qip 17/18 - medication reconciliation · qip 17/18 - medication reconciliation aim measure quality...

QIP 17/18 - Medication Reconciliation

AIM MEASURE

Quality dimension Objective Indicator

Current performance

Target for 2017/18

Target justification

Safe Medication Reconciliation on Admission Medication reconciliation is a formal process in which healthcare providers work together with patients to ensure accurate and comprehensive medication information is communicated consistently across transitions of care.

The total number of patients with medications reconciled on admission as a proportion of the total number of patients admitted to the hospital as measured by hospital’s electronic medication reconciliation system (“eMedRec”).

83%

(Q2 2015/16)

≥87%

By March

31, 2018

This is a multi-year plan of 4% annual increases working towards all patients having medication reconciliation on admission as per Accreditation Canada’s future target (this will apply to Sunnybrook’s next Accreditation in 2021).

CHANGE

Planned Improvement Initiatives (Change Ideas)

Methods

Process Measures Goal for Change Ideas

Implement the new electronic Medication

Reconciliation system. Final approval of

implementation plan (including rollout

schedule) expected February 2017.

The Medication Reconciliation Lead(s) will

implement and monitor the implementation

plan and report progress monthly to the

Medication Reconciliation Steering Committee.

Implementation of

electronic Medication

Reconciliation.

May 2017

Design and implement Medication

Reconciliation education in an e-learning

format for medication prescribers. Note:

pharmacy staff have already completed this

education.

The Medication Reconciliation Lead(s) will

monitor implementation and report progress

monthly to the Medication Reconciliation

Steering Committee. E-learning modules will be

developed for prescribers by April 2017.

% of required staff who

complete the e-learning

module

90% of prescribers (as per

Medication Reconciliation policy)

on required units will have

successfully completed the e-

learning module by September

30 2017. Collaborate with patients to enhance the

patient friendliness of the discharge

medication lists.

Medication Reconciliation Lead(s) will partner

with patients to enhance the design of the

discharge medication lists and report progress to

Medication Reconciliation Steering Committee.

Number of patients

whose input was

sought.

A minimum of 30 patients will be

consulted on the design of future

discharge medication lists by

March 31, 2018.

QIP 17/18 – Workplace Violence Prevention

AIM MEASURE


Current performance

Target for 2017/18 Target

justification Comments

Safe

Reduce harm to staff

Percentage of staff (permanent full-time & part-time) who receives new combined Code White/ Workplace Violence Prevention Training.

70% 80% by March 31, 2018

Definition: Numerator: Staff who completed training (measured in Sunnybrook’s on-line Learning Management System). Denominator: Count of permanent full-time and part-time staff as of April 1, 2017.

This is an ambitious target since the training will be implemented organization-wide and it is a new program however it is a key priority for the hospital.

This will be a new combined program; Code White and Workplace Violence Prevention Training are currently provided separately.

CHANGE Change Ideas Methods Process Measures Goal for Change Ideas

Create and implement New Code White/ Workplace

Violence Prevention training

• Combine Code White, Occupational Health’s Workplace Violence Prevention and Human Resources’ Bullying courses into one by end of February 2017

• Design program for easy adoption (≈ 30 minutes, on-line in Sunnybrook’s Learning Management System (LMS))

• Implement broad communication strategies to ensure leaders and staff awareness

• Provide compliance rates to managers for regular tracking and follow-up

Occupational Health and Safety will report

to Managers and the Occupational Health

and Safety Committee monthly and to the

Responsive Behaviour Working Group

quarterly on progress.

Percentage of staff (full-time

and part-time) that complete

the New Code White/

Workplace Violence Prevention

training.

Denominator: Count of

permanent full-time and part-

time staff as of April 1, 2017.

80% by March 31, 2018


Continue to provide Crisis Intervention Education

• Determine consistent educational content

requirements

• Develop an education schedule by April, 2017 for the

period April 2017 to March 2018

• Monitor staff attendance via the Learning

Management System (especially for staff in high-risk

areas).

• Develop and maintain a Trainer list • Develop process for room booking, education

materials management, funding requirements, etc.

The Responsive Behaviour Working Group

will provide guidance regarding staff

educational requirements.

The Emergency Preparedness Team will

report to the Responsive Behaviour

Working Group quarterly on the progress

of all other initiatives (all to be developed

by April 2017)

Percentage of full-time/part-

time staff* in high risk areas**

that attend a Crisis Intervention

education session.

*Registered nurses,

physiotherapists, occupational

therapists, Patient Service

Partners, Environmental

Services Partners (full-time only)

assigned on a regular basis to

high risk areas.

**High Risk Areas are the

Emergency Department,

Veterans Centre and Units C5,

D5 and F2.

70% full-time/part-time staff in

high risk areas attend a Crisis

Intervention education session

by March 31, 2018

Denominator: Count of

permanent full-time and part-

time staff* in high risk areas as

of April 1, 2017.

Implement a new standardized debrief processes for all

high risk incidents.

Process will include:

Criteria for a debrief

What the debrief process is

Who is involved

What is the follow up

What information is shared and with whom

Definition of a high risk incident is an incident in which a

weapon, attempted strangulation and/or verbal death

threat has occurred or serious physical injury that has left

an individual from doing the full capacity of their duties

for a given period of time or on a permanent basis.

The Occupational Health Team will report

progress to the Emergency Response

Committee and the Occupational Health

and Safety Committee bi-monthly and to

the Responsive Behaviour Working Group

quarterly on progress.

All recommendations from using the

debriefing tool will be shared with

appropriate teams that in turn will be

required to complete the

recommendations. Recommendation will

also be shared with the Vice President,

Human Resources and senior leadership.

Debrief process and tools

developed

Education rolled out

% High risk incidents in Q4 with

a debrief

June 2017 - Debrief process and

tools developed

August 2017 - implementation

and education begins

By December 2017 - 70% leaders

in high risk areas receive

education

January to March 2018 - 70% of

high risk incidents will have a

debrief. A higher target will be

set for 2018/19.


Augment and standardize Risk Identification, Care

Planning and Communication processes

Assess current risk identification, care planning &

communication processes when a patient is

transferred in order recommended changes to

ensure continuity of care planning for applicable

patients

Implement recommended changes

The Responsive Behaviour Working Group

will report progress to Professional Practice

Committee bi-annually and to the Violence

Prevention Committee quarterly

Risk identification, care planning

and communication process

revised as required

Revised risk identification, care

planning and communication

processes revised by December

2017 and implementation begun

in 2-3 units by March 2018.

Report on progress of all initiatives and number of incidents resulting in harm to staff that occur as a result of responsive behaviour* in high risk areas: Emergency Department, Veterans Centre and units C5, D5 and, F2.

*Responsive behaviour is defined as actions, words and/or gestures that can be exhibited as a consequence of:

Illness

Response to an unmet need/concern

Physical/environmental trigger

The Responsive Behaviour Working Group will report progress to the Interprofessional Quality Committee quarterly.

Reduce the number of incidents resulting in harm to staff that occur as a result of responsive behaviour in high risk areas.

Baseline: 11 (2015/16)

Target: ≤ 8 (2017/18)

QIP 17/18 – Surgical Site Infection Gynaecology-Oncology

AIM MEASURE


Current performance

Target for 2017/18 Target justification Comments

Safe Reduce Surgical Site Infections (SSI) post Gynaecology-Oncology procedures.

Proportion of patients undergoing Gynaecology-Oncology surgery who develop a Surgical Site Infection.

Jan-March 2016 Surgical Site Infection rate for the sample Gynaecology-Oncology cases (NSQIP population) was 10% (Risk adjusted).

Target Surgical Site Infection rate is 8%.

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) National benchmark & literature review

NSQIP Data will be provided on a quarterly basis as follow:

Q1 17/18 data will be provided on Sep 18, 2017

Q2 17/18 data will be provided on Dec 18, 2017

Q3 17/18 data will be provided on March 19th, 2018

Q4 17/18 data will be provided on June 18

th, 2018

CHANGE

Change Ideas Methods Process Measures Goal for change

ideas Establish Gynaecology-Oncology Surgical Site Infection task force. This team will meet

monthly in order to implement changes and monitor performance.

Meet with all stakeholders and identify champions. Assign tasks after identifying

change ideas for implementation.

Surgeon-in-Chief and Manager, Surgical

Performance Improvement will oversee

establishment of Task Force.

Gynaecology-Oncology Surgical Site Infection task force established.

Task Force established by April 1, 2017, execute role in project oversight and meet monthly April – March 2017/18.

Improve rates of Normothermia during operation. Keeping the patient’s body

temperature > 36 degrees during operation helps to reduce surgical site infections.

A new policy and guideline is under development which guides staff to implement

various measures pre-operatively and intra-operatively in order to keep the body

temperature >36 degrees such as; pre-operative warming in Same Day Surgery area,

use of intra-operative warming blanket and use of warm fluid during operation.

Patient temperature will be recorded and monitored through the operating room information management (PICIS) system at the end of procedure. This data will be reported to Gynaecology-Oncology Surgical Site Infection task force on a regular basis.

Percentage of patients with >36 degree temperature at the end of their operative procedures.

90% of patients have >36 degree temperature at the end of procedure.

CHANGE

Change Ideas Methods Process Measures Goal for change

ideas Pre-operative shower with Chlorhexidine 4% applied twice (for elective patients) via patient education in pre-assessment clinic All elective patients will be instructed to use CHG 4% body shampoo as their pre-operative wash the night before and the morning of surgery. Patient education pamphlet will be provided to patients in the Pre Assessment Clinic (PAC) area. Patient education material will be co-designed with patients.

Compliance will be monitored through chart audit (documented in pre-op checklist by nurses). This data will be reported to Gynaecology-Oncology Surgical Site Infection task force on a regular basis.

Percentage compliance with pre-operative shower with Chlorhexidine 4% applied twice (for elective patients).

90% compliance by March 31, 2017.

Use of wound protector intra-operatively. (A wound protector is a shield used during

operation that provides hands free retraction and maintains moisture at the incision

site. It can also reduce superficial surgical site infections.)

Compliance will be monitored through PICIS. This data will be reported to Gynaecology-Oncology Surgical Site Infection task force on a regular basis.

Wound protector use gynaecology-oncology cases.


Use of Antibiotic impregnated sutures: A new antibiotic suture will be introduced to

gynaecology-oncology services for all laparotomy cases. The product will be available in

Operating Room.

Compliance will be monitored through Operating Room Supply (PICK) List. This data will be reported to Gynaecology-Oncology Surgical Site Infection task force on a regular basis.

Compliance in usage of sutures on appropriate cases

50% compliance in usage of sutures on appropriate cases by March 31, 2017.

Introduce a separate closing tray in the Operating Room: Provide a separate sterile tray

for closure at the end of the case. This tray will be opened at the end of the case and

eliminate contamination with used/dirty equipment.

Compliance will be monitored through Operating Room audits. This data will be reported to Gynaecology-Oncology Surgical Site Infection task force on a regular basis.

Compliance with use of separate closing tray for each case.


Enhanced compliance with antibiotic re-dosing (re-dosing to be done after 4 hours

when applicable).

Antibiotic re-dosing will be monitored through PICIS and anaesthetic documentation. This data will be reported to Gynaecology-Oncology Surgical Site Infection task force on a regular basis.

Compliance with proper antibiotic re-dosing.

95% compliance with proper antibiotic re-dosing.

QIP 17/18: Post-Surgical Urinary Tract Infection

AIM MEASURE

Quality dimension Objective Indicator Current performance Target for 2017/18 Target justification

Safe

Reduce surgical

patient urinary

tract infections

(UTI)

Proportion of surgical patients with

UTI (based on Centers for Disease

Control and Prevention/ National

Healthcare Safety Network

(CDC/NHSN) definition), calculated

from independent chart abstractor

from the American College of

Surgeons National Surgical Quality

Improvement Program (NSQIP),

including two new subspecialties

(spine and gynecological oncology).

1.9%

Apr-2015 - Mar 2016

≤ 1.4%

By March 31, 2018

In a consecutive three

month period in

2017/18.

Best evidence suggests that at least

50% of healthcare-associated UTI is

preventable. This improvement

would result in Sunnybrook moving

from 5th

decile to the 3rd decile

compared to cohort of over 500

North American hospitals.

CHANGE


Methods Process Measures Goal for Change Ideas

Revise and improve compliance with the ‘Removal of

Urinary Catheter’ Medical Directive.

A medical directive was implemented in 2015 that

requires nurses on surgical units to remove urinary

catheters on post-operative day 2. This medical

directive was associated with a significant reduction

in urinary catheter utilization; however, several

opportunities for improvement exist. Audits have

demonstrated variable adherence. Revision of

medical directive is planned to improve clarity

around use of alternate strategies to avoid urinary

catheter use. By reducing indwelling urinary catheter

use, we expect to see a reduction in surgical UTI.

The medical directive is being revised for use

by all surgical staff. The advanced practice

nursing group will provide re-training of

nurses. Each unit’s advanced practice nurse

will be responsible for monthly data

collection. Analysis will be performed by the

Manager, Surgical Performance

Improvement, Department of Surgery and the

Clinical Associate, Infectious Diseases. Results

will be reported to Catheter Associated

Urinary Tract Infection (CAUTI) prevention

committee on quarterly basis.

Proportion of urinary catheters with

appropriate indication on surgical units

based on weekly random audits.

Urinary catheter days per patient days

calculated from the nursing workload

measurement system (INFOR) – a

validated catheter surveillance tool.

Aim is for 90% appropriateness of

urinary catheters on surgical units

Reduction of urinary catheter days

per patient days below 10%

(baseline is 15%).

CHANGE


Methods Process Measures Goal for Change Ideas

Implement new patient education materials so patients can make better-informed decisions.

A patient education tool has been developed for

inpatient units to facilitate nurses discussing the risks

of urinary catheters and promote their removal

based on the medical directive.

Patient education materials will be created by

a Patient Care Manager and Manager,

Surgical Performance Improvement. Results

will be reported to the corporate CAUTI

prevention committee.

Survey of nurses and patients/families

will be performed to get feedback on

education materials and identify

potential barriers to avoidance of urinary

catheters on inpatient units.

Aim is to address any deficiencies

in patient education tool and

barriers to avoidance of use of

urinary catheters, by December,

2017.

Implement new guidelines in the Emergency Department. New guidelines specifying appropriate indications for

urinary catheter insertions in the Emergency

Department are being launched. All staff will be

trained and resources provided to promote

alternative methods (e.g. Condom catheters,

commodes, urinals, bedpans). This change idea is

expected to result in decreased catheterization

among patients transferred to inpatient units, which

is the main risk factor for developing a UTI.

This initiative is being led by the Chief of the

Emergency Department, the Emergency

Department Educator along with the Clinical

Associate, Infectious Diseases and the

Coordinator, Infection Prevention and

Control. Data collection will be performed by

Infection Prevention & Control (IPAC) and a

medical resident supervised by the Clinical

Associate, Infectious Diseases. Results will be

reported to the corporate CAUTI prevention

committee on quarterly basis.

Proportion of urinary catheter insertions

with appropriate indication in the

Emergency Department.

Urinary catheter days per patient days

calculated from the workload

measurement system (GRASP) – a

validated catheter surveillance tool.

Aim is 90% appropriateness of

urinary catheter insertions in the

Emergency Department (baseline is

30%).

Aim is for reduction in inpatient

catheter-days per patient days to

below 10%.

Implement a new laboratory process to reduce over-diagnosis of UTIs. Ascertainment bias related to overutilization of urine cultures is a contributor to increased UTI rates. A laboratory-based intervention is planned to reduce the number of urine cultures processed from the inpatient units.

This initiative is a collaborative between the

Microbiology Laboratory and IPAC. A research

fellow will be leading this change initiative

with supervision by the Clinical Associate,

Infectious Diseases. Results will be reported

to the CAUTI prevention committee and

Choosing Wisely committee on quarterly

basis.

Number of urine cultures ordered and

processed monthly on surgical units.

Number of positive urine cultures

monthly on surgical units.

Aim is to reduce monthly urine

cultures processed on surgical units

by 50%.

Aim is to reduce number of positive

urine cultures monthly on surgical

units by 50%.

QIP 17/18 – Discharge Summaries

AIM MEASURE


Current performance

Target for 2017/18


Effective Increase completion

of Discharge

Summaries within 48

hours of discharge

from hospital.

Number of discharge summaries

completed within 48 hours

divided by the total number of

discharges completed for all

services.

45%

Average June 1, 2015

– November 30, 2016

≥75%

Averaged over two

consecutive months

before March 31st

,

2018

The target was established by the Medical Advisory Committee to significantly increase (66% increase over baseline) the rate at which patients’ primary care physicians receive discharge summaries in a timely way to enable appropriate follow up care .


Provide physician specific data on completion of Discharge Summaries to Department Chiefs for follow up with individual physicians within their team to address any performance below target. Review and discuss results and best practices leading to improved performance at Medical Advisory Committee on a monthly basis.

Medical Affairs Office, in collaboration with the Health Data Records, sends data to Department Chiefs monthly. Department Chiefs follow up with individual physicians within their department. Executive Vice President and Medical Affairs Office will schedule these activities into Medical Advisory Committee agendas.

% of departments that review and follow-up on their data regularly

100% of departments review and follow-up on their data regularly

Explore use of technology (for example: forcing functions or electronic prompts) to improve compliance rates. Report to the Medical Advisory Committee for feedback on any new information technology enhancements identified.

Executive Vice President and Chief Medical Executive, Vice president Corporate Strategy, Medical Leaders and Information Services will work collaboratively to identify use of technology to improve compliance.

Implement information technology enhancements.

Implement information technology enhancements, if appropriate, by September 30, 2017.

Provide all residents with training in discharge summary

completion as part of their orientation and include tips for

completion.

Sunnybrook Education Office will include training in the

orientation sessions for residents and fellows held throughout

the year.

% completion of training

module

100% of residents and fellows

complete training module

Analyze our performance with that of peer hospitals and

identify opportunities for improvement.

Medical Affairs Office will obtain data from the Toronto Central

Local Health Integration Network (TCLHIN) and share with

Medical Advisory Committee. Data and best practices will be

shared at Medical Advisory Committee.

Data and best practices

shared at Medical Advisory

Committee.

Set goal to improve

performance related to peers

by June 30, 2017. Implement

improvement plan July 1, 2017

– March 31, 2018.


Engage a sample of patients and families and primary care

providers on the post-discharge visit in primary care to find

out if they had their hospital discharge summary in a timely

manner and the information required about their hospital

admission. Review feedback by December 31, 2017 and

identify best practices in patient centred discharge summary

content and transmission and implement where possible prior

to March 31, 2018

Executive Vice President and Chief Medical Executive will

oversee this activity and will report results to Medical Advisory

Committee.

% of sampled patients who

felt their primary care

physician had the information

they needed from

Sunnybrook to continue their

care

% of primary care physicians

sampled who reported that

the content and timeliness of

Discharge Summaries was

satisfactory.

Goal: Minimum 75%

Goal: Minimum 75%

Review and update Medical Advisory Committee policy to

reflect the need for discharge summaries to be completed for

all inpatients within 48 hours.

Executive Vice President and Chief Medical Executive and

Medical Affairs Office will oversee this activity and will report

results to Medical Advisory Committee.

Policy updated Policy updated by June 2017.

QIP 17/18 – Senior Friendly Care: Delirium

AIM MEASURE


Current performance

Target for 2017/18

Target justification Comments

Effective Reduce the incidence of delirium*. Sunnybrook has a multi-year plan to achieve this and this year we are re-focusing on accurate identification & documentation of delirium. *Delirium can be defined as a sudden onset of confusion during a hospital stay possibly due to infection, severe or chronic illness, age, dehydration, or a combination of these and/or other factors. By addressing factors related to delirium as early as possible, we can help prevent and minimize any symptoms and associated complications.

% of patients who have delirium recorded in their health record.

Criteria for

documentation of

delirium: Health

Data Records staff

locate

documentation of

diagnosis in

Discharge Summary

section of the health

record as well as

documentation of

delirium through

patient’s stay.

6.4% of patients on specified units** have delirium recorded in their health record. (**Six units in Oncology, Trauma & Cardiology programs over 2015/16. Collected by Decision Support. Unit rates were: 7E (1%), C6 (4%), ED (5%), C2 (8.7%), D5 (9.5%) & D3 (10.1%)).

10.4% average in selected units from three Programs

This increase is a stretch target as the literature suggests a range of 15-40% of patients experience delirium over the course of hospitalization. Results of a Sunnybrook chart audit using a validated tool are aligned with these findings (2013/14 chart review found delirium rates of 32-44% in General Medicine and 26-34% in Trauma & Cardiology).

The Overall delirium plan is to reduce the incidence of delirium using a multi-year approach:

Phase 1 (2015/16): Compliance with assessment for delirium

Phase 2 (2016 /17 & 2017/18): Accurate identification & documentation of delirium

Phase 3: (2018/19): Measure a reduction in the incidence of delirium through success in phases 1 and 2 enabling interventions to be provided in a timely manner.

Selected units for 2017/18 to be confirmed in consultation with Operations Directors and if necessary target will be adjusted accordingly.

CHANGE Planned Improvement Initiatives

(Change Ideas) Methods Process Measures Goal for Change Ideas

Implement 9-week education program (to increase the accurate detection and documentation of delirium) across three programs addressing:

Use of the Confusion Assessment method (CAM) – a delirium

screening tool

Assessment timing

Interprofessional team dialogue

Family input

Physician engagement

Senior Friendly Team will implement education and report on status to involved Program Councils quarterly.

Proportion of inpatient records where the presence of delirium has been identified by the clinical team and where delirium is recorded in the physician Progress Notes. This will be measured within the 9-week period of the education program.

20% increase in physician documentation reflecting presence of delirium. Baseline data to be collected at the onset of the education program on each unit.

Implement strategies to prevent/ mitigate delirium and manage behavioural symptoms via knowledge to practice, in-the-moment education addressing:

The identification of delirium and appropriate use of diagnostic tests

Use of CHASM protocols (cognition, hydration, agitation, sleep & mobilization) to prevent and mitigate delirium

Antipsychotic drug oversight (ensuring optimal medications in place)

Person-Centred language (ensuring staff use neutral language when describing symptoms)

Senior Friendly Team will implement and report on status to involved Program Councils quarterly.

Proportion of patients with delirium who had interventions documented.

20% increase in documented interventions

Standardize delirium investigation and management via the use of a Delirium Order Set by residents, physicians and nurse practitioners. (Order Sets are sophisticated medical checklists that offer evidence-based treatment options in a single place.)

Senior Friendly Team will monitor the use of Order Sets on target units and report status to involved Program Councils quarterly.

Proportion of patients with delirium who had the Delirium Order Set completed.

>70% of patients with delirium have a Delirium Order Set completed. This will be measured two months after the Order Sets are implemented.

Develop five Senior Friendly E-Learning modules with input from patients and family partners to be delivered via Learning Management System as a mechanism to educate staff and sustain knowledge across three programs.

Senior Friendly Team and Organizational Development will co-develop the modules, reporting progress to the Senior Friendly Working Group quarterly.

# of Learning Modules developed % of staff completing the modules

Five Learning Modules are developed by September 2017. 20% of staff on 2 units complete the modules.

Develop corporate structure for Senior Friendly work at Sunnybrook. Develop an inventory of Senior Friendly work across the hospital, create communication structure to improve awareness and celebrate range and scope of work.

Senior Friendly Working group will develop corporate structure and report semi-annually to the Interprofessional Quality Committee

Develop and implement corporate structure.

Completed by December 31, 2017.

QIP 17/18 – Repatriation

AIM MEASURE


Current performance

Target for 2017/18


Comments

Timely Build capacity to ensure

access for patients with Life

or limb threatening

conditions, Trauma and

Burns. Repatriation (transferring a

patient to another hospital)

is increasingly recognized as

an important part of a well-

functioning health care

system. This indicator builds on the

16/17 QIP Repatriation plan,

but now includes additional

patient services and clinical

groupings.

Total number of

successfully repatriated

patients (including but not

limited to ‘Life or Limb’*,

Stroke and Trauma patients

and other relevant clinical

services). *’Life or Limb’ means

patients with conditions

that potentially cause loss

of life or limb if not

managed in a timely

manner, and can only be

cared for at certain

hospitals due to the nature

of the care they require

and/or the complexity and

severity of their condition.

[Source: Ministry of Health

and Long-Term Care

Provincial Life or Limb

Policy December 2013]

615 2016/2017

(Projected based

on April 1, 2016 –

Jan 20, 2017 data)

665 by March 31,

2018

The target is to

increase

repatriations by 50

patients in one

year. Target is a

stretch

improvement over

baseline

performance.

Patient feedback on

the QIP included

the following: “This

is a worthy goal. In

view of the fact

that some patients

come from far

beyond

Sunnybrook’s

catchment area,

the travel and

parking costs can

be a financial

burden for some

families.

Repatriation may

also lighten the

emotional burden

on patients if they

know their families

are close by.”

CHANGE

Planned improvement initiatives (Change Ideas) Methods Process Measures Goal for change ideas

Develop a process to improve communication with physicians and staff of patients eligible for repatriation under their care on a weekly basis. Ensure physicians are then appropriately contacting Repatriation desk (which organizes the transfer to the local hospital).

Program Chief, Trauma Emergency and Critical Care program (TECC), will work with implementation team to achieve this change and will report monthly at QIP meeting.

Average number of days from admission to contacting Repatriation Desk for successfully repatriated patients.

Baseline (April – Oct 2016):

9.3 days

Target (17/18): 8.4 days

Explore information technology solution to flag, notify and report on patients eligible for repatriation, to raise awareness among the interprofessional team.

Program Chief and Operations Director of TECC will lead this work. It will be reported to and facilitated through the Occupancy Executive Committee.

% of patients that have been successfully repatriated from total potential repatriation patients (excluding deaths).

Baseline (April-Oct 2016):

43% patients (360/845 cases)

Target (17/18): 50% patients

(724/1,449 cases)

Reduce length of stay after repatriation desk is called, by enhancing processes for transfers to patients’ local hospitals.

Manager of Patient Flow will continue to lead this work and refine escalation processes as required.

Average number of days from contacting Repatriation Desk until Discharge.

Baseline (April-Oct 2016): 2.8

days

Target (17/18): 2.5 days

Consult patients to identify new ideas for improving transfers.

Co-design an intervention with patients/families on the

Community Partnership Initiative patient/family advisory

committee to enhance awareness, understanding and/or processes

of repatriation.

Operations Director TECC will table repatriation at the September 2017 Community Partnership Initiative meeting (this meeting is scheduled for discussion of flow and occupancy issues). Feedback from this meeting will be incorporated in the October QIP meeting

Process measure to be determined based on intervention selected.

Target will be developed by November 2017 based on intervention identified

Optimize patient/family and Sunnybrook staff awareness of repatriation

Create task group of clinical leadership, Community and Stakeholder

Relations staff and patients/families to improve communication

about repatriation.

Develop pictographic postcards to provide general information to

patients/families regarding the reasons and process for repatriation

Enable staff to better communicate with patients/ families about

Sunnybrook’s role as a speciality hospital in Ontario and why that

impacts our need to repatriate certain patients

Operations Director TECC will create task group by May 2017. This group will assess status of information dissemination and discuss strategies for improvement. This information will be shared at the June QIP meeting.

Additional repatriation resources developed (as needed). Communication strategies implemented. Processes developed and implemented.

By June 30, 2017. By October 1, 2017. By December 31, 2017.

Sunnybrook and St. Mike’s Hospital, the two level one (the most highly specialized) trauma centres in the Greater Toronto area, are working together to establish partnership agreements with other hospitals to improve repatriation by creating a health system approach for the repatriation patient population similar to that for the Trauma patient population.

The Manager of Trauma Services will report on this at QIP meetings in April and September 2017.

Create partnership agreement(s) with 3 – 5 hospitals to address the need to transfer patients in an agreeable time frame. Number of repatriated trauma patients.

Negotiation and process to be started by Oct 1, 2017. April/2016 to March/2017: projecting to repatriate 15 Trauma patients By March 31, 2018, we plan to repatriate 20-25 trauma patients.

QIP 17/18 – Emergency Department Length of stay for Non-admitted patients

AIM MEASURE

Quality dimension Objective Indicator Current performance Target for 2017/18 Target justification

Timely Reduce length of stay for non-admitted patients in the Emergency Department.

90th percentile Length of Stay all Non- Admitted patients

8.5 hours

2016/17 year to date at November 6, 2016.

7.7 hours

by Q4 2017/18

Since the target was not met last year, we are keeping it the same. It equals an improvement of approximately 10%.


Physician Initial Assessment Work with the University of Toronto Department of Industrial Engineering to map out Emergency Department flow and identify and implement opportunities for improvement.

Chief of Emergency to meet with University of Toronto Department of Industrial Engineering and oversee student’s work.

Student completes analysis and identifies opportunities for improvement.

At least one improvement idea is implemented based on the Emergency Department flow analysis by March 2018.

Participate in Toronto Central Local Health Integration Emergency Department Quality Set time lines for initiatives by June 30, Baseline length of stay for CTAS IV and V Network’s (TC LHIN’s) 16-month project focussed on Improvement Plan Team to develop new 2017. Implement identified initiatives in patients (Average of 2015/16 Q4, 2016/17 improving length of stay for CTAS IV and V patients initiatives in this area. line with time lines set. Q1 & Q2 data) = 4.2 hours (least sick patients). Target: 4.0 hours in Q2 2017/18 and 3.6 in

Q4 2017/18 (note: there is a performance corridor on the Q4 target of ≤3.8)

Consult Arrival

1. Report new consultation* time measures (from consultation request date/time to patient discharge home date/time) by top 8 consulting services at Medical Advisory Committee (MAC)

*In the Emergency Department, a consultation is when an emergency medicine physician contacts another physician (specialist or otherwise) for advice or intervention regarding patient care.

2. Solicit feedback from Department Chiefs

1.

2.

Executive Vice President/Chief Medical Executive and Director of Medical Affairs will provide monthly report at the MAC meeting

Director Medical Affairs will record feedback from Department Chiefs and incorporate improvement ideas into future reports

Monthly reporting Monthly reviewing and reporting on progress

100% MAC meetings 100% MAC meetings


1.

2.

Establish a pilot with Psychiatry using technology to track time measures related to consultations including times for 1) consultation request, 2) bedside arrival, 3) staff physician contacted, 4) decision made, and 5) disposition/discharge. Review and analyze the consultation data from the pilot and recommend changes to improve consultation times.

1.

2.

Chief of Emergency, in partnership with the Department of Psychiatry will lead the pilot. Emergency Department Information Technology Lead will assist with data collection.

Chief of Emergency, Executive Vice President/Chief Medical Executive and Director Medical Affairs will review and report on results.

1. 2.

Data analysis completed

Report to the MAC on the outcome of the pilot and make recommendations regarding roll-out in, and establishing targets for, other services.

1. 2.

Complete pilot prior to April 1, 2017.

Present to MAC by April 30, 2017. Develop roll-out time line and targets for other services by June 30, 2017.

Partner with Clinical Champions to implement Chief of Emergency, Executive Vice Implement new process(es) in other Implement new process(es) in other improvement opportunities in other services. President/Chief Medical Executive, Director

Medical Affairs and Emergency Department Information Technology Lead will partner with Clinical Champions in consult services to roll-out improvements.

services and report to MAC on results services by March 31, 2018. Begin measurement and set new targets as appropriate by Mach 31, 2018 (dependent on availability of quality data).

Diagnostic imaging Analyze processes for computed tomography (CT) of abdomen / pelvis (a specific imaging test) to develop more streamlined approach. (Will include analyzing data, current protocols and literature on CT of abdomen/ pelvis performed with or without oral and rectal contrast.)

Develop new criteria for CT with or without oral and/or rectal contrast.

Implement and educate staff and residents on new criteria.

Change led by Head of the Emergency & Trauma Radiology Division

Criteria work group to monitor progress and provide monthly update at Department of Medical Imaging meetings.

Once implemented,

percentage of eligible patients that receive a CT abdomen / pelvis that adheres to the new criteria

If possible, obtain turnaround data (time between ordering exams and study (exam) completed) and report turnaround times before and after implementation of new criteria.

95% of patients receive care in line with new criteria within one month after their introduction. Analyze turnaround times (if available) in line with implementation of new criteria.


Improve reliability of performance data regarding turnaround times for ultrasound, X-ray and Magnetic Resonance Imaging (MRI).

Provide this data in regular reports to Emergency Department, Diagnostic Imaging and other appropriate leaders and staff.

Continue to report CT turnaround times (data is already reliable).

Address progress and set actions at every other Emergency Department Quality Improvement plan meeting.

Change led by Director, Medical Imaging.

Successful reporting of the data

90th percentile of turnaround times per modality (test type)

Complete improved reliability of data by October 2017 Current 90% turnaround times (where data available): X-rays: 1:55 hours CT: 4:09 hours Target 90% turnaround Times: X-rays: < 1:45 hours Ultrasound: < 4:00 hours CT: < 4:00 hours MRI target: to be set after successful data analysis.

Improve ultrasound accessibility for Emergency Department patients (shorten the time patients have to wait for an ultrasound) by

providing 24/7 coverage

creating a plan to add ultrasound technician

resources when volumes reach a certain level.

Change led by Head of the Emergency & Trauma Radiology Division and Director, Medical Imaging.

Report progress at every other Emergency Department Quality Improvement Plan meeting.

Percentage of requests for ultrasound executed by Diagnostic Imaging. Ultrasound wait time (if possible by case severity)

90% of Emergency Department ultrasound requests to done by Department of Diagnostic Imaging (in line with increased capacity)

Measure and then set goal for Ultrasound wait time (if possible by case severity)

Analyse impact of ultrasound and MRI turnaround time on total length of stay for non-admitted Emergency Department patients. This will be done by calculating a ‘theoretical turnaround times of 1 hour’ for imaging exams.

Note: This has already been done for CT.

Change led by Head of the Emergency & Trauma Radiology Division and Director, Medical Imaging.

Information technology staff will run scenarios.

To be shared at Emergency Department Quality Improvement Plan meetings.

Where analysis demonstrates impact of reduced ultrasound and MRI turnaround times on total length of stay for non-admitted Emergency Department patients, implementation of initiatives to enable turnaround time reductions.

Within one month of completion of analysis, set new targets for imaging turnaround times as appropriate.

Within three months of completion of analysis, develop changes ideas and times lines to support new targets.

Establish Emergency Trauma Radiology Division with overnight reporting.

A team of four dedicated Emergency & Trauma radiologists will start as soon as possible in 2017.

Change led by Head of the Emergency & Trauma Radiology Division and Chief, Medical Imaging

Rollout and performance metrics will be conveyed at the Emergency Department Quality Improvement Plan meetings.

Percentage of finalized reports within 4 hours of exam completion between 10pm-8am

50% improvement compared to current (will be measured in first half of 2017).

Create business case to add one (1) CT technologist for evening shift (1600-2400h) Monday to Friday.

Change led by Director, Medical Imaging. Emergency Department CT turnaround times between 6:00 p.m. and 2:00 a.m.

90% of CT turnaround times < 4:00 hours between 6:00 p.m. and 2:00 a.m.


Other

Consult Community Partnership Initiative (a patient advisory group that includes previous patients)

Review the Quality Improvement Plan at the February 2017 Community Partnership meeting for consultation and feedback on methods, measures and goals.

Based on feedback, modify plan as appropriate.

Integrate Community Partnership Initiative suggestions into Quality Improvement Plan work plan (where relevant) by April 30, 2017.

Increase appropriate Clinical Decision Unit (CDU) utilization (a patient flow designation during which time further diagnostics and monitoring take place). Continue to refine the notifications to Clinical Care Leaders, Physician Assistants and Physicians for when a patient can be designated ‘CDU’.

Chief of Emergency, Emergency Department, based on data from Information Technology Lead and Decision Support lead, will ensure practitioners are using the notification system to maximize utilization.

CDU Utilization Rate

CDU utilization rate: Baseline Jan – Dec 2016: 6.93% Target by Q3 2017/18: 7.50%

QIP 17/18 – MyChart

AIM MEASURE


Current performance

Target for 2017/18


Patient

Centred

Support the MyChart (Personal Health

Records) program to help patients

better manage their own health

The number of users of

MyChart

161,000

(Jan 26, 2017)

193,200

by March 31, 2018

The target is to increase the total MyChart membership by 20% in one fiscal year. Target is a stretch improvement over baseline performance.

CHANGE

Change Ideas Methods Process Measures Goal for Change Ideas

Increase the number of organizations whose patients/clients can use

MyChart.

Increase awareness, promote and facilitate

adoption and usage.

Number of new organizations

adopting MyChart.

Three additional organizations

adopt MyChart in 2017/18.

Increase Awareness

Host MyChart information sessions twice quarterly.

Increase awareness through promotional materials made available on

patient care units and public spaces at all three campuses.

MyChart support team will organize

information sessions twice quarterly and

routinely increase awareness through

Clinical areas during rounds, meetings and

report participation levels for each location.

MyChart support team will report monthly

on the number of flyers distributed

throughout the hospital.

Host MyChart information

sessions

Routinely update Clinical

areas, rounds, meetings

Number of print materials

distributed monthly

Host two MyChart information

sessions per quarter

Report adoption rates quarterly

to each clinical area

≥ 100 flyers distributed

monthly

Increase user satisfaction with MyChart

Patients registering with MyChart will be surveyed via email.

Patients can also take the survey on MyChart homepage.

New patients to MyChart will be sent a survey after one month.

MyChart support team will review and track

survey data on a monthly basis.

Number of completed surveys

per month

Receive a minimum of 50

completed surveys per month

Institute a formal feedback review process and implement user

suggestions. On a bi-yearly basis the MyChart team will perform an internal

review of qualitative feedback.

MyChart support team will analyse and

prioritize ideas for added features

/implementation

Based on “feedback review”

select ideas for

implementation

Aim to implement two user

suggestions per year (exact

number will be determined

based on the quality, feasibility

and development capacity)

Increase ‘circle of care (family, and friends, physicians, nurses, etc.)’

participation on MyChart in order to make experience better for patient

Increase awareness through promotional materials.

When conducting seminars, engage patients to invite their circle of

care into MyChart

The MyChart support team will create a

reporting template that will be populated

on a monthly basis to track the increase in

non-patient user adoption. The report will

be reviewed on a monthly basis.

Rate of non-patient adoption

of MyChart

Increase non-patient adoption

of MyChart by 653 (or 10% as

currently there are 6,535 active

non-patient accounts)

QIP Plan 17/18 – Advanced Care Planning Conversations

AIM MEASURE

Quality dimension Objective Indicator Current performance

Target for 2017/18


Patient Centred

Increase the number of

patients who are engaged in

Advanced Care Planning

(ACP) conversations.

Total number of ACP notes documented in the patient’s electronic health record at Sunnybrook (SunnyCare) in inpatient and outpatient areas.

April – Sep 2016 (6 months) = 865 Projected 2016/2017 = 1,730

≥ 2,000 A 15% increase is a stretch target as this is the first year for this work. This reflects our goal of ensuring access to ACP for patients in all programs and settings.

CHANGE


Increase organizational awareness of ACP.

Together with Patient and Family Partners, create and implement unit-based education to raise awareness of the importance of ACP conversations, the role of Substitute Decision Makers and where to access resources.

Patient and Family Partners to share stories of impact with staff.

Collaborate with the Communications team to create additional innovative awareness strategies

Social Work Professional Lead will lead unit-based education through the implementation of “Roving Information Cart” and will report progress to the ACP Steering Committee.

Total number of staff reached by ACP “Roving Information Cart” Staff will be asked to complete brief awareness

card evaluating four key areas:

1. Basic understanding of ACP

2. Knowledge of who is having ACP

conversations/who to refer patients to

3. Knowledge of location of ACP resources

4. Knowledge of location of ACP documentation

500 staff will be reached by roving ACP Information Cart by March 31, 2018

80% staff surveyed will rate positive awareness for four key areas

Increase staff ability to facilitate ACP Conversations.

In collaboration with the Sunnybrook Simulation Centre, create and implement ACP Facilitator Training

Identify champions, local leaders and early adopters to participate in Facilitator Training

Collaborate with TAHSN (Toronto Academic Health Science

Network) ACP Fellow regarding this training.

Member of the Division of Palliative Care will lead the development of the ACP Facilitator training and update the ACP Steering Committee monthly on progress.

Total number of facilitators trained

Improved confidence in ACP Conversations skills measured through self-assessment before and after facilitator training

Improved knowledge as measured by post evaluation in e-learning module.

30 ACP Facilitators will be trained by March 2018,

80% of facilitators will rate improvements in knowledge and confidence, in their post evaluation surveys

CHANGE


Provide coaching and support to teams to build their capacity to integrate ACP conversations into routine care. Self-identified early adopter teams include:

Head and Neck Cancer Site

TAVI* Clinic

Social Work Practice

Pre-Anesthesia Clinic

*TAVI (Transcatheter Aortic Valve Implantation) is a minimally invasive procedure that repairs diseased heart valves for patients deemed inoperable or too high risk to undergo open-heart surgery.

ACP Steering Committee Co-Leads will lead this work and report progress to the ACP Steering Committee quarterly.

Completion of “ACP – We are Starting the Conversation” Checklist by each team (includes provision of patient resources, timing of conversation opportunities, documentation methods).

End of life Patient Experience Survey Question #19:

Was your family member given the opportunity to discuss Advance Care Planning with his/her health care professional?

Proportion of End of Life Discussions initiated by Rapid Response Team. Our goal is to reduce the need for the Rapid Response Team to initiate these conversations as ACP conversations by regular staff are expected to increase.

100% of participating teams will complete checklist

Baseline and target to be set in April 2017 once have sufficient data.

Base Line = 56% (April – Sep 2016) Target = 47% (a relative decrease of 15%, similar to the overall plan).

Identify patients who might benefit from an ACP conversation through the use of a flagging system. Work with the Information Services team to develop an algorithm to enable flagging, notification and reporting of patients meeting eligibility criteria.

Consultant, Project Management Office, will lead development of flagging system and will report progress to ACP Steering Committee quarterly.

Technological capabilities enhanced by January 31, 2018.

Tracking process and a supporting tool established by March 31, 2018.

Create, implement, and evaluate a new program that enables patients who have a high degree of readiness to self-identify and engage in ACP conversations.

Head, Palliative Care Consult Team, will lead the development of this initiative and update the ACP Steering Committee monthly on progress.

Number of program participants

Evaluation by program participants

40 participants by March 31, 2018

Participants will report satisfaction with participating in the program and with engaging in an ACP conversation.

Develop process to identify patients in acute care who are scheduled to be moved into palliative care (‘Alternate Level of Care Palliative’) but who do have not have an ACP conversation documented and develop escalation protocol to notify clinical teams.

Professional Leader, Social Work, will track (weekly) and report (monthly) the number of patients who do not have documented notes and the outcome of the escalation protocol to the ACP Steering Committee.

Proportion of patients with ACP notes out of the total deaths in acute care (from Palliative Care Dashboard).

Base Line = 35% (Apr-Sep 2016) Target = 40% (relative increase of 15%, similar to the overall plan)

QIP 17/18 –Discharge and Transition Planning

AIM MEASURE

Quality Dimension

Objective Indicator Current performance Target for 2017/2018 Target justification

Efficient To achieve timely

discharges in line

with Sunnybrook’s

“DB11” Program

where appropriate.

% of patients

discharged in line with

“DB11” program

across all Bayview

campus acute care

units.

31%

(Composed of:

Medical Units = 28%

Surgical Units = 32%

April – Sep 2016

≥35%

(Composed of:

Medical Units ≥32%

Surgical Units ≥37%)

Due to the complex nature of

this process, a 13% relative

increase over baseline is

considered a stretch target.

The ultimate goal is 40% by

2019/20.

CHANGE

Planned improvement initiatives Methods Process Measures Goal for change ideas

Implement education sessions and awareness strategy to improve compliance and accuracy of documentation of Estimated Discharge Dates in the Bed Management System (BMS) and Sunnycare (Sunnybrook’s electronic clinical care system). Create a user-friendly method to enable monthly dissemination and review of Discharge Reports (contain compliance and accuracy of documentation of Estimated Discharge Dates) to: Clinical teams (including resident physicians)

Discharge and Transition Planning Committee

Occupancy Executive Committee

Interprofessional Quality Committee (biannually)

Co-leads of the Discharge and Transition Planning Committee will lead the education/ awareness strategy in collaboration with unit leaders and disseminate the Discharge Reports.

% Compliance with entering Estimated Discharge Dates into Bed Management System within 24 hours of admission. Note: Bed Management System automatically updates Sunnycare. % Accuracy of Estimated Discharge Date entered by 7:30 a.m. for patients who discharged on that same day.

Baseline: 41%; Aug – Oct 2016 (3 months) Goal: 75% (April 2017-March 2018) Baseline: 49%; Aug –Oct 2016 (3 months) Goal: 75% (April 2017-March 2018)

CHANGE


Implement revisions to format of Estimated Discharge Dates in Sunnycare to clearly identify patients who are to be discharged TODAY and TOMORROW, in order to improve utilization of Estimated Discharge Dates. Utilization plan to be developed.

Sunnycare Information Technology Team, in collaboration with Discharge Leads and Discharge Planning Committee, will implement new format in March 2017.

In September 2017, interprofessional team will evaluate new Estimated Discharge Date format.

If approved, any additional recommended revisions based on the consultation will be implemented by January 2018. Utilization plan developed by March 31, 2018.

Improve patient satisfaction with information they receive on

preparing for discharge and the transition home.

Implement and sustain Discharge Best Practices and Tools to

support discharge planning process and patient education.

Discharge Best Practices and Tools include:

1. Standardized questions in Discharge Planning Rounds *

2. Discharge Poster *

3. Discharge Video NEW

4. Patient Engagement Whiteboards *

5. Unit Discharge Pamphlet *

6. PODS (Patient Oriented Discharge Summary) NEW

* = Sustain

Clinical Teams will be provided with a Self-Assessment Tool to

evaluate how well the Discharge tools are integrated into practice

and to identify opportunities for improvement.

Teams will report Self-Assessment results and progress to the Discharge and Transition Planning Committee monthly. Discharge and Transition Planning Committee will provide oversight for impact of interventions on patient satisfaction and experience of discharge. Committee will monitor four questions on the Canadian Patient Experience Survey related to discharge (#19, #20, #37 & #38). In addition, comments related to discharge will be reviewed quarterly and mitigating strategies will be developed as required.

Based on Self-Assessment, teams identify areas to improve the discharge process. Canadian Patient Experience Survey questions:

#19: During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

#20: During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

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

Address areas identified for improvement as appropriate by March 31, 2018 Baseline and targets for the Canadian Patient Experience Survey survey will be developed once sufficient data is available for analysis (expected to be in April 2017).

CHANGE


Create Discharge Best Practice webpage, as part of Best Practice Matters intranet site, to provide access to discharge tools and information to support care (e.g. discharge booklet, poster, scripts, rounds questions). Implement an awareness strategy; seek stakeholder feedback on site, tools, and frequency of use.

Sub Committee Working Group will report to the Discharge Planning Committee on work plan, timelines, progress, and evaluation statistics.

Stakeholder feedback will be sought and usage statistics will be tracked over time.

75% of stakeholders will report satisfaction with ease and ability to access discharge planning tools for clinical care. 75% of staff can identify where the tools reside (based on sample).

Develop, implement and evaluate PODS (Patient Oriented Discharge Summary)

1 on four units. Implementation of PODS will

include education for staff on the core competencies of Health Literacy

2 and Teach Back

3.

Post discharge calls to patients and families will be used to evaluate the effectiveness of PODS. 1 A written summary provided to patients typically with five key

pieces of information they need to know in order to effectively manage their health after a hospital discharge:

Signs and symptoms to watch out for

Medication instructions

Appointments

Routine and lifestyle changes

Telephone numbers and info to have available 2 Health Literacy is the degree to which individuals have the

capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. 3 The teach-back method, also called the "show-me" method, is a

communication confirmation method used by healthcare providers to confirm whether a patient (and/or their care takers) understands what is being explained to them. If a patient understands, they are able to "teach-back" the information accurately.

PODS Working Group will be established by February 2017 to lead the implementation of PODS and to evaluate effectiveness and feasibility. The Working Group will report progress to the Discharge and Transition Planning Committee monthly. Staff education will be completed in partnership with Patient and Family Education and progress will be reported to both the Discharge and Transition Planning Committee and the Sunnybrook Education Advisory Committee (SEAC). Post Discharge Calls will be completed by designated unit leads.

On four Pilot Units:

Compliance of using PODS

with patients who are

discharged

Completion of both Health Literacy and Teach Back education

Healthcare provider

satisfaction – Focus Group

Patient and family satisfaction

– Post Discharge Telephone

Calls

80% compliance

80% completion

Positive satisfaction verbalized by healthcare providers

Positive satisfaction verbalized by patients/ families

In January 2018, follow-up as appropriate on identified areas for improvement based on evaluations.

QIP 17/18 – Total Margin

AIM MEASURE


Current performance

Target for 2017/18


Efficient Improve

organizational

financial health

Total Margin (consolidated): Percent, 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.

2.94%

Q3 FY 2016/17

≥0% Maintaining a balanced budget is

a greater and different challenge

each year and continues to be a

top priority for the hospital.


Improve bed utilization to enable higher volume of

patients to access Sunnybrook’s inpatient units. 1) Reduce pre-operative length of stay for cardiac

surgery patients

2) Reduce inpatient length of stay at St. John’s

Rehab in targeted areas. Initiatives include (a)

discussing the patient’s care pathway regarding

rehabilitation and discharge with patients and

families earlier in the patient's stay, (b)

explaining the importance and key aspects of

mobilization, and (c) introducing new

interventions e.g. walking group, when

applicable.

1) Capture length of stay through standard

coding processes monitored monthly

through the Sustainability Program Office.

2) Review length of stay data monthly through

the Sustainability Program Office.

1) Length of stay prior to surgery

2) Length of stay change for

specific inpatient rehab

populations.

1) Reduce pre-op Length of

Stay by a total of 100

days.

2) Reduce length of stay for

St. John’s Rehab inpatient

population by 3 bed

equivalents or 1000 days

Reduce nursing overtime utilization in order to

reduce staffing expenditures. Implement improved controls related to overtime

approval

Monitor compliance monthly via the

Sustainability Program Office. Agency hours will

be monitored as a balancing metric.

Proportion of nursing overtime

utilization (hours) 25% reduction from fiscal year

2015/16 in nursing overtime

hours.

Identify revenue opportunities Expand retail opportunities (retail pharmacy and

gift shop (to increase in revenue and net margin.

Achieve a higher retail food percentage

commission through a new contract negotiation.

Retail pharmacy / gift shop

retail revenue margin earned

Retail Food commission %

1) 10% increase in Net margin

earned

2)

3) 25% increase in commissions

earned

qip 17/18 - medication reconciliation · qip 17/18 - medication reconciliation aim measure quality...

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