quality improvement plan (qip) narrative for health care … · 2019. 4. 18. · insert...

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Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

3/29/2018

This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.


Overview The centre de santé communautaire Chigamik Community Health Centre is a non-profit, community-

governed, primary health care organization located in Midland, Ontario. This unique centre serves the

Indigenous and Francophone communities of the entire North Simcoe and Muskoka LHIN and the

Anglophone community of Midland, Penetanguishene, Tay, and Tiny. Chigamik provides a combination

of primary care, allied health services, health promotion programs, traditional Indigenous medicine and

culturally relevant community development initiatives which are holistic, and offered in French and

English.

This document provides an overview of the CHIGAMIK Quality Improvement Plan (QIP) for the 2018-

19 fiscal year and describes quality improvement achievements from the past year and plans for

improvement in the next. CHIGAMIK's 2018-19 plan focuses on safe, effective, efficient, equitable

client centred care. Within the last year changes have been implemented to drive a new and robust QIP

that includes collaboration with community partners, clients and the interdisciplinary team to provide an

excellent patient experience at Chigamik.

Our upcoming QIP includes new indicators which match our strategic plan goals, those dictated in our

MSAA and priorities identified by Health Quality Ontario. The QIP priorities include:

Developing seamless communication and transitions between partnering agencies including Health Link and local hospitals.

Developing thorough interdisciplinary assessments and care plans for clients with living with diabetes

Increasing health equity in our community by collecting more robust data from community members attending programming to further inform service and program development

Addressing the opioid crisis through practice analysis and change

Ongoing measurement of client satisfaction and engagement

The details of the change ideas to be implemented can be found in our concurrently submitted work

plan.

The upcoming QIP has maintained a clinical focus and includes new indicators for our other services

and programs. Community Health Centres (CHCs) work within a model that allows wrap around care

for clients. We have a strong focus on the mitigation of the influences of social determinants of health

on clients’ lives. This work is achieved by providing services and programs which address health

inequities both in the local community, and systemically.

Describe your organization's greatest QI achievements from the past year During this fiscal year, Chigamik’s most influencing change initiative toward quality improvement was

the rejuvenation of the QI committee. The committee previously had a very narrow focus on the

attainment of Advanced Access. With the addition of new members, including a client advocate and a

new quality improvement chair, the committee was able to broaden the scope of quality improvement

within Chigamik. This included a plan for a quality dashboard and report card to keep QI initiatives

closely in line with our MSAA and strategic plan objectives. These plans are currently being initiated

and will help to guide the QI work of the upcoming year.


Over the last four years, the Chigamik team have embarked upon the journey toward Advanced Access.

This scheduling process creates available appointments for clients on the same or next day. The concept

of Advanced Access remains foreign to many clients who have expectations of extensive wait times to

see their primary care provider- as this is typical of the physician starved rural areas of Ontario.

Chigamik has achieved Advanced Access and is now offering same day appointments with primary care

providers. This change has been received positively by Chigamik’s clients. During the implementation

of this change we were cognisant that some appointments require future booking and have therefore

carved out four appointments per day that allow us to meet the specific needs in special circumstances.

During the upcoming year, the client satisfaction survey will be used as a tool to measure satisfaction

among our clients ensuring that this booking strategy meets the needs of all Chigamik clients.

In our past two QIPs, we addressed transition to the community from our local hospitals and Chigamik

collaborated with the data management team at Georgian Bay General Hospital (GBGH), the local acute

care hospital to facilitate the transfer of relevant discharge data. The two data teams worked together to

develop a system which is meant to provide the Chigamik team with timely discharge information,

including reason for admission. Unfortunately, this system has not been effective and without electronic

communication, timely access to discharge information is not possible. As such, we have opted not to

place these indicators in our QIP 2018-19 since the data we receive from community hospital is not

complete. Our focus this year will be to continue our conversations and advocacy efforts to improve data

sharing and hope to set a target for improvement next year.

Resident, Patient, Client Engagement In the past year, client satisfaction surveys were completed by over 10% of Chigamik clients. This

significant increase in the completion of the survey is a result of the inclusion of a biannual phone blitz

to facilitate the completion of the survey by a random sampling of clients. The results of the survey have

been analyzed and findings have contributed to this QIP and informed the indicator whose action item

ensures clients are included in decision making related to their care. Current initiatives include:

interdisciplinary case management of complex clients which incorporate clients’ health care goals and

ensure a full understanding of the rationale associated with their care plans.

A significant effort to engage our clients and the community at large through a membership campaign

has resulted in the addition of over 150 members this year. Membership brings with it special privileges

including eligibility to vote at the annual general meeting. The next steps in engaging our members will

include the establishment of client advocacy groups including: substance users, those who are

precariously housed, or homeless, people who identify within the LGBTQ2 communities, francophone

and indigenous clients. These advocacy groups will then further allow Chigamik to meet the needs of

those most vulnerable in the North Simcoe region. Additionally, members who are passionate about the

work done at Chigamik can transition into board roles as informed participants.

Collaboration and Integration Interagency partnership and collaboration is a cornerstone of the work at Chigamik. The North Simcoe

Health Link has had a home within Chigamik since its inception. Health Link is a system navigation

service available for the highest users of the medical system within Chigamik’s catchment area. This


service has been established to provide close one-to-one guidance for those who have a number of

chronic conditions that need multiple services. Health Link has successfully diverted clients from

unnecessary hospital visits by guiding them through the medical system. It is through feedback from

Chigamik’s primary care providers that a gap in the services was identified- a lack of communication

between Health Link navigators and the referring provider. Our close partnership has positioned

Chigamik to include Health Link in our QIP and jointly develop a communication tool from which all

referring providers will benefit. It is anticipated that providing a robust update on the progress of clients

to the referring providers will build further confidence in the service and increase uptake by standalone

physicians.

Engagement of Clinicians, Leadership & Staff The engagement of all CHC staff is paramount to quality improvement at Chigamik. Internal staff

committees are working to facilitate this engagement and address systemic issues at the front line level.

Our committees are created to align with the board of director’s strategic plan. They include:

Indigenous, Francophone, Harm Reduction, health and safety and interdisciplinary workgroups. The

work of these groups is communicated fluidly from front line staff to leadership and through to the

board. This global sharing of information offers staff, and board members the opportunity to engage in

meaningful dialogue about the shared quality improvement goals and commitments developed for the

centre. These groups also provide opportunity for front line staff to use practice to inform new and

ongoing quality improvement initiatives.

Population Health and Equity Considerations

Chigamik’s mission statement is: To provide culturally relevant holistic programs and services to equip

our communities to achieve optimal health and well-being through awareness, health promotion and

illness prevention

Our mission to meet the needs of the specific cultural groups within our community has lead Chigamik

to create culturally specific committees which include staff, clients and community members. These

new, culturally specific committees address the health disparities experienced by the francophones and

Indigenous community members of the North Simcoe Muskoka region. Intentionally reducing barriers

to health and well-being for marginalized groups facilitates the creation of an environment of cultural

safety and relevant care. As part of our mission, this is an ongoing priority which is incorporated into all

decisions made at an organizational and operational level.

Access to the Right Level of Care - Addressing ALC

Chigamik’s primary care services are often an entry point for clients into the medical system. Our

collaborative interdisciplinary management of complicated clients is a key factor in reducing admission

to hospital by teaching self-management and increasing people’s engagement in activities which

promote health and well-being. Our upcoming QIP implements two change ideas specifically related to

the interdisciplinary care of clients living with diabetes. This care and education will more deeply

establish therapeutic relationships between client and care providers empowering clients with self-care

practices that mitigate admissions to hospital with diabetes related health consequences.


Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder

Community Health Centres across the province have been advocates of harm reduction practices for

many years. Our experience with clients who use substances and how misuse effects their lives

significantly informs our practice and is one of the corner stones of our practice. Our commitment to

these clients has been addressed this year with the establishment of a harm reduction committee.

Decisions are made on this interprofessional committee through evidence based research and a harm

reduction lens to support clients with substance use and misuse issues. The current priority of the

province on opioid use and overdose prevention has been addressed in our practice by implementing the

following changes:

A change initiative to be implemented with the upcoming QIP; full medication reviews of those clients who have been prescribed opioids and other controlled substances for longer than 6

months. The reviews will evaluate effectiveness, dosing of current medications and the addition

of allied services to support pain management. The interdisciplinary initiatives supporting pain

management and opioid use are:

dance therapy for chronic pain access to acupuncture as an alternative therapy facilitation of the self-management program Living Life with Chronic Pain an

evidence based program developed by Stanford University

Partnership with the local shelter in the development of a drop-in support group for people with substance use issues.

All staff have been trained in the distribution of nasal naloxone kits and are able to distribute to anyone requesting a kit. Primary care providers are also encouraging clients on long standing

opioid prescriptions to have a kit at home in case of accidental overdose by themselves or a

family member.

Ongoing distribution of harm reduction supplies to facilitate relationships with substance users in our community by creating a safe, judgement free space to ask for help.

In this upcoming fiscal year we will be taking part in the establishment of a Rapid Access Addiction Medical clinic in partnership with local acute care centre, Royal Victoria Health

Centre providing timely response for those seeking treatment for their substance use issues.

The upcoming QIP focuses on our internal measurable change initiatives. The data initiative focuses on

developing a tool to extract appropriate data on our clients who have been prescribed opioids for longer

than 6 months. During this upcoming fiscal year we will be transitioning to a new EMR, PS Suites, and

we intend to use it to better manage our data then our current EMR Nightingale on Demand (NOD).

Workplace Violence Prevention At CHIGAMIK we ensure staff feel safe in their work environment and are free from workplace

violence in a number of ways:

- All new staff must complete a thorough Workplace Health and Safety orientation upon hire that

includes the following: WHIMIS, emergency exit procedures, accessibility standards, rights and

responsibilities, hazards in the workplace, privacy and confidentiality, use of personal protective

equipment and reporting accidents and injuries. Furthermore new employees are provided with a tour of

the space to observe the locations of exits, first aid supplies, the defibrillator, alarms, health and safety

board with all required information as per the OHSA, and fire extinguishers.


- We conduct annual staff training on workplace violence and harassment with corresponding quiz and

policy review

- All staff are fitted for masks every (3) years to be worn in the event of an outbreak

- Most staff are trained in First Aid/CPR

- We have a Business Continuity Plan in place in the event of an external disaster

- Every 2 years we conduct a confidential staff survey regarding workplace violence and harassment

evaluating perceived staff safety

- Every 2 years all staff take part in Crisis Intervention Training with a focus on crisis intervention,

communication and self defense.

- Staff are offered ergonomic assessments of their work space by our physiotherapist to ensure a safe

and comfortable work environment

- Every office where clients are seen include a panic button in case of emergency. When the panic

button is activated a silent alarm will notify reception and police of the office location.

- We have a policy and procedure to cover employees who conduct home visits to ensure their safety

and security. This policy covers our in/out board at reception, work cell phones, and a buddy system.

- Incident reports are reviewed on a bimonthly basis by the Health and Safety Committee where

appropriate changes to processes and policies are initiated to mitigate the impact of future incidents.

Contact Information Quality Improvement Cttee Chair

Name: Gabrielle Maurice

Email: [email protected]

Executive Director

Name: David Jeffery

Phone: (705)527-4154 ext. 201


Board of Directors Chair

Name: Sean Bisschop

Phone: (705)549-3181 ext. 2863


Other

CHIGAMIK CHC currently utilizes Nightingale on Demand (NOD) as its information management

system. NOD is the primary method for collecting data related to our client populations. For the 2017-18

fiscal year NOD continues to be the main resource for the collection of data associated with quality

improvement. For example, information related to the CHC’s supply and demand, provider activity, and

client demographics, is collected solely through NOD.

During the 2016-17 year, NOD was purchased by TELUS. TELUS software platform called PS SUITES

is currently being validated by the AOHC to ensure that it meets our needs. Once this validation is

complete they will begin to transfer CHC's onto the new Electronic Medical Records system, PS

SUITES. This is expected to occur during the 2018/19 fiscal year. At that time PS SUITES will then be

the main resource for the collection of data associated with quality improvement.


Sign-off

It is recommended that the following individuals review and sign-off on your organization’s Quality

Improvement Plan (where applicable):

I have reviewed and approved our organization’s Quality Improvement Plan

Board Chair _ ______________ (signature)

Quality Committee Chair or delegate __ _____________ (signature)

Executive Director / Administrative Lead ____ ___________ (signature)

Other leadership as appropriate _______________ (signature)

ID

INDICATOR

(UNIT; POPULATION;

PERIOD; DATA SOURCE)

ORG

ID

PERFORMANCE

STATED IN

PREVIOUS QIP

PERFORMANCE

TARGET AS

STATED IN

PREVIOUS QIP

CURRENT

PERFORMANCE COMMENTS RESULTS ACTIONS

1

Percent of patients who stated that when

they see the doctor or nurse practitioner,

they or someone else in the office

(always/often) involve them as much as

they want to be in decisions about their

care and treatment?

( %; PC organization population

(surveyed sample); April 2016 - March

2017; In-house survey)

91566 82.81 85.00 79.71

The survey

remained

available online in

both French and

English. The

question on the

current survey

asks the clients

perception

regarding being

involved in their

care. Using the

client advocacy

groups to better

inform inquiries

made via the

client survey may

be an effective

way to augment

client

involvement in

care decision

making.

2

Percent of patients/clients who see their

primary care provider within 7 days after

discharge from hospital for selected

conditions.

( %; Discharged patients with selected

HIG conditions; April 2015 - March

2016; CIHI DAD)

91566 CB 80.00

Collecting this

data for the first

year it is evident

that an 80% target

was very

ambitious. We

appreciate the

need for focused

efforts on

effective

transitions

however, we have

opted not to place

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ID

INDICATOR

(UNIT; POPULATION;


ORG

ID

PERFORMANCE

STATED IN

PREVIOUS QIP

PERFORMANCE

TARGET AS

STATED IN

PREVIOUS QIP

CURRENT


these indicators in

our QIP 2018-19

since the data we

receive from

community

hospitals is not

complete. Our

focus this year

will be to mitigate

hospital visits for

clients living with

chronic

conditions.

Clients will be

educated on the

importance of

transition back to

the care of their

family

practitioner.

3

Percentage of patients and clients able to

see a doctor or nurse practitioner on the

same day or next day, when needed.

( %; PC organization population

(surveyed sample); April 2016 - March

2017; In-house survey)

91566 28.57 50.00 27.42

The survey

remained

available online in

both French and

English. This year

the survey was

distributed twice.

It is noted that the

question directly

related to this

indicator is based

on client

perception. In the

upcoming year,

the wording of

this question will


ID

INDICATOR

(UNIT; POPULATION;


ORG

ID

PERFORMANCE

STATED IN

PREVIOUS QIP

PERFORMANCE

TARGET AS

STATED IN

PREVIOUS QIP

CURRENT


be changed to ask

the client to focus

on the last time

they called for an

appointment if

same day

accessibility was

offered.

4

Percentage of patients who were

discharged in a given period for a

condition within selected HBAM

Inpatient Grouper (HIGs) and had a non-

elective hospital readmission within 30

days of discharge, by primary care

practice model.

( %; Discharged patients with selected

HIG conditions; April 2015 - March

2016; DAD, CAPE, CPDB)

91566 8.40 6.20 8.40

Chigamik is

currently working

with GBGH to

improve our

method of

communication

regarding our

clients being

discharged from

their facility.

Once a reliable

system is

established for

obtaining this

information we

expect to see a

profound increase

within this

indicator.

5

Percentage of patients with diabetes,

aged 40 or over, with two or more

glycated hemoglobin (HbA1C) tests

within the past 12 months

( %; patients with diabetes, aged 40 or

over; Annually; ODD, OHIP-

CHDB,RPDB)

91566 69.00 80.00 57.70

Chigamik's clinic

team has engaged

with clients to

complete biannual

HbA1C exams.

The clinical team

will continue to

seek out


ID

INDICATOR

(UNIT; POPULATION;


ORG

ID

PERFORMANCE

STATED IN

PREVIOUS QIP

PERFORMANCE

TARGET AS

STATED IN

PREVIOUS QIP

CURRENT


monitoring

measures that

provide reliable

data and meet

client needs.

6

Percentage of screen eligible patients

aged 50 to 74 years who had a FOBT

within the past two years, other

investigations (i.e., flexible

sigmoidoscopy) within the past 10 years

or a colonoscopy within the past 10

years.

( %; PC organization population eligible

for screening; Annually; See Tech

Specs)

91566 61.90 65.00 67.00

Chigamik has

exceeded the

commitment to

the LHIN on this

indicator and will

continue to strive

to improve

methods to

engage clients in

cancer screening.

7

Percentage of those hospital discharges

(any condition) where timely (within 48

hours) notification was received, for

which follow-up was done (by any

mode, any clinician) within 7 days of

discharge.

( %; Discharged patients ; Last

consecutive 12 month period.;

EMR/Chart Review)

91566 32.60 60.00 52.50

Chigamik is

currently working

with GBGH to

improve our

method of

communication

regarding our

clients being

discharged from

their facility.

Once a reliable

system is

established for

obtaining this

information we

expect to see a

profound increase

within this

indicator. Clients

who are seen in


ID

INDICATOR

(UNIT; POPULATION;


ORG

ID

PERFORMANCE

STATED IN

PREVIOUS QIP

PERFORMANCE

TARGET AS

STATED IN

PREVIOUS QIP

CURRENT


other hospitals

where the

information is

obtained

electronically are

contacted within

seven days.

8

Percentage of women aged 21 to 69 who

had a Papanicolaou (Pap) smear within

the past three years

( %; PC organization population eligible

for screening; Annually; See Tech

Specs)

91566 74.60 85.00 77.00

Chigamik's clinic

team has recently

implemented PAP

are working

towards reaching

our target and

continue to strive

to ensure our

cancer screening

is completed.

© Queen's Printer for Ontario 2018


Aim Measure Change

Quality

dimensionIssue Measure/Indicator Type

Unit /

PopulationSource / Period

Organiza-

tion Id

Current

performanceTarget Target justification

Priority

level

Planned improvement

initiatives (Change Ideas)Methods Process measures

Target

for process measureComments

created

communication

tool

New indicator:

Collecting baseline data

to compare and set

target in the following

fiscal year.

Joint effort with Health Links

to develop a communication

tool between Health Links and

referring care providers.

All Health Link clients will have completed care plans

shared with their primary care provider at Chigamik.

This correspondence will be added to the clients charts

as response to referrals.

done/not done 100% of Chigamik clients

using Health Link

navigators will receive

current care plans and

client status reports.

New indicator:


to compare and set


fiscal year.

Clients with diabetes, who are

identified at risk of developing

foot ulcers, are assessed by a

trained foot care nurse using

the monofilament test.

Clients will be identified by their providers or the foot

care nurse and the test will be administered.

done/not done 20% of all clients with

diabetes over the age of

18 will be assessed for

risk of foot ulcers.

Percentage of clients with

diabetes, aged 40 or over, with

two or more glycated

hemoglobin (HbA1C) tests

within the past 12 months.

A % / clients with

diabetes, aged 40

or over

EMR 91566* 57.70 80.00 By the end of fiscal year

2017/18 we aim to be

having 80% of our

clients with diabetes

(aged 40 or over) have

a minimum of 2 HbA1C

high 1) Nurse to review all eligible

medical records to ensure

clients are coming in twice a

year for HbA1C testing.

A quarterly report of eligible clients will be shared with a

delegated staff member to complete a medical record

review. All clients with missed tests will be contacted to

schedule a HbA1c test, as required.

done/not done Quarterly report.

100% of eligible clients

contacted to schedule

testing.

Equity New indicator:


to compare and set


fiscal year.

1) Improve socio-demographic

data collection methods with

non-rostered clients

(community members),

specifically equity-based

indicators.

Upon program registration, community members will be

asked to answer questions about OHIP, social

determinants of health, self-identification, Core 8

variables, Loneliness scale, sexual orientation, and

gender. We hope to use this data to inform program

planning as of 2019-20.

Number of non-rostered clients who receive and are

asked to complete a community intake form.

By end of 2018-19, 70%

of non-rostered clients

will have been asked to

complete a community

intake form.

1) Ensure the Client Experience

Survey is implemented

appropriately.

In 2017-18, a plan was developed to ensure good data

collection and sampling throughout the year. This year,

we will aim to Implement the plan accordingly and have

a biannual connection with clients by telephone to

prompt survey completion..

Number of clients who complete the survey. 250 responses per

annum.

2) Review client and

community member

compliments and complaints.

In 2017-18, the client relations process was reviewed

and enhanced. This year, we will conduct bi-annual

audits to watch for emerging trends and key issues.

done/not done 2 audits per year.

1) Develop and implement

process for easy report-

retrieval of clients with 6+

months of controlled

substance use.

Develop an easy report template to be retrieved on a

quarterly basis and shared with providers to encourage

controlled substance use medication review.

done/not done Quarterly report as of Q3

2018-19.

2) Providers to conduct

medication review of clients

charts with 6+ months of

controlled substanced use.

Physicians and Nurse Practitioners will identify

qualifying clients as prescription requests are received.

Clients will be called to come for appointments to

review medications and where appropriate begin the

tapering process.

Percentage of clients with 6+ months of controlled

substance use with completed medication review.

By end of 2018-19, 30%

of clients with 6+ months

of controlled substance

use will have completed

a medication review.

1) Pilot a same-day

appointment model.

As part of a quality improvement initiative, we are

piloting an appointment model whereby most

appointments are made same-day, with the exception of

4 appointment slots per day for advanced booking (such

as required follow-ups or based on other individual

needs).

Number of appointments booked same-day vs.

appointments booked beforehand.

By end of 2018-19, we

hope to change our

appointment model

permanently so that 70%

of all appointments

made will be same-day.

This is a change idea

that will begin its

PDSA cycle in Q1

2018-19.

2) Efficient booking of follow-

up appointments quality

improvement initiative.

As part of a quality improvement initiative, clients

requiring a follow-up appointment (after an initial visit)

are given a paper slip from the healthcare provider to

bring to the reception. Slips are tallied at the end of each

month to identify trends in reasons for follow-up visits

and to identify which providers request the most follow-

up visits.

Monthly report tracking paper slips and reasons for

follow-up appointments.

Reduction in the amount of unnecessary follow-up

appointments (and promotion of making same-day

appointments).

Monthly report.

Increase access to same-

day afternoon

appointments by 20%.

No data has been

compiled to date on

these indicators. The

data will be collected

over 2018-2019.

Greater focus this

year on proper data

collection; next year,

improvement

initiatives will more

directly impact

results.

Safe Medication

safety

Percentage of clients with 6+

months of opioid and

benzodiazapine use who

participate in a medication case

review.

highModerate target allows

time for data collection

process to be

developed and

implemented, then

some action.

30.00CB91566*A % / clients with

6+ months of

controlled

substance use

(see specific

substances)

EMR/Chart

Review

79.71

medium

medium

Timely 27.42 35 Target is set based on

the North Simcoe

Muskoka LHIN "primary

care" indicator average

of 30.9% (March 2018).

In addition, our Centre

aims to pilot a same-

day appointment

model.

2018/19 Quality Improvement Plan"Improvement Targets and Initiatives"

Centre de sante communautaire CHIGAMIK Community Health Centre Inc. 10-845 King Street, Midland, ON L4R 0B7

88.00Person

experience

Percentage of clients who stated

that when they see the doctor

or nurse practitioner, they or

someone else in the office

(always/often) involve them as

much as they want to be in

decisions about their care and

treatment; client perception.

P % / surveyed

sample of clients

In-house survey /

April 2017 -

March 2018

91566*

Equitable

ODD, OHIP-

CHDB, RPDB

highTimely access

to care/

services

Percentage of clients who stated

that they were able to see a

doctor or nurse practitioner on

the "same day" or "next day",

when needed; client perception.

P % / surveyed

sample of clients

In-house survey /

April 2017 -

March 2018

91566*

91566*

Patient-

centred

This is an ambitious

target, set based on the

North Simcoe Muskoka

LHIN "primary care"

indicator average of

87.6% (March 2018).

CB CB

A % / clients

meeting Health

Link criteria

Population

health

Percentage of non-rostered

clients (community members)

who provide self-reported socio-

demographic and equity-related

data.

C % / non-rostered

clients

(community

members)

participating in

programs.

Effective

91566* CB CB mediumPercentage of clients with

diabetes, age 18 or over, who

are identified at risk of foot

ulcers are assessed for pedal

neuropathy.

91566* CB CB mediumCoordinating

care

A % / clients with

diabetes, aged 18

or older

EMR/Chart

Review

Wound Care

Percentage of clients identified

as meeting Health Link criteria

who are offered access to

Health Links approach.

quality improvement plan (qip) narrative for health care … · 2019. 4. 18. · insert...

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