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Almonte General Hospital 1 75 Spring Street, Almonte Ontario K0A 1A0

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

25/03//19

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

Almonte General Hospital (AGH) is a small, rural hospital located in Almonte, Ontario, 40 kilometers west of

downtown Ottawa. It serves a catchment population of over 30,000 people. The Hospital offers a wide range of

acute and continuing care services including an Emergency Department. There are 21 Medical/Surgical beds,

five level-one Obstetrical beds, 26 Complex Continuing Care beds and two Operating Rooms. In addition, the

Hospital operates the Fairview Manor (FVM), a 112 bed Long Term Care Home located on the Hospital campus,

as well as the Lanark County Paramedic Service. The Hospital campus also includes the Ottawa Valley Family

Health Team; the Leeds, Grenville & District Health Unit and Lanark County Mental Health. Together, these

facilities provide our patients and residents with integrated, coordinated healthcare to support their seamless

movement from one care setting to another.

This year’s Quality Improvement Plan (QIP) builds on the success of the Mississippi River Health Alliance

(MRHA), which includes AGH and Carleton Place & District Memorial Hospital (CPDMH) aligning the QIP

initiatives for both organizations. We will be focusing on improving the quality of the patient experience through

completion of post discharge phone calls to determine a streamlined discharge process, improving patient safety

through revising the medication reconciliation process both on admission and discharge, ensuring best practices

are in place through the use of pre-printed orders, enhancing patient safety through validation of Point of Care

Testing and focusing on ensuring a safe workplace for staff. Fairview Manor will be building on the successes

from this past year to reduce falls and in reducing use of antipsychotics for residents, implementing a

multidisciplinary approach to increase or maintain physical activity, enhance resident experience by timely

complaint acknowledgement and focus on ensuring a safe workplace for staff.

Describe your organization's greatest QI achievements from the past year

AGH and FVM are very pleased to have initiated a partnership with Studer/ Huron Consulting called “Better

Together” to implement an Evidenced-Based Leadership Framework to promote leadership accountability,

leadership training and staff and physician engagement with the ultimate goal of enhancing patient/resident care

and experience. Through this partnership we have implemented a leadership evaluation tool, a rounding for

outcomes model and the roll-out of AIDET through-out the organization. We are excited to continue this

partnership with Studer/Huron Consulting to enhance evidenced based processes through-out the organization.

In addition we are very proud of the success of surpassing our corporate goal of achieving a 75% flu vaccination

rate for staff and physicians with overall staff and physician rate at 81%. A flu vaccine campaign was launched

and promoted through-out the organization to promote the benefits of receiving the flu vaccine to our staff,

physicians, patients and their families.

Eighty eight percent of responses to the survey question of “would you recommend this hospital to friends and

family” did agree which is greater than our 80% target collected through the National Research Council mail-out


survey. In addition to these survey results a post discharge survey tool was developed for the Med/Surgical Unit

and initiated in September to follow-up with patients following discharge from the hospital. The results for would

you recommend this hospital came through with an excellent result of 100%. AGH launched a major campaign to

enhance medication reconciliation on admission and at discharge. Medication reconciliation education has been

provided to all staff and physicians and our rate of compliance to complete medication reconciliation at admission

is at a 93% completion rate. Medication reconciliation at discharge is improving steadily and we will continue to

monitor completion within next year’s QIP again.

The Fairview Manor (FVM) have put strategies into place to successfully reduce the number of Emergency

Department visits by residents through partnerships developed with AGH Emergency physicians and staff. This

work provides timely care to residents without the stress of transferring from their residence. The team has also

decreased the percentage of antipsychotic medications prescribed without a diagnosis of psychosis through

timely medication reviews on admission, consultation services provided by Lanark Mental Health Services and the

utilization of the Behavioral Support Ontario (BSO) program at FVM. Ongoing education for staff have included

Gentle Persuasive Approach (GPA), PIECES and Teepa Snow strategies.

A major focus at FVM was to decrease the number of falls of residents while limiting use of restraints. A monthly

multidisciplinary meeting is held where an in-depth analysis of the fall patterns of residents are reviewed and

prevention options implemented. A debrief process following a fall is initiated following a fall to investigate root

cause of the fall and modifiable factors to prevent further falls. Additional equipment has been purchased to

support residents through the falls prevention program.

Resident, Patient, Client Engagement and relations

AGH has a very active Patient and Family Advisory Committee (PFAC) to assist the hospital in delivering quality

health care services around the needs of our patients and their families. The meetings are bi-monthly and the

PFAC Committee members have been very engaged and committed to improving the patient experience.

Through-out the year the PFAC Committee has been advising the hospital on initiatives such as the Patient/

Resident Feedback Form, Patient Incident Policy, Medication Reconciliation, Post discharge phone calls and how

to promote partnerships with patients and families. The members will advise on ways that AGH can continue to

learn from and incorporate the patient and family experience in its actions and processes as the organization

continues to enhance a patient and family centered approach. A PFAC member recently presented at a

Leadership Development Institute to promote the work of the PFAC Committee but more importantly to encourage

promotion of partnerships with patients and family in our care processes.

FVM have well-established and engaged Resident Council and a Family Council. The Councils meet monthly to

discuss any issues that the residents/families bring forward as well as to share information from the

organization. The councils focus on issues that directly impact the quality of life and safety of the residents and


they also provide input on existing and new initiatives. The FVM Family Council have assisted with development

of the Resident Satisfaction Survey and have advised the staff on improvements recommended for the home,

enhancements to the Falls Prevention Program and ideas for the new Walking Program. FVM QIP initiatives are

presented at resident and family councils and ideas generated for indicators to select for the upcoming year.

Workplace Violence Prevention

Almonte General Hospital (AGH) is committed to staff safety, which in turn, creates a safer environment for

patients and families. AGH strives to provide and advocate for an environment that reduces the risk of all types

of violence and harassment in the workplace, as reflected in the 2018/19 Quality Improvement Plan to track the

number of workplace violence incidents reported by hospital workers.

A variety of measures have been developed to support an ongoing culture of safety:

Risk Assessments are conducted throughout the organization and includes a physical environmental risk

factor review as well as capturing any specific concerns of staff.

Security measures which includes the use of surveillance cameras and the locking of entrance doors

between 2300h – 0700h.

Communication tools which includes the use of panic alarms both hard-wired and personal devices

worn by frontline staff and/or staff members working in isolation.

Training and Education which includes all staff participating in the annual completion of an electronic

learning module on the E-Learning Management system. Class room sessions/workshops are offered to

front line workers teaching de-escalating techniques and physical safety techniques. Front line staff who

may have direct interactions with patients including clinical staff (including paramedics and physicians),

dietary services and housekeeping staff.

Incident management and electronic reporting that allows staff to report concerns about patients that

pose a safety concern and provides the organization with an opportunity to identify organizational

needs or improvement opportunities. Incidents are reported at the occupational Health and Safety

Committee.

Patient Flagging through the use of communication on the EMR as well as the use of physical signage

outside the patient’s room directing non-clinical staff to check at the nursing station for further

information. This allows staff to be aware of the potential for identified individuals to exhibit acting out

behaviours placing the staff member at increased risk. The Violence Flagging Policy and Procedure was

developed and approved by the Senior Leadership Team and education provided to all staff.

Program Evaluation and ongoing monitoring will allow the effectiveness of these initiatives to be

evaluated.


As mentioned earlier, the integrated Director of Occupational Health and Safety will work closely with both

hospitals (AGH and CPDMH) to ensure workplace violence education and training are provided for staff this year.

Performance Based Compensation

In Accordance with legislative requirements, the following positions (Senior Management Team) are subject to

performance-based compensation:

• President and Chief Executive Officer

• Chief of Staff

• Vice President, Patient Services and Chief Nursing Executive

• Vice President and Chief Financial Officer

• Vice President, Corporate Support Services

The performance-based compensation plan reflects our corporate values and has been created to contain

congruent, non-conflicting, goals for each member of the Senior Management Team, and which rewards the

members for working together towards achievement of the goals.

Achievement of the goals is measured on a 5 point scale, with 3 being acceptable performance. If the Senior

Management Team achieves an average score of 3 or greater across the goals, each member will be paid 100%

of the at-risk compensation. If the Senior Management Team achieves an average score of 2 or lower, the at risk

compensation will be reduced.


2019/20 Senior Management Team Performance Goals and Structure

Domain

Indicator and Target

% of Salary Linked to Achievement of QIP Target

Scale AGH & FVM

Safety – AGH and FVM

Percentage of full-time and part-time staff and active medical staff trained on the management and reporting of Workplace Violence. Target is 90% by December 2019

Score Measure

5 > 96%

4 91% to 95%

3 90%

2 75% to 89%

1 < 74%

Domain Indicator and Target Scale AGH

Medication Safety – AGH

Percentage of discharged patients for whom a Best Possible Medication Discharge Plan was created. Target is 85% in Q3 and Q4

5 > 96%

4 86% to 93%

3 85%

2 70% to 84%

1 < 69%

Domain Indicator and Target Scale AGH

Patient Experience –

AGH

Percentage of complaints acknowledged to the individual who made the complaint within 5 business days. Target is 75%

5 > 91%

4 76% to 90%

3 75%

2 65% to 74%

1 < 64%

Domain Indicator and Target Scale FVM

Resident Experience –

FVM

Percentage of complaints acknowledged to the individual who made the complaint within 5 business days. Target is 90%

5 > 96%

4 91% to 95%

3 90%

2 75% to 89%

1 < 74%

Domain Indicator and Target Scale FVM

Effective Care – FVM

Percentage of Medication Reviews completed within 72 hours of admission.

Target is 90% in Q3 and Q4

5 > 96%

4 91% to 95%

3 90%

2 75% to 89%

1 < 74%

AIM Measure Change

Quality

dimensionIssue Measure/Indicator Type Unit / Population Source / Period Current performance Target Target justification

Planned improvement initiatives

(Change Ideas)Methods Process measures

Target for process

measure

Safe

ty

Workplace

Violence

Prevention

(WVP)

Number of reported

workplace violence incidents

by hospital workers (as

defined by OHSA) within a 12

month period.

M Total count of reported

incidents

Internal data collection

20184 incidents reported

> 4 incidents reported

in 2019

To increase the reporting of

WVP incidents in the work

setting.

Provide lunch & Learn sessions on

mgmt and reporting of WV

incidents 2x/year.

Develop new LMS module for

WVP. Promote safety culture -

share results with staff on units

Education to staff

Number of staff

that complete LMS

module by

December 2019

90% of FT/PT staff

and Active Medical

Staff trained on

WVP by Dec. 31

2019

Patient

Experience

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?

Focus on Obstetrics patients.

P% of survey respondents

who answered "completely"

NRC Data Q1 to Q3

2018/19

71.7% Q1 to Q3

Ont. top 10% 76.8%

Ont. average 62%

77%

Q3 and Q4 2019/20

To meet or exceed

provincial top 10% of

76.8%.

Develop a post dischage phone

survey for obstetrics patients by

August 2019.

Survey all patients dischaged home

from Obstetrics starting Sept.

2019.

Develop action list from feedback

received from surveys.

Post discharge phone

calls by Obstetrics staff to

patients within 48 hours.

Number of OBS

post discharge

phone calls /

number of

discharges per

quarter.

80% of OBS

patients called post

discharge.

Patient

Experience

% of complaints

acknowledged to the

individual who made a

complaint within 5 business

days.

P

# of complaints

acknowledged within 5

business days divided by

the total # of complaints

received in the reporting

period

Internal data collected

quarterly.

No Baseline data90%

2019/20

This is a new indicator.

Response rate not collected

in past.

Educate Managers and physicians

on new Patient Relation form.

Forms are to be completed and

complaints acknowledged within 5

business days.

Collect all forms in CNE office.

Manual data collection

into excel spread sheet.

% of Managers

educated.

100% Managers

educated

Effe

ctiv

e

Care

Completion rate of

Congestive Heart Failure

(CHF) order sets on patients

with Most Responsible

Diagnosis of CHF.

C# of CHF order sets / # Most

Responsible Diagnosis of

CHF patients


quarterly.No Baseline data

75%

Q3 and Q4 2019/20


Start to reach target by Q4.

Education to physicians and staff.

Track utilization of order sets.

Educate Physicians and

Staff by July 15, 2019

Health Records to start

capturing data August

2019.

% of physicians and

staff educated.

% order sets used

75% of physicians

and staff educated.

Number of CHF

order sets used /

Number of CHF

Most Responsible

Diagnosis

Pat

ien

t C

en

tere

d

Almonte General Hospital "Improvement Targets and Initiatives"

2019/20 Quality Improvement PlanLegend

M = Mandatory (all cells must be completed)

P = Priority (complete ONLY the comments cell if you are not working on this indicator)

A = Additional (do not select from drop down menu if you are not working on this indicator)

C = custom (add any other indicators you are working on)

AIM Measure Change

Quality




Target for process

measure

Care

Completion rate of Sepsis

order sets on patients with

Most Responsible Diagnosis

of Sepsis.

C# of Sepsis order sets / #

Most Responsible Diagnosis

of Sepsis patients


quarterly.

No Baseline data75%

Q3 and Q4 2019/20


Start to reach target by Q4.

Education to physicians and staff.

Track utilization of order sets.

Educate Physicians and

Staff by July 15, 2019

Health Records to start

capturing data August

2019.

% of physicians and

staff educated.

% order sets used

75% of physicians

and staff educated.

Number of Sepsis

order sets used /

Number of Sepsis

Most Responsible

Diagnosis

Safe Care/

Medication

Safety

Medication reconciliation at

admission: Average Med Rec

quality score at admissionA

Average Med Rec Quality

Score at admission

based on Safer

Healthcare Now Patient

safety metrics score

Internal data (Med Rec

quality audit tool built

into Cerner) collected

quarterly.

February/March 2019

40%60%

Q3 and Q4 2019/20

Certification process will

impact quality.

Develop certification process.

Process developed and

certification initiated in June 2019.

BPMH certification for ER, OBS, RR,

Pre-Op Nursing nursing staff.

Pharmacy technician staff to

update home meds after discharge.

This will require significant

Pharmacist resources to do initial

certification.

Cerfiy ER, OBS, RR, Pre-

Op, Nursing staff by

August 2019. Certify

Pharmacy Technicians to

update home meds by

June 2019.

Note: certification

requirements will be

different for diferent

areas.

% of ER, OBS, RR,

Pre-Op, Nursing

staff / Pharmacy

technician staff

who successfully

complete

certification.

50% staff trained by

July 2019.


August 2019.


September 2019.

Safe Care/

Medication

Safety

Medication reconciliation at

discharge: Total number of

discharged patients for whom

a Best Possible Medication

Discharge Plan was created as

a proportion the total

number of patients

discharged.

PRate per total number of

discharged patients


quarterly.

Q3 data 2018/19

57% 75%

Q3 and Q4 2019/20

Compliance improving with

each quarter in 2018/19

Complete education with all

prescribers on D/C Med Rec.

Complete education for Nursing

and Ward Clerk Staff re: Form

Completion.

Educate prescribers re:

discharge med rec

process. Educate nursing

and ward clerk staff re:

form completion.

% of prescribers

who have received

education on Med

Rec on D/C.

% of Nurses and

WC's trained on

D/C Med Rec Form

completion

75% of prescribers

trained.

80% of Nurses and

WC's trained

Safe Care/

Medication

Safety

Repeat measure of initial

critically high Point of Care

Test (POCT) glucose values

within 10 minutes

CGlucometer readings >20 on

patients requiring BS

measurement


quarterly.

Q3 and Q4 2018/19

38%90%

Q3 and Q4 2019/20

Target set high based on

significance of completing

this practice

Update Policy & Procedure by July

2019.

Educate nursing staff on P & P by

August 2019.

Post signs on glucometers to

repeat high values.

Run monthly report to

identify specific users not

in compliance and

complete follow up

starting September 2019.

Monthly report sent and

reviewed by staff.

% of nurses

educated by

September 2019.

% glucometer

readings > 20

repeated

80% of nurses

educated by

September 2019.

90% glucometer

readings >20

repeat tested.

Effe

ctiv

e

AIM Measure Change

Quality




Target for process

measure

Safe

ty Workplace

Violence

Number of reported

workplace violence incidents

by resident staff(as defined

by OHSA) within a 12 month

period.

M Total count of reported

incidents Internal data collection

201838 incidents reported

>38 incidents reported

2019

To increase the reporting of

WVP incidents in the work

setting.

Provide lunch & Learn sessions on

mgmt and reporting of WV

incidents 2x/year.

Develop new LMS module for

WVP. Promote safety culture -

share results with staff on units

Education to staff

Number of staff

that complete

LMS module by

December 2019

90% of FT/PT staff

and active medical

staff trained on

WVP by Dec. 31

2019

Pat

ien

t C

en

tere

d

Patient

Experience

% of complaints

acknowledged to the

individual who made a

complaint within 5 business

days

P

# of complaints

acknowledged within 5

business days divided by

the total # of complaints

received in the reporting

period


quarterly.

No Baseline data90%

2019/20


Response rate not collected

in past.

Educate Managers and physicians

on new Patient Relation form.

Forms are to be completed and

complaints acknowledged within 5

business days.

Collect all forms in CNE office.

Manual data collection

into excel spread sheet.

% of Managers

educated.

100% Managers

educated

Care

% of residents who fell during

the 30 days preceding their

resident assessmentC

# of residents who fell

during the 30 days

preceding their resident

assessment

Internall data collection

Q1 to Q3 2018/1917.16%

14.5%

Q2 and Q3 2019/20Provincial target 14.5%

Implement walking programs

Integrate new equipment to

prevent falls

Regular resident reassessment

Monthly multi-D falls meetings


#patients

participating in

walking program

50% particiaption

of residents who

meet criteria to

participate

Care

% of residents who were

given antipsychotic

medication without diagnosis

of psychosis

C

# of residents who were

given antipsychotic

medication without

diagnosis of psychosis

Internal data collection.

Q1 to Q3 2018/19 20% 17.7%

Q3 and Q4 2019/20Provincial Average

Med reviews on admission

Liason with Lanark Mental Health

Team

De-prescribing on admission

Maximize BSO Program


# of med reviews

on admission

within 72 hours

# of assessments

by North Lanark

Mental Health

Team

90% Med Reviews

within 72 hours on

admission

Care

% of residents with decreased

mid-loss ADL.

Mid loss includes: transfer,

locomotion on unit, walking

corridor

C# of residents with

decreased mid-loss ADL


quarterly

RAI Tool

2018/19

36.45%35%

Q2 and Q3 2019/20Provincial average 35%

Initiate walking program

Enhance physio participation with

residents

Multi discipline approach to

increasing or maintaining physical

activity

More consistent data collection

Enhancing activity of

residents.

% participants in

walking program

% of residents

who met criteria/

those who

participate

50% particiaption

of residents who

meet criteria to

participate

Effe

ctiv

e

Fairview Manor "Improvement Targets and Initiatives"

2019/20 Quality Improvement PlanLegend

M = Mandatory (all cells must be completed)

P = Priority (complete ONLY the comments cell if you are not working on this indicator)

A = Additional (do not select from drop down menu if you are not working on this indicator)

C = custom (add any other indicators you are working on)


Contact Information

Joyce Rolph

VP Patient Care Services & Chief Nursing Executive

[email protected]

613-256-2514 ext. 2235

Other

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) Mr. Randy Larkin Quality Committee Chair ________________________ (signature) Mrs. Faith Bird

Chief Executive Officer ____ (signature) Mrs. Mary Wilson Trider Other leadership as appropriate ________________________ (signature)

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