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Quality Improvement Plan (QIP): 2014/15 Progress Report

ED Wait Times

ID Measure/Indicator from

2014/2015

Current Performance as stated on

QIP14/15

Target as stated on QIP 14/15

Current Performance

2015

Comments

1

ED Wait Times: 90th percentile ED length of stay for Admitted patients. Hours ED patients Q4 2012/13 – Q3 2013/14 CCO iPort Access

21.2 hours 21.0 hours 22.23 hours

Increasing patient volumes coupled with a complex patient population continues to be a challenge for St. Michael's. We did not achieve our target; however, Emergency Department length of stay will continue to be a priority focus area in 2015/16. We will continue to work toward our 21.0 hours target in 2015/16.

Change Ideas from Last Year’s QIP (QIP 2014/15)

Was this change idea implemented as intended?

Lessons Learned

Simulation Model analysis and improvement

No

• Partnered with the Centre for Research in Healthcare Engineering (CHRE) at the University

of Toronto to customize two models: (1) a surgical simulation model which would allow for

scenario testing of factors effecting Perioperative services, and (2) a strategic planning

occupancy model which examines the patient demand at a service level and informs

footprint and surgical smoothing discussion.

• Developing and running multiple scenarios in the surgical model assisted in the optimizing

of the Operating Room booking process for one high volume service.

• Furthering the work started with both models, Ernest & Young has been engaged to perform

an operational review of Perioperative services and assess and recommend options for

corporate optimal footprint. The surgical simulation model will be utilized to test

recommendations coming out of the operations review and, where possible, quantify any

potential improvement opportunities. This work will carry over into the 2015/16 Pay for

Results (P4R) action plan.

St. Michael’s Hospital Quality Improvement Plan (QIP) | 2014-15 Progress Report | 2

Lessons Learned: The strategic planning occupancy model was unable to take into account complex corporate demands i.e. isolation and flexing of beds so another model is being developed to help answer questions around that, which will further the current analysis done.

Measurement/Feedback: Improve patient flow performance information

Yes

• As part of a broader performance reporting strategy work was conducted to engage with

key stakeholders in reviewing and re-developing corporate, unit-level and physician-level

performance reporting

• Standardized monthly unit-level QIP performance report developed and being distributed

i.e. weekly before 11 a.m. discharge time (B.E.D) at unit level; quarterly ED Admit length of

stay (LOS) and discharge satisfaction at the corporate and program level

• Visualization strategy for QIP metric performance at unit-level under development

• Bed Optimization System upgrade was completed and this improves availability of real-time

patient flow related data in the organization i.e. bed availability and expected date of

discharge (EDD)

Process Intervention: ED to Inpatient working group: Examine and improve upon delays for admitted patients

No

• High-level mapping of current in-patient unit process to intake an admitted patient from ED/

PACU/ clinics completed

• Working group for ED to in-patient bed delay developed; change plan for 2015/16 being

developed

• Corporate and program level leadership engaged, providing input and prioritizing 2015/16

change ideas for improvement plan for ED to in-patient bed delay which includes

understanding the process for notification of available bed, understanding initiation,

completion and notification of in-patient bed cleaning process; determining appropriate turn-

around (bed empty) time for discharge to next patient admitted

• Due to competing priorities in ED such as Ebola preparedness work, the development and

pilot testing of tools as well as processes to support ED to in-patient intake process not

achieved; this work is to be rolled over to 2015/16 action plan

Process Intervention: Evaluate Rapid Assessment Zone (RAZ) Canadian Triage and Acuity Score (CTAS) 4-5

Yes

• Improvements made with minor RAZ model in 13/14 were sustained and evaluated

• Qualitative and quantitative evaluation complete

• Improvements noted in 2014 YTD (90th percentile) performance for: PIA (2013: 2.8 hours.,

2014: 2.6 hours.); CTAS 4-5 (2013: 4.7 hrs, 2014: 4.5 hours)

• RAZ-type model being pilot tested for CTAS 1-3 population in the ED Intermediate area

Before 11:00 a.m. Discharge (B.E.D.)

Yes See Discharge Satisfaction Progress Report: Implement hybrid corporate/unit specific discharge target time.


Total Margin

ID Measure/Indicator from 2014/2015


QIP14/15


Current Performance

2015

Comments

2

Total Margin (consolidated): % by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expense, excluding the impact of facility amortization, in a given year. % N/a Fiscal Year to Date Q3 2013/14 OHRS, MOH

1.9% 0.0% 0.3% We achieved our target for total margin. In the current fiscal climate, this indicator will be monitored closely throughout the next fiscal year.



Lessons Learned

For each Quality Based Procedure (QBP): 1) Conduct education and ensure awareness 2) Conduct data analysis and identify improvement opportunities 3) Implement, evaluate and sustain improvements

Yes

The internal support structure for QBP work was refined and a multi-disciplinary steering committee assigned to support decision making and provide guidance. A prioritization exercise - based on data analysis of SMH performance compared to peers and internal performance over time - was completed for all current and future QBPs. This prioritization allowed for the team to delineate resources in relationship to opportunities and impact of improvements.

Systemic Treatment - Chemotherapy Significant process improvements were made to current data collection with the successful implementation of Systemic Treatment Activity Level Reporting (ST-ALR). All ~170k data elements are subject to review and validation by key stakeholders. Any treatments that fall outside CCO Best Practice Guidelines (a very small portion) are assessed; staff meetings incorporate a review of ST-ALR data and issues. Data quality and information has improved dramatically with St. Michael’s having an error rate of 0.27% on Dec 2014.

Congestive Heart Failure (CHF) After an in-depth data and current state analysis, the Acute Management portion of the Patient's journey was prioritized due to impact on Length of Stay (LOS). By the end of fiscal 2014/15, the CHF Working group implemented items within the three streams of improvement work: Order sets, Daily Weights and Algorithm. Performance reporting will enable improvement to be measured and PDSA cycles will be used as additional opportunities are identified.

Chronic Obstructive Pulmonary Disease (COPD)


This QBP was put on hold until next fiscal, to allow for alignment with other QBPs affecting our Internal Medicine service and to ensure appropriate utilization of resources.

Endoscopy Our QBP process focused on two data quality pieces. An extensive coding review and gap analysis outlined opportunities within the capture and coding of specialized endoscopy cases. A chart label system was introduced to enhance the clarity of the documentations as well as monthly data reconciliations. This resulted in improved data quality with 21% or 3000 charts flagged for review in 2012/13 and 1.3% or 234 charts reviewed in 2013/14. Previous case costing was conducted using an averages approach and not reflective of the highly specialized, heterogeneous cases completed in the hospital. With accuracy significantly improved, Cancer Care Ontario/Ministry of Health funding and internal analysis is better informed. Further, internal use of data has expanded to find internal efficiencies and to better forecast/model funding results.

Stroke After an in-depth data and current state analysis, the transitions in care portion of the Patient's journey was identified as the most significant area for improvement in the LOS. A taskforce including multidisciplinary members from St. Mikes and Bridgepoint health was formed. By the end of fiscal 2014/15 the implementation on three work streams: Saturday Discharges, Discharge Planning, and Order Sets will be in progress. Performance reporting will enable improvement to be measured and PDSA cycles will be used as additional opportunities are identified.

Non - Cardiac Vascular Data analysis highlighted the need for improvements along the health information continuum which included registration, chart documentation and coding. Comprehensive chart reviews and a shared understanding of the process resulted in an additional 25 cases being captured as qualifying QBP. This resulted in additional earned revenue, positively benefiting the hospitals bottom line and total margin. Throughout the process communication across departments was enhanced and relationships were strengthened.

Pneumonia Some preliminary analysis was started, but was put on hold to align with other QBPs due to resources constraints and the number of QBPs underway this year. Pneumonia and COPD will be revisited together next fiscal year.

Hip Fractures Leveraging lessons learned from the Stroke QBP with regards to weekend discharges and early referral, the Hip Fracture QBP is targeting implementation in late fiscal 2014/15. Working at the local level, the Hip Fracture Expert Panel will run short improvement cycles with key measures being per cent of patients discharged on weekends and day of referral in order to improve LOS.


HSMR


2014/2015


QIP14/15


Current Performance

2015

Comments

3

HSMR: Number of observed deaths/number of expected deaths x 100. Ratio (No unit) All patients 2012/13 DAD, CIHI

84.0 89.0 86.0 We achieved our hospital standardized mortality ratio (HSMR) target for this year.



Lessons Learned

Foundational Improvement Work: Develop a standardized process for the dissemination and utilization of HSMR data at the program level

Yes

Historically, reports of patient-level data of the HSMR were distributed on a service level; however, it was found to be of little use to conceive an action plan. This year, a deep dive analysis was done for HSMR at a program and service level and it was found that breaking the ratio was inappropriate as analysis at that granular of a level is not the intention of the methodology. According to HQO, the HSMR is not designed for comparisons between hospitals, but instead to track a hospital’s trend over time. We are removing HSMR from our QIP because reducing mortality is a part of all the work being done in our standing QIP indicators; however, we will continue to monitor this indicator internally.

Additionally, the Health Quality Ontario makes this indicator publicly available on an annual basis through the Canadian Institute for Health Information Your Health System website.

Moving forward, we will be adopting the Institute of Healthcare Improvement’s mortality table. Physician division heads will be provided a sample of all patient deaths who were admitted to the ward or intensive care units and who were admitted for comfort care or not to review.


Percentage ALC Days


Current

Performance

as stated on

QIP14/15

Target as

stated on

QIP 14/15

Current

Performance

2015

Comments

4

Percentage ALC Days: Total number of acute inpatient days designated as ALC, divided by the total number of acute inpatient days. % All acute patients Q3 2012/13 – Q2 2013/14 Ministry of Health Portal

7.79% 7.79% 6.03% We achieved our target for percentage of Alternate Level of Care (ALC) days. In fact we saw a significant improvement from our baseline.



Lessons Learned

Process Intervention: Examine Beyond Expected Length of Stay (BELOS)

Yes

Our goal for ALC in 2014/15 was to understand how we collect and report our data across the hospital and then examine our Beyond Expected Length of Stay (BELOS) at a service level to improve upon our discharge planning processes, which was achieved.

Our ALC performance level is well below our peer and Toronto Central Local Health Integration Network (TC LHIN) average. We are removing this indicator from the 2015/16 as the improvement work is interwoven throughout the 90th Percentile Emergency Department Length of Days change ideas. Targeted interventions will also be planned for our discharge planning processes and will include our ALC patient population.


Readmission Rate for Select CMGs



QIP14/15


Current Performance

2015

Comments

5

Readmission Rate for Select CMGs: Percentage of acute hospital inpatients discharged with selected Case Mix Groups (CMGs) that are readmitted to any acute inpatient hospital for non-elective patient care within 30 days of the discharge for index admission. % All acute patients Q2 2012/13-Q1 2013/14 DAD, CIHI

18.84% 18.84% 19.45%

We did not achieve our corporate target for readmissions within 30 days for the select case mix groups. Our current Q2 2013/14 to Q1 2014/15 rate stands at 19.6%, an increased from our baseline performance of 18.8%.



Lessons Learned

See HSMR change plan Yes

The focus this year was gaining a deeper understanding of the seven case mix groups through the Quality Base Procedure (QBP) work under the Total Margin indicator. Based on our internal data for patients being readmitted back to St. Michael’s hospital only, 19% patients in 2013/14 had more than one readmission visit. Or another way of looking at it, of all readmission visits (rather than patients) 41% were attributed to patients with two or more readmissions to St. Michael's. Furthermore, removing all patients with only one readmission visit, we see that the CMGs that have the largest proportion are: chronic obstructive pulmonary disease (COPD), gastrointestinal (GI), and congestive heart failure (CHF). In addition to investigating the data and through stakeholder feedback, program and medical directors are receiving their respective readmission rates on a quarterly basis. Moving forward, we will narrow improvement work with the QBP work in CHF patients and focus on the health system integration.


Timely Discharge Summaries



QIP14/15


Current Performance

2015

Comments

6

Timely Discharge Summaries: The number of times a discharge summary was distributed within 48 hours from the day of discharge for patients discharged from the inpatient units, divided by the number of patient discharges multiplied by 100. % All acute patients Q3 2013/14 eDischarge and SoftMed

69.4% 80.0% 79.7%

We completed and sent discharge summaries within 48 hours of a patient’s discharge slightly less than our target of 80% of the time.



Lessons Learned

Process intervention: Focus on shifting from dictation to electronic discharge summaries and continue with completion timeliness (completed and sent within 48 hours)

Yes

Our goal for the end of the 2014/15 fiscal year is that all services at SMH will be using the eDischarge tool for the completion of their discharge summaries. This past year we have successfully transitioned Obstetrics, Gynecology, Pediatrics and Orthopedics to the eDischarge system. Orthopedics transitioned in early March allowing us to meet our goal of transitioning each service to the system within this fiscal year. By working with some of the services individually we moved closer to our 80% corporate target.

Measurement/ Feedback: Quality of discharge summary

Yes

There were two methods that were intended to be used for this change idea. The first was to obtain the perspective of the Family Health Team on the quality of the discharge summaries they receive and the second was the continued measurement of the turnaround time for discharge summaries. The measurement of quality has now been tied into the Toronto Central Local Health Integration Network (TC LHIN) project standardizing discharge summaries across the LHIN that SMH is leading. The evaluation project with the LHIN will see several primary care providers across the LHIN be interviewed by the SMH research team for their perspective on the quality of discharge summaries at SMH and other facilities across TC LHIN. This will be coupled with a chart review at SMH and across the LHIN looking at the completeness and accuracy of discharge summaries. The report will combine both qualitative and quantitative elements and will be ready for the end of March 2015. It should provide valuable feedback in regards to the quality of St. Michaels’s discharge summaries and areas of focus moving forward.


Overall Patient Satisfaction



QIP14/15


Current Performance

2015

Comments

7

Overall Patient Satisfaction From NRC Canada: "Overall, how would you rate the care and services you received at the hospital (inpatient care)?" (Add together % of those who responded "Excellent, Very Good and Good"). % All patients Oct 2012- Sept 2013 NRC Picker

95.1% 95.1% 96.0% We exceed our target for patient satisfaction with overall care and realized a 1% increase in our corporate patient satisfaction score.



Lessons Learned

Foundational Improvement Work: Understand the characteristics of different response groups

Yes

An Overall Satisfaction Steering Group was assembled, 2013/14 NRC Picker patient satisfaction survey data was examined and characteristics of high and low scoring responders to the Overall Satisfaction question were assessed. In particular, low scorers who rated Overall Satisfaction to be poor or fair were examined in more detail. Corporately, it was discovered that younger age cohorts have a lower overall satisfaction rating compared to older age cohorts. However, this same trend was not found at the program level. Questions related to doctors, nurses, hospital staff, and admission were found to be the most significant drivers for overall satisfaction for both low and high scorers. High scorers were generally confident in the doctors and nurses, while low scorers were unhappy with the availability of doctors and nurses. Based on the analysis, communication and caring were identified as an improvement area. After discussion with the Overall Satisfaction Steering group, it was agreed that further exploration of actions to address overall satisfaction would be incorporated into the patient-centeredness strategy of the Quality Strategic Framework, a related corporate strategy within the hospital.

Process Interventions: Focus improvement work on patient experience

Yes

Patient complaints reported through Patient Affairs as well as the free-text comments within NRC Picker were analyzed and triangulated to identify common themes and areas for improvement. It was discovered that there is some overlap between complaints directly reported to Patient Affairs by patients or families and those found in the free-text comments in the NRC Picker patient satisfaction survey. However, NRC Picker had fair number of complaints not found in Patient Affairs, which suggested that it would still be worthwhile to


analyze complaints from both databases. Based on the analysis, patients (or families) were more likely to issue complaints related to caring, communication, and treatment via Patient Affairs, and more likely to express complaints regarding food and facilities through the NRC Picker free-text comments.


Discharge Patient Satisfaction


2014/2015


QIP14/15


Current Performance

2015

Comments

8

Discharge Patient Satisfaction % All acute patients 2013 NRC Picker

67.3% 68.0% 68.2%

We improved our discharge patient satisfaction score by 1.0%. The discharge satisfaction score is an aggregate score of five questions on our patient satisfaction survey instrument (e.g. staff discussed medication side effects, when to resume normal activities). Effective discharge planning will continue to be a priority improvement area in 2015/16.



Lessons Learned

Process Intervention: Discharge planning improvement: Implement updated discharge planning toolkit

Yes

• Change initiative was championed and promoted by executive and program level leadership.

• Assembled Discharge Planning Steering Group, along with a Discharge Toolkit Working

Group and reviewed relevant literature to inform the development of a corporate discharge

planning toolkit.

• Completed evaluation and update of multiple components of the current discharge planning

toolkit i.e. information on patient communication whiteboard in in-patient rooms, patient

discharge letter, staff whiteboard; process and changes informed by staff, patients and best

practice

• With the guidance of hospital leadership, a surgical/medical inpatient unit was selected to

pilot test the corporate discharge planning toolkit

• Current state discharge planning process analysis and process mapping was completed on

one in-patient unit (Trauma Neurosurgery)

• Based on current state process mapping, discharge-related improvement opportunities

identified were recommended on Trauma Neurosurgery ; Toolkit components being pilot

tested include (in progress): refreshed patient whiteboard; and early identification &

communication of expected date of discharge (EDD) for elective and unscheduled

neurosurgery, acute care surgery and trauma patient populations

• Performance reporting: Developed quarterly corporate and program-level ‘spot light’ report

to share 5 NRC Picker patient satisfaction survey and ED admit LOS performance and

disseminate unit-level B.E.D. performance on a weekly as well as monthly basis to the


program, unit and physician-level leadership

Lessons Learned: • Current state analysis (specifically process mapping in this case) is an important step in

designing an effective discharge planning toolkit

• It is important to involve patients and families in the planning and toolkit development

process. Patients were involved in the co-designing of tools and processes through

membership in the Steering group as well as a subset of in-patients and families were

surveyed on the Orthopedic, Medicine and Trauma Neurosurgery units to assist with

designing the patient whiteboard including the expected date of discharge (EDD)

communication process for patients ; this ensures that there is an alignment of key

discharge related priorities for patients/families and those noted by staff as well as best

practice as being important for patients

Process Intervention: Implement hybrid corporate/unit specific discharge target time

Yes

• Change initiative was championed and promoted by executive and program level leadership

• Assembled Discharge Planning Steering Group, along with a Discharge Time working group

to inform the corporate target for before 11 a.m. discharge time (B.E.D.)

• Refreshed and implemented corporate B.E.D. target of 40%; Met with local leadership teams

to determine specific unit-level targets, informed by historical data, and to develop action

plans to achieve the unit-level target

• Performance Reporting: Developed weekly B.E.D. performance report, which was shared

with unit and program-level leadership to highlight performance compared to set target and

previous week’s performance; report on discharge volumes by service and by time as well

as discharge disposition shared with unit-level leadership at touch points in October and

December 2014, and March, 2015. Reporting structure formalized for 2015/16; with frequent

touch points with low performing units

• Performance data shared at corporate Access & Flow Council (program-level, physician

and executive level leadership present)

• Continue to send quarterly B.E.D progress reports outlining the discharges by time of day

and disposition; and weekly performance reports

• Continue to engage physicians and consider performance reporting at the physician-level

• Patient-centered discharge tool for communicating corporate discharge time to be piloted in

early 2015/16

Lessons Learned : • High performing units have physician engagement in sustaining B.E.D. performance


• Tracking barriers discharging patients before 11 a.m. allowed units to conduct more focused

changes

• Significant corporate leadership involvement was a key success factor in the change

process

• Unit-level involvement in target setting and in the development of action plans, promoted

buy-in, commitment and local ownership


Medication Reconciliation at Admission



QIP14/15


Current Performance

2015

Comments

9

Medication Reconciliation at Admission: The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital. % All patients Most recent quarter available (e.g. Q2 2013/14, Q3 2013/14 etc.) Hospital collected data

67.3% 67.3% 71.0%

St. Michael's hospital met our performance goal for the completion of Medication Reconciliation on admission for admitted patients for the year. This continues to be a priority for the organization.



Lessons Learned

Skills Development (Education & Training): Corporate medication reconciliation at admission refresh

Yes

The electronic module for medication reconciliation education on the Learning Management System was evaluated and refreshed based on Best Practices, which satisfies this change idea listed on the 2014/15 QIP. Secondly, a targeted education roll-out was undertaken for medical trainees and residents. Specifically, rotating residents and fellows were encouraged to complete the e-module during registration and orientation, while medical students were provided med rec education during the Transition to Clerkship course. Furthermore, med rec education was proposed to be integrated into the Toronto Academic Health Sciences Network (TAHSN) training. Third, the project team met with all units performing below the corporate target for medication reconciliation upon admission rate to determine their barriers to med rec compliance and whether specific education initiatives would be required. Lastly, incorporating med rec education as part of the physician credentialing process will be discussed with our Vice President of Education and other relevant groups in the 2015/16 QIP cycle.


Process Intervention: Develop tools to support medication

reconciliation on transfer focusing across the patient journey (i.e. from the pre-admission facility

(PAF) for elective cardiovascular patients, to cardiovascular intensive care (CVICU) and

extending to the cardiac rehab clinic)

Yes

A cardiovascular (CVS) working group was assembled to inform this improvement initiative. The medication reconciliation upon transfer process was examined for elective cardiovascular patients following their patient journey starting from pre-admission facility or the cardiovascular nursing unit, and an electronic tool was designed and piloted among this patient population. A detailed current state process map was developed and validated by clinical stakeholders and set of key principles for an ideal med rec process was devised. These key principles were used to develop an electronic med rec tool that is being piloted among CVS patients. CVS clinicians have been involved in defining the pilot plan, which includes anticipating significant workflow changes and determining how the pilot will be evaluated for effectiveness. The electronic tool was built by IT and Informatics at the end of January and the pilot was launched in early March. Since the pilot began, the uptake and feedback has been positive from staff within the pre-admission facility, intensive care unit, and nursing unit. Suggestions are being captured and compiled on a daily basis and the pilot is being evaluated for its effectiveness based on the evaluation plan agreed upon by the CVS working group.


CDI Rate



QIP14/15


Current Performance

2015

Comments

10

CDI Rate per 1,000 patient days: Number of patients newly diagnosed with hospital-acquired CDI, divided by the number of patient days in that month, and multiplied by 1,000 - Average for Jan-Dec. 2013, consistent with publicly reportable patient safety data. Rate per 1,000 patient days All patients 2013 Publicly Reported, MOH

0.32 0.32 0.28 We achieved our target and saw a 12.5% decrease in the rate of C. Difficle infections.



Lessons Learned

See Hand Hygiene Yes We achieved our target and saw a 12.5% decrease in the rate of C. Difficle infections. See Hand Hygiene Progress Report for an update on the 2014/15 Hand Hygiene Change Ideas.

Process Intervention: Improved Environmental cleaning by using Glitterbug technique to increase compliance with cleaning of high touch areas

Yes

The most notable improvement initiative that was implemented to reduce the C. Difficle infection rate was improved environmental cleaning through the use of the Glitterbug technique. Through the Glitterbug program the thoroughness of discharge and terminal room cleaning was evaluated in hospital inpatient and critical care units, and the results were used to inform, educate and stimulate quality improvement of cleaning practices.

Additionally, we achieved and exceeded our 80% cleanliness target. All supervisors were trained on a new training video in order to be able to train their respective staff. The training of front line staff is planned for the 2015/2016 year.

Antimicrobial Stewardship: Coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose,

Yes

Full implementation of a daily audit and feedback antimicrobial stewardship program was achieved in our Intensive Care Units (ICUs). The Trauma Neurosurgery ICU saw a reduction in the mean monthly level of defined daily doses per 1,000 patient days. Additionally, the mean monthly antimicrobial use decreased in the Trauma Neurosurgery ICU. Results from the Medical Surgical ICU demonstrated a reduction in the monthly trend of defined daily doses per 1,000 patient days. Results from the evaluation of this program demonstrated that there was a reduction in the number of C.Difficle infections, but the results were not statistically significant.


duration of therapy, and route of administration

Lessons learned: There were low baseline rates of nosocomial C.Difficle, which made it difficult to show significant change associated with the antimicrobial stewardship program intervention alone. The multidisciplinary approach to this intervention was effective. The team is working to improve data accuracy of the metrics they are collecting.


Hand Hygiene



QIP14/15


Current Performance

2015

Comments

11

Hand Hygiene compliance before patient contact (moment 1): The number of times that hand hygiene was performed before initial patient contact divided by the number of observed hand hygiene indications for before initial patient contact multiplied by 100 - consistent with publicly reportable patient safety data. % Health providers in the entire facility 2013 Publicly Reported, MOH

56.7% 65.0% 57.6%

Although we did not meet our stretch target of 65.0%, St. Michael’s achieved an improvement in our Moment 1 compliance rate. Hand Hygiene compliance improved from 56.7% to 57.6%, a 1.6% improvement. We will continue to work toward our target in 2015/16.



Lessons Learned

Measurement and Feedback (Audit): Completion of at least 24 audit sessions of twenty minute per unit every quarter

Yes

A new hand hygiene auditor was hired in July. The incoming auditor received detailed training from the outgoing auditor to ensure consistent auditing methodologies and techniques. The new auditor is now collecting and theming barriers to Moment 1 on a select unit. This will be continued in the 2015/16 QIP and will help inform further quality improvement efforts. Additionally, new unit specific monthly hand hygiene compliance posters were developed and posted on each unit.

Skill Development (Education & Training): e-learning module

Yes The hand hygiene e-learning module was successfully updated by the Hand Hygiene Working Group, supported by the Infection Prevention and Control team. Compliance with the e-module is actively being monitored.

Skill Development/ Motivation (Education & Training): Champions corner. Creation of a champions corner on the Hand Hygiene Intranet page

Yes

The Infection Prevention and Control team worked with an education specialist to successfully create a hand hygiene champions corner on the Hand Hygiene Intranet page. Included on the corner are promotional and learning materials including video stories and a message board for champions to ask questions and share lessons learned.

Process Intervention: Focus improvement initiatives for lowest performing professions

Yes In-services were held for laboratory technologists, including an interactive problem solving ‘TRIZ’ exercise, with the aim for staff to identify current practices which could potentially transmit infection to patients. An education session tailored to x-ray technologists and


sonographers was developed with the operations lead of the department. Preliminary job shadowing was conducted with the aim to process map work flow and identify and standardize moments for hand hygiene. IV team nurses trialed personal sized hand sanitizer with retractable belt clip. The group is considering implementing this for their group.

New Initiative: Senior Leadership walkthroughs

Yes

A series of hand hygiene walkabouts were completed in the Spring and Summer of 2014. The purpose of the walkabouts was to secure and enhance senior leadership commitment to improving hand hygiene across the organization as well as to raise the profile of the importance of conducting hand hygiene on all units. Prior to the walkabout the leader was provided with hand hygiene compliance data to bring to the units.


Falls


2014/2015


QIP14/15


Current Performance

2015

Comments

12

Falls Rate per 1,000 All acute patients 2013 Hospital Collected Data from internal reporting database

4.25 4.25 4.17

Preventing falls has been a priority at St. Michael's for many years. Our corporate target of 4.25 falls per 1,000 patient days was achieved. Even though our improvement initiative was foundational, we saw a 1.9% reduction in our corporate falls rate compared to last year.



Lessons Learned

Foundational Improvement Work: Evaluate the impact of the Inter-Professional Falls Risk Screening and Prevention Program (implemented in 2012)

Yes

We completed a multi-year pre and post evaluation of our corporate Inter-Professional Falls Risk Screening and Prevention Program. The program has two main components: the falls screening tool and the falls prevention interventions. The program that was evaluated replaced an earlier prevention program. The evaluation was led by a multi-disciplinary team and included representation from Professional Practice, Quality, Decision Support, Risk, Clinical Informatics and front line staff. We found that our falls risk screening tool was identifying the patients who were at high risk of falling; however, our results showed that there is an opportunity to improve the falls prevention interventions. Our analysis of the corporate falls rate prior, during and post implementation of the falls prevention program revealed that the use of a falls prevention program did not reduce the corporate rate of falls. Post implementation of the program there was an overall increase in the corporate falls rate, which was in part due to the increased awareness of the importance of reporting falls events. A series of recommendations were identified which were grouped into three work streams. One of the work streams focuses specifically on the unit that had the highest number of falls during the evaluation period as well as prior to the period. We are currently in the process of implementing these recommendations, which will form the basis of our change plan for the 2015/16 QIP cycle.

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