atie

nt e

xper

ienc

e an

d o

n m

ini-

surv

eys,

ple

ase

go to

the

HQ

O Q

ualit

y Im

pro

vem

ent M

ap P

ositi

ve P

atie

nt E

xper

ienc

e se

ctio

n (h

ttp:

//w

ww

.hq

onta

rio .c

a/en

/imap

/

po

sitiv

e .ht

ml) .

The

to

ols

area

list

s, a

mon

g ot

her

mat

eria

l, an

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A g

uid

ance

do

cum

ent

on

dev

elop

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surv

eys .

pro

cess

este

ach

bac

kU

tiliz

e a

teac

h-b

ack

met

hod

to

ensu

re p

atie

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and

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t

has

bee

n ex

pla

ined

to

them

Rep

ort t

o th

e Q

ualit

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atie

nt C

omm

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and

Em

erge

ncy

Clin

ical

Tea

m

Goa

l is

to im

pro

ve

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ss in

the

ED

by

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lle

Gen

eral

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spita

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dis

char

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inst

ruct

ions

Pro

vid

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ear,

writ

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dis

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inst

ruct

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to

pat

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s re

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med

icat

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aft

erca

re in

stru

ctio

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t

hom

e an

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llow

-up

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Rep

ort t

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Gen

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Whi

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s fo

r co

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f the

nam

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pro

vid

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exp

ecte

d d

isch

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s, e

tc .

Num

ber

of t

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100%

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al

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awa

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roup

(men

tal h

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)

taB

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27:

ch

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ide

as

to

imp

ro

ve

pa

tie

nt

sa

tis

fac

tio

n

http://www.hqontario.ca/en/imap/positive.html

http://www.hqontario.ca/en/imap/positive.html


ch

ang

e

co

nce

pt

ch

ang

e

su

b-c

ateg

ory

ch

ang

e id

ea

pro

cess

mea

sure

pro

cess

targ

et

ho

spit

al (

typ

e)

pro

cess

es

(con

tinue

d)

Dai

ly r

oun

din

g

wit

h p

atie

nts

Imp

lem

ent

clin

ical

tac

tics

for

serv

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exce

llenc

e ac

ross

all

inp

atie

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nits

.

Tact

ics

incl

ude:

hou

rly r

ound

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bed

sid

e sh

ift r

epo

rtin

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are

boa

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and

pat

ient

rou

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g b

y le

ader

s .

The

intr

od

uctio

n of

the

se b

est

pra

c-

tices

will

ens

ure

pat

ient

s ar

e w

ell

info

rmed

and

eng

aged

in t

heir

care

pro

cess

Ad

optio

n of

the

clin

ical

tac

tics

will

be

mea

sure

d q

uart

erly

; com

plia

nce

with

hou

rly ro

undi

ng w

ill b

e m

onito

red

usin

g b

edsi

de

roun

din

g lo

gs

dai

ly

for

first

thr

ee m

onth

s an

d t

hen

qua

rter

ly b

y au

dit

100%

ad

optio

n b

y

Mar

ch 2

013

The

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awa

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spita

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pat

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gag

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t

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dvi

sory

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cils

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ient

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viso

ry C

ounc

il

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ient

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db

ack

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itorin

g S

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m

rene

wal

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ient

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nce

Task

Fo

rce

Imp

lem

enta

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of fa

mily

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care

1) M

easu

rem

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luat

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of

pat

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com

pla

ints

and

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2) N

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ucat

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4) C

reat

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ateg

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to

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the

mes

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enha

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pro

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of fa

mily

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e an

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pro

ac-

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in a

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g to

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ient

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s

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ence

s C

entr

e

(acu

te t

each

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fo

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gro

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duc

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focu

s g

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user

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reco

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the

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the

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ient

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ints

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ve N

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ns

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ons

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ker

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ctio

n

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nnai

res

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ckvi

lle

Gen

eral

Ho

spita

l (la

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ity)

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le

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ve

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nt

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Integrated: 30-Day Readmission Rate to Any Facility (Specific Case Mix Groups)Eighteen hospitals chose 30-day readmission rate to

any facility (specific case-mix groups) as Priority 1 and

74 hospitals chose it as any priority .

definition

The 30-day readmission rate to any facility (specific

case mix groups) is defined as readmission within

30 days for selected CMGs to any facility .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

TBD15 .1%

(Q4 2010/11)18% 0% 35%

taBle 28: 30-day readmission rate to any facility target setting, 2012/13 Qips

figure 14: 30-day readmission rate to any facility — current performance and targets

Within 2012/13 Qips

A A A B C D E F G H

Acute Teaching

CCC and Rehab

Large Community

Current Value 18% 29% 10% 11% 11% 13% 16% 18% 22% 13%

Target 13% 20% 8% 6.9% 11% 13% 13% 15% 18% 12%

0%

15%

30%

Rate

Readmission for Selected CMG+ (by Hospital), 2012/13 QIPs

Provincial Average = 15.1% (Q4)

Theoretical Best = TBD

BETTER

Evidence shows that readmission rates can improve through an integrated health focus and individualized transition planning. Additional resources, including two webinars on optimizing transitions, can be found on the HQO Quality Improvement Map. Note that Ontario’s small community hospitals are not included in this graph due to lack of data provided, or data that focused on speci�c conditions (e.g., COPD).


Integrated: Percentage of Alternative Level of Care (ALC) DaysThirty-six hospitals chose percentage of ALC days as


definition

The percentage of ALC days is defined as the total

number of inpatient days designated as ALC, divided

by the total number of inpatient days .


in ontario

theoretical

Best

provincial

average



target

lowest

target

highest

target

0% for acute teaching, large

community, small community and

mental health; 2% for CCC (<5)

Zero 17% FY 2010 10% -97%* 64%


taBle 29: percentage of alc days target setting, 2012/13 Qips

figure 15: percentage of alc days — current performance and targets Within 2012/13 Qips

A A B A B C D E F G H I J K L M N O A B C D E F G H I J K L M N O

Acute Teaching

CCC and Rehab


Current Value 13.20%26.00% 52.00% 10.10% 11.41% 11.60% 11.88%13.60% 13.94% 15.00% 16.10% 19.60% 19.63%19.73% 20.18% 23.55% 26.40% 29.60% 9.10% 9.90% 11.00% 15.00% 17.00%17.68% 18.40% 18.75% 20.10% 21.40%26.00% 28.00% 33.00% 40.20% 68.00%

Target 11.00%22.00% 35.00% 9.00% 14.55% 9.00% 12.50% 15.00% 12.59% 12.50% 11.00%17.00% 17.00%17.73% 20.00% 21.20%9.46% 28.12% 9.10% 11.00% 21.64%13.60% 13.50%14.55% 17.00% 15.00% 11.00%19.30% 22.00% 17.00% 30.00% 38.00% 63.00%

0%

40%

80%

Perc

enta

ge

Percentage of ALC Days (by Hospital), 2012/13 QIPs



BETTER

Did you set a stretch target that is below and better than the provincial average of 17%? Are you collaborating with other healthcare sectors to reduce your rate?


ch

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void

inp

atie

nt a

dm

issi

ons,

a

feas

ibili

ty s

tud

y w

ill b

e in

itiat

ed fo

r

add

ition

al c

linic

s fo

r ca

ncer

and

card

iac

pat

ient

s

Trac

king

the

num

ber

of G

ener

al

Med

icin

e ad

mis

sion

s av

erte

d b

y

the

Rap

id R

efer

ral C

linic

Com

ple

tion

of

feas

ibili

ty s

tud

y

Sun

nyb

rook

Hea

lth S

cien

ces

Cen

tre

(acu

te

teac

hing

)

taB

le

30:

ch

an

ge

ide

as

to

imp

ro

ve

pe

rc

en

tag

e o

f a

lc d

ay

s (C

ON

TIN

UE

D)


ch

ang

e

co

nce

pt

ch

ang

e

su

b-c

ateg

ory

ch

ang

e id

ea

pro

cess

mea

sure

pro

cess

targ

et

ho

spit

al (

typ

e)

pro

cess

es

(con

tinue

d)

inte

gra

ted

dis

char

ge

pla

nnin

g

Wor

k w

ith th

e C

SS

Sys

tem

Nav

igat

or

to li

aise

with

ass

iste

d liv

ing

pro

vide

rs,

CS

S, C

CA

C a

nd m

enta

l hea

lth a

nd

add

ictio

ns p

rovi

der

s to

co

ord

inat

e

asse

ssm

ents

/re-

asse

ssm

ents

to

sup

po

rt in

teg

rate

d d

isch

arge

pla

nnin

g in

line

with

the

Hom

e

Firs

t p

hilo

sop

hy

As

per

the

Hom

e Fi

rst a

nd In

tegr

ated

Dis

char

ge P

lann

ing

wo

rk

Non

e lis

ted

Tim

min

s an

d

Dis

tric

t H

osp

ital

(larg

e co

mm

unity

)

Dis

char

ge p

lann

ing:

Ass

ista

nce

of

Agi

ng a

t H

ome

Co

ord

inat

or

and

Ab

orig

inal

Nav

igat

or

in d

isch

arge

pla

nnin

g

Wee

kly

mee

ting

sN

one

liste

dH

ôpita

l

Not

re-D

ame

Ho

spita

l (sm

all

com

mun

ity)

falls

pre

vent

ion

in c

omm

unity

Par

tner

with

and

tar

get

retir

emen

t

hom

e an

d LT

C fa

cilit

ies

with

falls

pre

vent

ion

pra

ctic

es/t

ools

to a

dd

ress

the

resu

lts o

f a r

evie

w o

f ED

ad

mits

from

LTC

/ret

irem

ent h

omes

prim

arily

due

to

falls

Per

cent

age

of id

entifi

ed fa

cilit

ies

to

whi

ch t

ool

kits

/pra

ctic

es d

istr

ibut

ed

100%

of t

ool

kits

dis

trib

uted

No

rth

Bay

Reg

iona

l Hea

lth

Cen

tre

(larg

e

com

mun

ity)

sk

ills

sta

ff t

rain

ing

Ed

ucat

e al

l nur

ses

that

100

% o

f

pat

ient

s w

ho a

re A

LC m

ust

be

refe

rred

to

the

CC

AC

for

cons

ult

Per

cent

age

of A

LC p

atie

nts

refe

rred

to C

CA

C

100%

Gle

ngar

ry

Mem

oria

l

Ho

spita

l (sm

all

com

mun

ity)

E

duc

ate

all s

taff

on

flow

pro

cess

es,

Med

wo

rxx

and

exp

ecta

tions

Trai

n al

l nur

sing

sta

ff in

the

stan

dar

d

wo

rk p

roce

ss a

nd b

ehav

iour

al

exp

ecta

tion

asso

ciat

ed w

ith t

rans

fer

or

care

90%

of n

ursi

ng s

taff

trai

ned

in s

tand

ard

wor

k p

roce

sses

, flow

goal

s an

d e

xpec

ta-

tion

by

Q3

2012

/13 .

100%

of n

ew n

ursi

ng

staf

f orie

nted

at “

new

hire

” or

ient

atio

n

Leam

ing

ton

Dis

tric

t M

emo

rial

Ho

spita

l (sm

all

com

mun

ity)

taB

le

30:

ch

an

ge

ide

as

to

imp

ro

ve

pe

rc

en

tag

e o

f a

lc d

ay

s (C

ON

TIN

UE

D)


ch

ang

e

co

nce

pt

ch

ang

e

su

b-c

ateg

ory

ch

ang

e id

ea

pro

cess

mea

sure

pro

cess

targ

et

ho

spit

al (

typ

e)

res

ou

rces

pla

n fo

r

com

mun

ity

ger

iatr

ic

serv

ices

Use

sec

ured

fun

din

g an

d c

onsu

ltant

to p

rep

are

a d

istr

ict s

pec

ializ

ed g

eri-

atric

ser

vice

s p

lan

to id

entif

y sy

stem

fund

ing

gap

s an

d op

por

tuni

ties

Com

ple

te b

y A

pril

201

2 an

d s

ubm

it

to t

he L

HIN

100%

com

ple

teN

ort

h B

ay

Reg

iona

l Hea

lth

Cen

tre

(larg

e

com

mun

ity)

sup

po

rtiv

e

hous

ing

/saf

e

hous

ing

We

will

con

tinue

to

wo

rk w

ith

phy

sici

ans

and

com

mun

ity p

artn

ers

to e

nsur

e al

l sup

po

rts

are

avai

lab

le

to b

e ut

ilize

d t

o th

e fu

llest

ext

ent

to e

ncou

rage

saf

e an

d t

imel

y d

is-

char

ge f

rom

ho

spita

l . T

his

incl

udes

timel

y im

ple

men

tatio

n of

dis

char

ge

pla

nnin

g p

roce

sses

and

ap

plic

atio

n

for

LTC

pla

cem

ent

if ap

pro

pria

te o

r

assi

stan

ce t

o fin

d s

uita

ble

so

cial

hous

ing

as r

equi

red

. Our

suc

cess

is

high

ly c

orr

elat

ed t

o th

e av

aila

bili

ty

of c

omm

unity

car

e se

rvic

es a

nd

sup

po

rts,

ava

ilab

ility

of a

pp

rop

riate

pla

cem

ent

of in

div

idua

ls in

to L

TC

hom

es, s

uita

ble

gea

red

-to

-inc

ome

soci

al h

ousi

ng, s

afe

hous

ing

for

tho

se w

ith m

obili

ty im

pai

rmen

ts

and

co

oper

atio

n w

ith t

he e

ntire

cont

inuu

m o

f car

e

Wee

kly

mo

nito

ring

of

ALC

bed

utili

zatio

n re

po

rted

to

LH

IN,

mo

nito

ring

of

LTC

wai

t lis

ts,

wee

kly

revi

ew o

f all

ALC

pat

ient

s

dur

ing

mul

tidis

cip

linar

y m

eetin

gs

with

phy

sici

ans

and

car

e te

am;

shar

ing

of d

ata

with

MA

C

ALC

rat

es w

ill

cont

inue

to b

e hi

gher

as t

here

are

man

y

miti

gatin

g fa

cto

rs:

limite

d a

pp

rop

riate

hous

ing,

0%

vac

ancy

in a

ll LT

C h

om

es

with

wai

ting

lists

,

insu

ffici

ent

prim

ary

care

phy

sici

ans

in

the

com

mun

ity a

nd

use

of lo

cum

ho

spi-

talis

ts in

the

ho

spita

l,

gap

s in

ser

vice

s fo

r

men

tal h

ealth

and

add

ictio

ns c

are,

as w

ell a

s lim

ited

avai

lab

ility

of h

om

e

care

sup

po

rts

Kirk

land

Dis

tric

t

Ho

spita

l (sm

all

com

mun

ity)

pat

ien

t

en

gag

emen

t

ass

ist

fam

ily

care

giv

ers

(hel

p t

hem

cont

inue

to

sup

po

rt p

atie

nt

in c

om

mun

ity)

Trai

ning

ses

sion

s fo

r fa

mily

mem

ber

s

and

car

egiv

ers

who

ass

ist

seni

ors

in

the

com

mun

ity

Ses

sion

s fo

r 25

par

ticip

ants

Non

e lis

ted

Hôp

ital

Not

re-D

ame

Ho

spita

l (sm

all

com

mun

ity)

taB

le

30:

ch

an

ge

ide

as

to

imp

ro

ve

pe

rc

en

tag

e o

f a

lc d

ay

s (C

ON

TIN

UE

D)


North Bay Regional Health Centre produced an excellent change plan in support of ALC reduction (see Table 31) .a

imm

easu

reQ

ual

ity

dim

ensi

on

ob

jec

tive

mea

sure

/in

dic

ato

r

cu

rren

t

per

form

ance

targ

et f

or

2012

/13

targ

et J

ust

ifica

tio

n

pri

ori

ty

lev

el

inte

gra

ted

Red

uce

unne

cess

ary

time

spen

t in

acut

e

care

Per

cent

age

ALC

day

s: T

otal

num

ber

of i

npat

ient

day

s

des

igna

ted

as

ALC

, div

ided

by

the

tota

l num

ber

of i

npat

ient

days

23 .5

5% a

vera

ge,

Jan .

–Dec

. 201

1,

No

rth

Eas

t Lo

cal

Hea

lth In

teg

ratio

n

Net

wo

rk (N

ort

h E

ast

LHIN

)

21 .2

% a

vera

ge,

Jan .

–Dec

. 201

2,

No

rth

Eas

t LH

IN

10%

ave

rag

e re

duc

-

tion

tow

ard

s m

eet-

ing

the

No

rth

Eas

t

LHIN

tar

get

of 1

7%

1

ch

ang

e p

lan

pla

nn

ed im

pro

vem

ent

init

iati

ves

(ch

ang

e id

eas)

met

ho

ds

and

pro

cess

mea

sure

s

go

al f

or

ch

ang

e

idea

s (2

012

/13)

co

mm

ents

Con

tinue

to

exp

and

the

HE

LP p

rog

ram

thr

ough

vol

unte

er r

ecru

itmen

tN

umb

er o

f new

vol

un-

teer

s p

artic

ipat

ing

in

HE

LP p

rog

ram

14+

vol

unte

ers

to a

llow

for

ongo

ing

recr

uitm

ent

due

to

turn

over

The

ALC

initi

ativ

es a

re

linke

d t

o th

e 20

12‐1

3

Sen

ior

Frie

ndly

Ho

spita

l

Act

ion

and

Imp

lem

enta

-

tion

Pla

nnin

g P

roce

ss

thro

ugh

the

No

rth

Eas

t

LHIN

Imp

rove

aw

aren

ess

of t

he G

eria

tric

Day

Pro

gra

m a

vaila

ble

in O

P R

ehab

to s

take

hold

ers,

phy

sici

ans’

offi

ces

and

com

mun

ity F

all P

reve

ntio

n

Pro

gra

m (“

Sta

y on

You

r Fe

et”)

by

pro

vid

ing

sche

dul

ed in

form

atio

n

sess

ions

for

them

Ave

rage

num

ber

of

mon

thly

ref

erra

ls

rece

ived

Five

ref

erra

ls p

er m

ont

h

Dev

elop

and

imp

lem

ent

a P

atie

nt F

low

Co

ord

inat

or

po

sitio

nIm

ple

men

t b

y Ju

ne 2

012

100%

com

ple

te

Eva

luat

e, a

sses

s an

d r

esto

re a

nd u

se le

sson

s le

arne

d t

o d

rive

imp

rove

men

t

Per

cent

age

of p

atie

nts

dis

char

ged

hom

e w

ithin

90 d

ays

60%

Com

ple

te v

alue

str

eam

map

pin

g of

the

ho

spita

l dis

char

ge p

lann

ing

pro

cess

incl

udin

g ut

iliza

tion,

com

mun

ity p

artn

ers

and

dis

char

ge

pla

nner

s, a

nd u

se t

o d

rive

pro

cess

imp

rove

men

t

Com

ple

te b

y Ju

ne 2

012

100%

com

ple

te

Dev

elop

a h

osp

ital‐

wid

e p

roce

ss fo

r in

teg

rate

d d

isch

arge

pla

nnin

g/

ALC

des

igna

tion

so a

ll p

roce

sses

are

alig

ned

po

st-a

mal

gam

atio

n

Com

ple

te b

y Ju

ne 2

012

100%

com

ple

te

Dev

elop

an

onlin

e ho

spita

l dis

char

ge s

umm

ary

for

use

in t

he E

D, C

CA

C

and

phy

sici

an’s

offi

ces,

incl

udin

g th

e d

isch

arge

pla

n

Com

ple

te b

y Ja

nuar

y

2013

100%

com

ple

te

taB

le

31:

no

rt

h B

ay

re

gio

na

l h

ea

lth

ce

nt

re

’s c

ha

ng

e p

la

n f

or

alc

re

du

ct

ion


ch

ang

e p

lan

(con

tinue

d)

pla

nn

ed im

pro

vem

ent

init

iati

ves

(ch

ang

e id

eas)

met

ho

ds

and

pro

cess

mea

sure

s

go

al f

or

ch

ang

e

idea

s (2

012

/13)

co

mm

ents

Inte

gra

te d

isch

arge

pla

nnin

g w

ith C

CA

CC

omp

lete

by

June

201

210

0% c

omp

lete

Dev

elop

and

imp

lem

ent

a B

ehav

iour

al R

esp

onse

Tea

m t

o ad

dre

ss

scre

enin

g, t

eam

/fam

ily t

rain

ing

and

pat

ient

dis

char

ge t

o ho

me

and

/or

com

mun

ity

Com

ple

te b

y Ju

ne 2

012

100%

com

ple

teW

e ar

e p

artn

erin

g w

ith

NE

Beh

avio

ural

Sup

-

po

rt O

ntar

io t

o d

evel

op

bas

elin

e an

d p

erfo

rman

ce

mea

sure

s to

eva

luat

e

effe

ctiv

enes

s of

beh

av-

iour

al r

esp

ons

e te

am

Con

tinue

to

exp

and

and

bui

ld u

pon

ISA

RN

umb

er o

f pat

ient

s >

69

year

s ol

d s

een

by

the

So

cial

Wo

rker

/Dis

char

ge

Pla

nner

in E

D

Imp

lem

ent

Sen

iors

’ Men

tal H

ealth

Inte

gra

ted

Ser

vice

s to

exp

edite

pat

ient

s th

roug

h tr

ansi

tion/

pla

cem

ent

to c

om

mun

ity

Com

ple

te b

y Ju

ne 2

012

100%

com

ple

teA

t th

is t

ime

we

have

par

tner

ed w

ith s

imila

r

serv

ices

in S

outh

ern

Ont

ario

to

find

a t

ool

that

mea

sure

s th

e

effe

ctiv

enes

s of

the

serv

ice

and

all

are

stru

ggl

ing .

Ong

oing

wo

rk

to c

olle

ct m

easu

res

as

per

our

Med

ical

Dire

cto

r

with

ong

oing

mon

itorin

g

Use

sec

ured

fun

din

g an

d c

onsu

ltant

to

pre

par

e a

dis

tric

t sp

ecia

lized

geria

tric

ser

vice

s p

lan

to id

entif

y sy

stem

fund

ing

gap

s an

d op

por

tuni

ties

Com

ple

te b

y A

pril

201

2

and

sub

mit

to t

he L

HIN

100%

com

ple

te

Con

tinue

to

exp

and

gen

eral

pra

ctiti

oner

(GP

) rec

ruitm

ent

stra

tegi

esN

umb

er o

f new

GP

s

recr

uite

d

Min

imum

num

ber

= 4

taB

le

31:

no

rt

h B

ay

re

gio

na

l h

ea

lth

ce

nt

re

’s c

ha

ng

e p

la

n f

or

alc

re

du

ct

ion

(CO

NTI

NU

ED

)


ch

ang

e p

lan

(con

tinue

d)

pla

nn

ed im

pro

vem

ent

init

iati

ves

(ch

ang

e id

eas)

met

ho

ds

and

pro

cess

mea

sure

s

go

al f

or

ch

ang

e

idea

s (2

012

/13)

co

mm

ents

Mon

itor

the

use

of t

he D

AS

H t

ool

imp

lem

enta

tion,

ens

urin

g p

atie

nts

are

pla

ced

in t

he r

ight

leve

l of c

are

Per

cent

age

of p

eop

le

pla

ced

into

a L

TC h

ome

who

do

not

have

hig

h o

r

very

hig

h ne

eds

for

LTC

serv

ices

as

mea

sure

d

usin

g th

e M

AP

Le s

core

s

Bas

elin

e: 3

1% (2

009

/10)

Dev

elop

a L

HIN

-wid

e p

olic

y fo

r co

nsis

tenc

y of

LTC

pla

cem

ent

and

acce

ss t

o b

eds

acro

ss L

HIN

if b

eds

are

avai

lab

le e

lsew

here

Com

ple

te b

y M

arch

201

310

0% c

omp

lete

Dev

elop

an

exp

edite

d p

roce

ss t

hat

is b

uilt

on p

red

eter

min

ed in

dic

ato

rs

to e

nab

le a

com

mun

ity r

esp

onse

to

hosp

ital o

ver-

cap

acity

to

enac

t th

e

C1A

des

igna

tion

Com

ple

te b

y M

arch

201

310

0% c

omp

lete

Par

tner

and

targ

et r

etire

men

t hom

e an

d LT

C fa

cilit

ies

with

falls

pre

vent

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Conclusion

This Analysis for Improvement highlighted many of

the successes achieved across quality improvement

domains over 2011/12 and the excellent work that

hospitals put into creating their quality improvement

plans for 2012/13, as required under ECFAA . Many

hospitals developed effective QIPs that identified clear

aims aligned with strategic priorities, included measures

and motivational targets, and provided change plans

that lead towards improvement .

Although a number of hospitals identified bold aims

and innovative ideas for change, others did not set

clear priorities or goals, achievable stretch targets

or comprehensive change ideas . This analysis of the

QIPs is a learning tool that will help all Ontario hospitals

going forward — to share innovative change ideas,

effective strategies and success stories, to communicate

progress achieved and to highlight continued areas for

improvement .

Moving forward, we hope to see greater improvements

in hospitals’ QIPs, which will result in continued improve-

ment and success for hospitals: Patients will experience

and receive better care and better outcomes, and

hospitals will achieve success by providing the right

care in the right place at the right time . In the future,

more detailed change plans, stretch targets and better

data quality will enable HQO to evaluate progress,

broker improvement and catalyze spread .

HQO expects that hospitals will continue to use their

QIPs to drive performance improvement, and to ensure

that they are focusing on key priority areas .

Congratulations to all Ontario hospitals for their continued

efforts this year . Their hard work and commitment to

developing effective QIPs are laying the groundwork for

improved quality across the Ontario healthcare system .


Appendix A: Suite of Capacity-Building Supports

ecfaa (excellent Care for All Act)

hQo strategic roles

• Focus system on common agenda

• Build evidence of knowledge

• Broker improvement

• Catalyze spread

• Evaluate progress

hQo functional roles for capacity Building

• Facilitate

• Dissemination of change ideas, effective

strategies and QI success stories through

using the resources below

resources for capacity Building

hQo Quality improvement map: An online tool created to help hospitals develop their quality improvement

plans . The Quality Improvement Map is a source for best practice change ideas and provides links to recom-

mended resources . See http://www .hqontario .ca/en/ecfaa .html .

2012/13 Quality improvement plans: an analysis for improvement: This report communicates progress

achieved and highlights continued areas for improvement for hospital QIPs .

hQo Qip specialists: The QIP Specialist works with partners and hospitals to support the development of

QIPs . To connect with a QIP specialist, send an email to QIP@hqontario .ca .

hQo’s live web-based learning opportunities: These sessions are facilitated on a variety of improvement

topics . We encourage you to suggest topics of interest for the future . You can join our email list and receive

notification of upcoming events by sending an email to QIP@hqontario .ca .

peer-to-peer Qip feedback: The proposed Plan–Do–Study–Act cycle is set to begin in fall 2012 . HQO is

working with partners to identify opportunities to facilitate regional peer-to-peer QIP feedback sessions .

institute for healthcare improvement (ihi) open school: The school offers a vast array of QI supports

through its website, www .IHI .org . HQO is providing an opportunity to enroll two employees from each hospital

in IHI Open School improvement courses for health professionals, designed for the next generation of leaders .

To enroll, contact us at QIP@hqontario .ca .

mentorship program: The Ontario Hospital Association (OHA) and the Canadian Health Care Risk

Management Network (CHRMN) are offering individuals an opportunity to participate in a Patient Safety,

Quality and Risk Management Mentorship Program . See www .oha .com/SERVICES/PATIENTSAFETY/

Pages/QualityandPatientSafetyMentorshipProgram .aspx .

www.oha.com/SERVICES/PATIENTSAFETY/Pages/QualityandPatientSafetyMentorshipProgram.aspx

www.oha.com/SERVICES/PATIENTSAFETY/Pages/QualityandPatientSafetyMentorshipProgram.aspx


hQo capacity-Building linkages

• hQo integrated program delivery Branch

– access and chronic disease: As part of its work to foster quality improvement capacity in Ontario’s

healthcare system, HQO offers improvement initiatives in Advanced Access, Efficiency and Chronic

Disease Management in Primary Care . See www .hqontario .ca/en/supporting_qi_pc .html .

– bestpath: Quality improvement coaches facilitate health system integration for participating communities .

bestPATH products include evidence-informed best practices for transitions in care targeted to reduce

avoidable rehospitalizations .

– long-term care: Residents First is a provincial quality improvement initiative that supports all Ontario

long-term care homes in providing safe, effective and responsive care to their residents . See

www .hqontario .ca/en/supporting_qi .html .

• hQo evidence development and standards Branch: HQO’s Evidence Development and Standards (EDS)

team works with clinical experts, scientific collaborators and field evaluation partners to conduct evidence-

based analyses to evaluate the effectiveness and cost-effectiveness of health technologies and services in

Ontario . Based on the results of EDS’s evidence-based analyses, the Ontario Health Technology Advisory

Committee (OHTAC) — a standing advisory sub-committee of the HQO Board — makes recommendations

about the uptake, diffusion, distribution or removal of health interventions to Ontario’s Ministry of Health and

Long-Term Care, clinicians, health system leaders and policy-makers . See www .hqontario .ca/en/mas/mas .html .

• hQo health system performance Branch: As part of HQO’s mandate, the health system performance

(HSP) team monitors and reports to the people of Ontario on access to publicly funded health services,

health human resources in publicly funded health services, consumer and population health status and

health system outcomes . The primary vehicles for evaluating progress are the Quality Monitor and the

comprehensive suite of public reporting websites . HSP is also active with other projects related to

primary care performance measurement, benchmarking of key quality indicators, and the development

and alignment of indicators for monitoring and reporting on the quality improvement initiatives supported

by HQO . See www .hqontario .ca/en/framework .html .

other support organizations

• local health integration networks (lhins) plan, fund and integrate health service locally and develop

LHIN-specific Integrated Health Service Plans (IHSPs) . Consequently, the LHIN IHSPs differ from one LHIN

to the next, since each is tailored to local health services needs and priorities . See www .lhins .on .ca .

• professional organizations, including the Ontario Hospital Association, Association of Family Health Teams

Ontario, etc .

• the Quality healthcare network is a community-based, not-for-profit organization with a mission to elevate

system performance through collaborative and innovation means . See www .QHN .ca .

• accreditation canada provides program-specific standards, tools and processes . See www .accreditation .ca .

• the canadian patient safety institute is a national not-for-profit organization that raises awareness and

facilitates implementation of ideas and best practices to achieve a transformation in patient safety . See

www .patientsafetyinstitute .ca/English/Pages/default .aspx .

• the institute for safe medication practices canada is an independent, national not-for-profit organization

committed to the advancement of medication safety in all healthcare settings . See www .ismp-canada .org .


Appendix B: Technical Report

introduction

The purpose of the Technical Report is to provide public

access to details of the process used to generate indicator

results . This information will be useful to others interested

in replicating the indicators presented . Further details

on the process and methods used to select the indicators

on the Health Quality Ontario (HQO) website can be

obtained from HQO .

data sources

The indicator results presented were provided to HQO

by several sources, including the Canadian Institute

for Health Information (CIHI), the Ontario Hospital

Association (OHA) and the Ministry of Health and

Long-Term Care (MOHLTC) .

discharge abstract databases (dad)

DAD is a data collection tool used by CIHI to collect

information on patients treated in acute care facilities .

DAD contains administrative, clinical and demographic

data . CIHI receives data directly from acute care facilities

or from their respective health/regional authority or

ministry/department of health .

ontario mental health reporting system (omhrs)

OMHRS data are sourced from the Resident Assessment

Instrument-Mental Health (RAI-MH), a unique standardized

data collection system for mental health . OMHRS contains

data about individuals admitted to adult mental health

beds in Ontario . The data are collected at admission,

discharge and every three months for patients with

extended stays .

national ambulatory care reporting system (nacrs)

NACRS is a data collection tool developed by CIHI to

capture information on patient visits to hospital- and

community-based ambulatory care facilities . NACRS

data used in this report are collected on a routine basis

by all emergency departments (EDs) in Ontario .

continuing care reporting system (ccrs)

CCRS is a data collection tool developed by CIHI to

capture demographic, clinical, functional and resource

utilization information on individuals receiving continuing

care services in hospitals or residential care facilities

in Canada . Participating organizations also provide

information on facility characteristics to support

comparative reporting and benchmarking .

critical care information system (ccis)

CCIS is a data collection tool developed by MOHLTC to

collect information on admitted ICU patients, interventions

performed to address care needs and the utilization of

critical care response teams .

Web-enabled reporting system (Wers)

WERS is an easy-to-use online tool developed by

MOHLTC for the complete preparation and tracking

of reports prepared by hospitals and other institutional

users .

ontario hospital reporting system (ohrs)

OHRS databases developed by MOHLTC provide the

only integrated source of data on the actual financial

and operational activities of hospitals in the province .

nrc picker/hospital consumer assessment of

healthcare providers and systems (hcaphs)

NRC Picker/HCAPHS uses standardized surveys to

capture patients’ perspectives on the hospital care .

This provides the public with comparable information

on hospital quality .


■ Acute Teaching

■ CCC and Rehab.

■ Large Community

■ Small Community

■ Mental Health

154

58

17

51

figure 1. numBer of hospitals By oha classification (total = 145)

oha classifications

The following are brief descriptions of the five hospital

types used in the current QIP report .

1. acute teaching hospitals

Acute teaching hospitals are defined as those acute

and pediatric hospitals that are members of the Council

of Academic Hospitals of Ontario (CAHO) . Member

hospitals provide highly complex patient care, are

affiliated with a medical or health sciences school and

have significant research activity and postgraduate

training . (Source: www .hospitalreport .ca/downloads/2007/

AC/acute_report_2007 .pdf .)

2. large community hospitals

Large community hospitals encompass those

hospitals not defined as small or teaching . (Source:

www .hospitalreport .ca/downloads/2007/AC/

acute_report_2007 .pdf .)

3. small community hospitals

Small community hospitals are defined according to the

guidelines set by the former Joint Policy and Planning

Committee (JPPC) . In general, these hospitals are

a single community provider and the total inpatient

acute, CCC and day surgery-weighted cases are

under 2,700, based on 2005/06 data . (Source:

www .hospitalreport .ca/downloads/2007/AC/

acute_report_2007 .pdf .)

4. complex continuing care hospitals and

rehabilitation hospitals

Complex continuing care (CCC) hospitals generally

meet the following criteria: (a) do not have acute care

patients; (b) report statistical, clinical and financial

data separately (from other hospitals or facilities) to

MOHLTC; (c) have their own chief executive officer (CEO)

and board; and (d) are physically separate buildings .

(Source: www .hospitalreport .ca/downloads/2007/CCC/

ccc_report_2007 .pdf .)

Rehabilitation hospitals provide rehabilitation in publicly

funded designated adult rehabilitation beds, either in

free-standing specialty inpatient rehabilitation hospitals

or in beds or units designated for rehabilitation purposes

that are part of a general hospital . This type of hospital

does not include rehabilitation in acute care, outpatient

settings or home-based settings . The facilities or units

care for clients with a primary health condition that is

physical in nature — e .g ., stroke, orthopedic conditions,

brain dysfunction, spinal cord dysfunction or amputation .

(Source: www .hospitalreport .ca/downloads/2007/rehab/

rehab_report_2007 .pdf .)

5. mental health hospitals

Mental health hospitals serve individuals with more

complex treatment and behavioural-management needs,

who typically require a longer length of stay . Specialty

hospitals include both dedicated mental health hospitals

and mixed-service hospitals (which also provide acute

care for mental health and other conditions) . Many

specialty facilities are former provincial psychiatric

hospitals . (Source: www .hospitalreport .ca/downloads/

2007/MH/2007_MH_techman .pdf .)

www.hospitalreport.ca/downloads/2007/AC/acute_report_2007.pdf






www.hospitalreport.ca/downloads/2007/CCC/ccc_report_2007.pdf

www.hospitalreport.ca/downloads/2007/CCC/ccc_report_2007.pdf

www.hospitalreport.ca/downloads/2007/rehab/rehab_report_2007.pdf

www.hospitalreport.ca/downloads/2007/rehab/rehab_report_2007.pdf

www.hospitalreport.ca/downloads/2007/MH/2007_MH_techman.pdf

www.hospitalreport.ca/downloads/2007/MH/2007_MH_techman.pdf


attribute indicator numerator denominator data source

safety C. difficile infection (CDI)

rate per 1,000 patient

days

Overall

Acute teaching

Large community

Small community

Chronic/rehabilitation

Mental health

inclusion: The CDI

count is the number of

new nosocomial cases

of CDI by month

exclusion: children

under one year of age

inclusion: The denomi-

nator, patient days data,

should be sourced from

the hospital’s daily bed

census data

exclusion: children

under one year of age

MOHLTC

safety Ventilator-associated

pneumonia (VAP) rate

per 1,000 ventilator days

Overall

Acute teaching

Large community

Small community


Mental health

inclusion: The total

number of newly

diagnosed VAP cases

in the ICU after at least

48 hours of mechanical

ventilation

exclusion: Any patient

with a recorded incident

of VAP within the first two

calendar days of admis-

sion will be excluded

inclusion: The number

of ventilator days in that

month

Ventilator days are the

number of days spent

on a ventilator for all

patients in the ICU

18 years and older

MOHLTC

safety Hand hygiene

compliance before

patient contact

Overall

Acute teaching

Large community

Small community


Mental health

Number of times hand

hygiene performed

before initial patient/

patient environment

contact by hospital type

Number of observed

hand hygiene indications

before initial patient/

patient environment

contact by hospital type

MOHLTC

safety Rate of central line

associated blood stream

infections (CLI) per 1,000

central line days

Overall

Acute teaching

Large community

Small community


Mental health

inclusion: Total number

of newly diagnosed

CLI cases in the ICU after

at least 48 hours of

receiving a central line

exclusion: Any patient

admitted to the unit with

an existing CLI

The number of central

line days in that month,

multiplied by 1,000

Central line days are the

total number of days a

central line was used in

ICU patients 18 years

and older

MOHLTC

taBle 1: technical information on indicator definitions



safety Percentage of CCC

residents with new

pressure ulcer in the last

three months (stage 2

or higher)

Overall

Acute teaching

Large community

Small community


Mental health

inclusion: If any of the

following apply:

• M1b>0 on the target

assessment

• M1c>0 on the target

assessment

• M1d>0 on the target

assessment

inclusion: All assess-

ments for chronic patients

in fiscal 2011/12 that

meet general inclusion/

exclusion criteria for

incidence indicators

exclusion: If any of

the following apply:

M1b>0 on prior

assessment

M1c>0 on prior

assessment

M1d>0 on prior

assessment

M1b, M1c or M1d is

missing on the prior

assessment

M1b, M1c or M1d is

missing on the target

assessment

CCRS, CIHI

safety Percentage of CC

residents who fell in

the last 30 days

Overall

Acute teaching

Large community

Small community


Mental health

inclusion: If J4a=1 (fell

in past 30 days) on the

target assessment

inclusion: All assess-

ments for chronic

patients in FY 2011/12

that meet general

inclusion/exclusion

criteria

exclusion: J4a is

missing on the target

assessment

CCRS, CIHI

safety Surgical safety checklist

compliance

Overall

Acute teaching

Large community

Small community


Mental health

Number of times all

three phases of the

surgical safety checklist

were performed

Total number of surgeries MOHLTC

taBle 1: technical information on indicator definitions (CONTINUED)



safety Physical restraints in

mental health

Number of patients who

are physically restrained

at least one of the three

days prior to a full

admission

Total number of cases

with a full admission

assessment

OMHRS, CIHI

effectiveness Hospital standardized

mortality ratio (HSMR)

Overall

Acute teaching

Large community

Small community


Mental health

Observed deaths or

actual number of

in-hospital deaths that

occurred

Expected deaths or

number of deaths that

would have occurred

in a hospital had the

mortality of these

patients been the

same as the mortality

of similar patients across

the country, based on

the reference year

inclusion:

1 . Discharge between

April 1 of a given year

and March 31 of the

following year

2 . Admission to an acute

care institution

3 . Discharge with

diagnosis group of

interest (i .e ., one of

the diagnosis groups

that account for

approximately 80%

of in-hospital deaths)

4 . Age at admission

between 0 and

120 years

5 . Sex recorded as male

or female

6 . Length of stay up to

365 consecutive days

7 . Admission category is

elective or emergent/

urgent

8 . Canadian resident

DAD, CIHI




effectiveness Hospital standardized

mortality ratio (HSMR)

Overall

Acute teaching

Large community

Small community


Mental health

(continued)

exclusion:

1 . Cadavers

2 . Stillborns

3 . Sign-outs (that is,

discharged against

medical advice)

4 . Neonates (age of

admission less than

or equal to 28 days)

5 . Records with brain

death as most

responsible diagnosis

code

6 . Records with palliative

care as most respon-

sible diagnosis code

effectiveness Total margin

(consolidated)

Overall

Acute teaching

Large community

Small community


Mental health

Percentage by which total corporate (consolidated)

revenues exceed or fall short of total corporate

(consolidated) expenses, excluding the impact of

facility amortization, in a given year

OHRS, MOHLTC

access ER wait times: 90th

percentile ED length

of stay for admitted

patients

Overall

Acute teaching

Large community

Small community


Mental health

90th percentile ED length of stay for admitted

patients .

ED length of stay is defined as the time from triage

to registration, whichever comes first, to the time

the patient leaves the ED

NACRS, CIHI




patient-

centred

Would you recommend

this hospital to your

friends and family?

Overall, how would

you rate the care and

services you received

at the hospital?

Overall

Acute teaching

Large community

Small community


Mental health

Number of respondents

who responded “Yes,

definitely” (NRC Picker)

or “Definitely yes”

(HCAHPS) to the

question


who responded

“Excellent, very good

and good” (NRC Picker)


who registered any

response to this

question (exclude

non-respondents)


who registered any

response to this

question (exclude

non-respondents)

NRC Picker/

HCAPHS

integrated Readmission within

30 days for selected

CMGs to any facility

Overall

Acute teaching

Large community

Small community


Mental health

The sum of readmis-

sions for all index

cases

inclusion: Select all

discharges among the

selected CMGs with

discharge dates for

period in question and

age restrictions as

described in Inclusions

section . Include only

typical and outlier cases

(based on DAD RIW

exclusion indicator)

among the index cases

Acute inpatients in the

specified CMGs, age

restrictions are cohort

specific

The readmission

hospitalization is

deemed non-elective

or unplanned if:

a) the admission date is

within 30 days of the

index case discharge

date

DAD, CIHI




integrated Readmission within

30 days for selected

CMGs to any facility

Overall

Acute teaching

Large community

Small community


Mental health

(continued)

b) the DAD field

“admission category”

is urgent

exclusion: Deaths,

transfers, patient sign-

outs against medical

advice, records with

missing valid data on

discharge/admission

date, health number,

age, gender

integrated Percentage of alternate

level of care (ALC) days

Overall

Acute teaching

Large community

Small community


Mental health

Total bed days

designated as ALC

inclusion: Total inpatient

days in the year

exclusion: Invalid or

missing discharge date

from hospital, newborns,

stillborns

DAD, CIHI



taBle 2: freQuency With Which a topic Was chosen as priority 1, for different types

of hospitals

priority 1

acute teaching

ccc and rehab

large community

small community

mental health

province

cdi rate per 1,000 patient

days

4 3 15 8 0 30

ed wait times for admitted

patients

0 0 1 0 0 1

falls 0 0 1 0 0 1

hand hygiene compliance

before patient contact

0 2 3 5 0 10

hsmr 0 3 3 6 0 12

nrc picker/hcaphs or

in-house survey (if available)

2 0 2 4 0 8

percentage alc days 0 2 1 2 3 8

pressure ulcers 2 0 4 0 0 6

rate of central line blood

stream infections per 1,000

central line days

5 8 24 24 1 62

readmission within 30 days

for selected cmgs to any

facility

7 0 37 10 0 54

total margin (consolidated) 0 0 1 0 0 1

vap rate per 1,000 ventilator

days

4 6 25 21 3 59


taBle 3: freQuency With Which a topic Was chosen as any priority (1, 2 or 3) for different

types of hospitals

any priority

acute teaching

ccc and rehab

large community

small community

mental health

province

cdi rate per 1,000 patient

days

11 12 34 34 0 91

ed wait times for admitted

patients

7 0 25 6 0 38

falls 8 0 24 6 0 38

hand hygiene compliance

before patient contact

2 8 15 19 0 44

hsmr 1 7 14 18 0 40

nrc picker/hcaphs or

in-house survey (if available)

10 0 28 22 0 60

percentage alc days 1 4 16 5 4 30

pressure ulcers 8 0 30 3 0 41

rate of central line blood

stream infections per 1,000

central line days

13 15 37 52 4 121

readmission within 30 days

for selected cmgs to any

facility

10 0 50 36 1 97

total margin (consolidated) 10 0 48 35 1 94

vap rate per 1,000 ventilator

days

0 0 2 1 0 3

www.hqontario.ca

Health Quality Ontario

130 Bloor Street West, 10th Floor

Toronto, ON M5S 1N5

Tel: 416-323-6868 | 1-866-623-6868

Fax: 416-323-9261

ISBN 978-1-4606-0271-3 (Print)

ISBN 978-1-4606-0272-0 (PDF)

© Queen’s Printer for Ontario, 2012

www.hqontario.ca

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