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

3/16/2017

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.

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Overview Rainbow Valley CHC (RVCHC) identifies quality improvement opportunities which inform the QIP through such internal processes as client feedback, complaints processes and team meetings as well as local, regional and provincial initiatives including Health Links. Priorities include identification of those complex clients (for specific diagnoses) who are high users of the health system and ensuring processes are in place to reduce emergency room visits and hospital admissions for this group ensuring alignment with Health Links initiatives. This will build on existing hospital and community partnerships to ensure the timely sharing of discharge summaries enabling RVCHC to schedule follow-up appointments within 7 days of discharge. The integrated RVCHC/St. Francis Memorial Hospital Strategic Plan focuses on four priority areas – Quality of Care, System Integration, Strength in People and Financial Performance. Within each of these areas, goal statements are supported by action-oriented outcomes which are reflected in the organizational priorities of RVCHC. These include: Quality of Care – We continue to look for opportunities for clients, community and partners to offer feedback on services and recommendations for change through surveys, complaints process, partnership meetings. A Rainbow Valley CHC client now sits on the Patient and Family Advisory Committee of the organization. Achieving and maintaining MSAA targets will continue to be a high priority as will sustaining client programs such as Seniors' Fitness, Smoking Cessation, Social Work and Diabetes care. Emphasis continues to be placed on ensuring that client services are enhanced due to optimizing data collection opportunities for practitioner efficiencies (ex: cancer and pap screenings). RVCHC is participating in Health Quality’s Primary Care Reporting Quality Indicators to better equate services and compare achievement of targets across the Champlain CHC region. System Integration - Expanding & sustaining community partnerships such as the home visiting paramedic initiative, Healthy Communities Partnership, collaborative project with local seniors’ centre to offer education & activities, e-Consults, Health Links and Primary Care Network. RVCHC, in partnership with SFMH, participates in a joint, multi-partner ethics committee which provides education opportunities with a focus on community cultural diversity. The Rainbow Valley CHC Executive Director has recently become a member of the Board for the Killaloe Community Resource Centre, with a view to develop future partnerships. RVCHC is a member of the Association of Ontario Health Centres (AOHC). The COO of SFMH regularly attends these meetings as the RVCHC Executive Director. In addition, a representative of the Board of Directors has attended the semi-annual constituency meetings. In addition, the unique integrated employment relationship between the Manager of Health Services RVCHC and SFMH has allowed for increased access to the Manager of Health Services 5 days a week instead of the paid 3 days per month resulting in increased and timely flow of communication. A Rainbow Valley CHC physician attends and reports on the RVCHC activities to the monthly Medical Advisory Committee. This, in addition with the Manager of Health Services has increased RVCHC

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organization representation at all levels including: management, physician and committee. Recently, RVCHC was able to build on the SFMH OTN agreement to permit RVCHC staff to access the OTN platform including clinical and educational opportunities at no charge to the CHC. Strength in People - Continue to work at recruitment of practitioners to meet funded positions through innovative approaches including partnership with SFMH to create shared full time opportunities. Continue to work with SFMH to provide a venue for professional staff to access continuing education and practice expertise through such opportunities as Medical Advisory Committee for physicians and Emergency Room experience for nurse practitioners. RVCHC continues to face Human Resources challenges due to the nature of part time positions. At times, we have had funds available to increase Nurse Practitioner hours, but due to staff having primary positions elsewhere, they were not available. We have been fortunate to recruit a new Social Worker (1 day per week). Due to a reduction in practice following a return from Maternity leave, we have not been able to utilize all of our physician hours which has impacted our MSAA indicators. A plan is in place to address this and our hope is to increase roistered patients, increase same day appointments and decrease waiting time for appointments. Our goal for the upcoming year is to stabilize Human Resources in order to alieve any client anxiety about loss of practitioners. Financial Performance – RVCHC continues to be accountable for financial stability while advocating for funding to provide basic services that align with the CHC Model of Care including health promotion/prevention and community development. These services are critical components of a functional care package that supports facilitated self-management for those with chronic illnesses and recurring hospital visits. At the present time, RVCHC continues to function only on a part time basis (3 days per week) which significantly reduces access to primary care for community residents and limits ability to recruit professional practitioners. RVCHC, and its sponsor SFMH, will continue to advocate on behalf of their clients to the Champlain LHIN for increased investment in order to maximize primary care benefits to the communities as clearly identified in a 2015 Needs Assessment. The people living and working in RVCHC’s catchment area are committed to working together and leveraging community assets to meet their primary care needs, however it is also recognized that a base level of investment is required to move forward. While progress has been made, the current funding and mode of operations is not optimal. The submitted assessment outlined the service and infrastructure investments required to ensure that the primary health care needs are met and health system efficiencies can be realized. There is a shared belief throughout the community that RVCHC has the potential to evolve in a way to fully meet the primary health care needs of those living in the northern portion of South Renfrew County. When given the opportunity to provide feedback in the annual client satisfaction survey on how RVCHC can improve, 47% of all client comments requested increased clinic hours and access to practitioners. This cannot be realized without financial investment.

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Compounding this, with more than half of the local physician compliment contemplating retirement over the next 2 years, there is a genuine need to see investment in RVCHC so it can assume a pivotal role in supporting the health and well-being of people living in the area. Otherwise these patients will be left without a primary care practitioner and will instead be left with no choice but to utilize the local hospital emergency room services.

QI Achievements From the Past Year In a move to improve the physical workspace for both clients and staff, management committed to removing all asbestos and lead pipes from the building. Due to project spread, this also provided opportunity for upgrades to electrical wiring, heating and cooling, plumbing, IT networking, lighting, flooring, painting and addressing privacy and confidentiality in the practitioner rooms on both floors. RVCHC recruited new social worker for one day per week and worked with partner hospital to recommend same social worker for Health Links position keeping employee in the rural area and increasing continuity of care. The increased mental health service should allow for support of community individuals who are not primary care clients of RVCHC which has not been offered previously. RVCHC initiated monthly privacy audits of access to client records throughout EMR. These are completed by our IT specialist and submitted to the Privacy Officer. To date, there has been no unauthorized activity. Changing from an in house satisfaction survey to the HQO Primary Care Satisfaction survey and signing on to participate in Health Quality’s Primary Care Reporting Quality Indicators have allowed for better comparative data which is shared with the team. Findings from those decisions include: - Distribute surveys twice a year instead of once per year to target summer residents as our area sees an increased population in the summer months due to seasonal cottagers. - Give clients advance notice that we will be requesting them to complete the survey and advise them of the time required at the end of the appointment so they can make arrangements and not feel pressed to complete. -Satisfaction survey results have allowed us to better equate services and setting/achievement of targets - Results from the annual Patient Experience Survey continue to be very high with 99% “probably” and “definitely” recommending services to family and friend. The overall satisfaction rate with care provided at RVCHC averages 92.77%. - Provides feedback on staff performance from the client perspective - Confirms our needs assessment as we see repeated requests (47% of all client comments) for additional staffing hours - Share and assess anecdotal comments along with statistical information as often this is the most informative Future QI Improvements include: MDRD services, lab services, increased Social Services

Population Health The Aging Population The South Renfrew HLA has the highest proportion of seniors of all Health Link Areas in the Champlain LHIN with 22 per cent of the population over 65, of which half are over 75. At the census division level, our local area has the highest proportion of seniors (23.1%) in Renfrew County. Population projections also predict Renfrew County will

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have the highest growth of senior age cohorts in the Champlain LHIN. This is of particular significance when planning for health and community care services; seniors have significantly higher health service utilization rates than the younger age cohorts. Renfrew County also has the highest dependency ratio in the Champlain LHIN. This is due to the high proportion of seniors and the low proportion of younger age cohorts. See Population Projections by Age Cohort (attached) Health Status The residents of the Renfrew County possess higher rates for several risk factors associated with poor health and increased health service utilization. See Risk Factors (attached) Compared with to other Champlain LHIN Health Link Areas, residents of the South Renfrew HLA have a lower life expectancy, higher rates of infant mortality and deaths related to chronic diseases. South Renfrew HLA residents’ mortality rates are higher than Champlain LHIN for six of the ten leading causes of death. RVCHC works to tailor programs accordingly to meet these needs ex: Partnership with the Lanark Renfrew Lung Health Program which increases awareness about lung disease. See Top 10 Leading Causes of Death - % Higher or Lower than Champlain for Age- adjusted Mortality Rates (attached) Overall, the growing need for health care services within the communities served by RVCHC will result from • the aging population • the high rate of risk factors associated with poor health and increased health care use among the population • the significant travel distances to access services in other communities See Population Projections for Renfrew Census Division (attached)

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Equity RVCHC continues to offer staff education opportunities that capitalize on partnerships such as regional CHC initiatives that create education modules for use by all CHC teams (e.g. cultural sensitivity, Human Rights, Equity.) 94% of clients responded “very good” or “excellent” to the question: “they treated you with dignity and respect.

Integration and Continuity of Care RVCHC continues to participate in an interagency collaborative (Madawaska Community Circle of Health – MCCH) through representation by the shared COO. The MCCH includes hospital, long-term care, community health and support services, CCAC and mental health and holds a collaborative mandate to enhance and support the health of all residents in the Madawaska Valley through rural health hub planning. As such, the MCCH was a critical driver of the South Renfrew Health Links initiative which was the first Health Links in the area to have its business plan approved and begin to see clients. The South Renfrew Health Links has continued to expand beyond original scope and during the past year the RVCHC team continues to work with the South Renfrew Health Links Director and Nurse Navigator to develop a plan to maintain/update the coordinated care plan for Health Links clients transitioned to RVCHC. Partnering with local health and social service providers supports an integrated system that respects diversity, optimizes expertise and realizes efficiencies. Integrating with St. Francis Memorial Hospital has supported opportunities for partnering in such areas as staff education, infection control, medical devise reprocessing, payroll, bulk purchasing and utilizing services provided by the RVCHC Respiratory Technologist (e.g. smoking cessation and spirometry). Future partnering (if funding allows) would include social workers providing individual and group counseling. RVCHC also provides space for other health providers to offer services such as mental health outreach and addictions and supports the concept of a ‘hub’ through agreements with such specialties as women’s shelter counseling, massage therapy and chiropractic services. A regional Active Aging partnership has been formed with Barry’s Bay and Area Home Support to recruit, train and retrain a diverse group of leaders, staff and volunteers to promote, organize, lead and advocate for initiatives that encourage physical activity in our communities. Finally, RVCHC was the lead agency for the Renfrew County Community Study. This study was implemented as an initiative of the Health Communities Partnership – Renfrew County (HCP) of which RVCHC is a member. HCP is a collaborative made up of multi sector stakeholders committed to improving the quality of life, health and well-being of our communities and residents. The Collaborative focused on the development of healthy policy and coordinated community efforts that positively address the physical, mental, social, environmental and economic health of our communities and community members. The Renfrew County Community Study built on the earlier work of the Community Picture to further understand how the Social and Environmental Determinants of Health are shaping our local statistics and is a partnership with the University of Ottawa.

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Access to the Right Level of Care - Addressing ALC Issues With the only other physician in the community contemplating retirement, RVCHC could experience a large influx of orphaned patients. However, without additional resources, we cannot increase hours of operation or staffing. Adding clients to the roster without additional resources has the possibility to increase wait times, increase stress on practitioners, decrease quality due to time constraints and therefore decrease client satisfaction.

Engagement of Clinicians, Leadership & Staff RVCHC is a small organization with no full time staff and a complement of eight regular part time staff, one relief staff and one regionally shared staff. Currently, team meetings (where QIP is a standing agenda item) are held on a monthly basis providing an opportunity to discuss challenges and improvement ideas as well as the evaluation of new programs and services. Updates on regional and provincial initiatives are also brought to these meetings including information on Health Links. Staff are invited to be RVCHC representatives on regional initiatives to support engagement and to attend educational events and provincial forums such as the annual CHC conference. These meetings also provide a venue to share information from education sessions and external committee meetings. Staff attend meetings either in person or via teleconference and minutes are shared. A shared electronic space has been created where all staff can discuss ideas, issues and opportunities in real time. The Manager of Health Services attends all team meetings and provides updates to the Executive Director who represents the CHC at regional and provincial meetings including Health Links meetings. The Board of Directors of SFMH and RVCHC continue to participate in education opportunities to develop knowledge and understanding of the unique challenges facing CHC’s. Our focus last year was to build engagement between staff, clinicians and Leadership. Attendance at team meetings by Sr. Leadership has provided opportunity to strengthen ties between staff and leadership and expand knowledge of the unique needs of both organizations. In addition, the unique employment relationship between the Manager of Health Services RVCHC and SFMH has allowed for increased access to the Manager of Health Services 5 days a week instead of 3 days per month resulting in better flow of communication. A Rainbow Valley CHC physician attends and reports on the RVCHC activities to the monthly Medical Advisory Committee. This, in addition with the Manager of Health Services has increased RVCHC representation at all levels including: management, physician and committee (recreation).

Resident, Patient, Client Engagement RVCHC works with their patients and residents to focus on keeping them, and the community in which they live, in good health through delivery of primary care services and health promotion. This is achieved through the following ways: Following the direction set out by HQO and “Patients First”, a Rainbow Valley CHC client sits on the Patient and Family Advisory Committee of St. Francis Memorial Hospital to better engage clients in the development of QIP activities and ongoing quality feedback.

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- Annual Client Satisfaction surveys – results are shared and discussed with all staff - Ensuring client visits are scheduled appropriately giving practitioners enough time to ensure “whole health” is discussed and assessed - Ensuring clients and caregivers are always invited to attend appointments together, as needed or as appropriate in order to receive feedback from all - Home visits or phone appointments by Physician, Nurse Practitioner, RN as needed allow for informal feedback in a relaxed setting - Senior’s Fitness Classes “Imagine Feeling Healthy” program for community members at large is run through a partnership between RVCHC and Barry’s Bay and Area Senior’s Home Support. - Chronic Disease Self-Management program (Stanford’s “Living a Health Life”), offered to community as well as clients - RVCHC initiated a needs and capacity assessment in 2014 which priority needs were identified through consultation with community members and RVCHC clients through focus groups, partner agencies through the Madawaska Circle of Health, key informant interviews with select agency representatives, health care and community service providers. All of the above help inform and direct staff and management on the future development of programs and activities at RVCHC which in turn, help direct the QIP.

Staff Safety & Workplace Violence All staff are required to participate in mandatory Crisis Prevention and Intervention training and yearly refreshers are provided for front line staff. Health and Safety is a standing item on monthly team meetings. RVCHC was inspected by the Occupational Health and Safety coordinator and recommendations developed to increase safety for staff and clients. Significant renovation took place to remove asbestos from work environment. A panic alarm has been purchased to be used for staff working alone. The alarm automatically dials 911.

Contact Information Greg McLeod, Executive Director Phone: 613-756-3044 # 231, Email: mcleodg@sfmhosp.com Joanne Pecarskie, Manager of Health Services Phone: 613-756-3044 # 234, Email: pecarskiej@sfmhosp.com

Other Although major renovations were undertaken to address asbestos removal, the clinic’s footprint did not change and therefore significant challenges to infrastructure remain. 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 Quality Committee Chair or delegate Executive Director / Administrative Lead CEO/Executive Director/Admin. Lead _______________________ (signature)

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Other leadership as appropriate _______________________ (signature)

2017/18 Quality Improvement Plan for Ontario Primary Care"Improvement Targets and Initiatives"

Rainbow Valley CHC 49 Mill Street, Killaloe, ON K0J 2A0

AIM Measure Change

Quality dimension Issue Measure/Indicator Unit / Population Source / Period Organization IdCurrent performance Target

Target justification

Planned improvement initiatives (Change Ideas) Methods1)Continue to educate our patients on the importance of having a follow up appointment within 7 days post-discharge of hospital.

Post signs in the waiting room and practitioner rooms

2)Implement Hospital Report Manager

Work with local Hospital and IT staff to implement Hospital Report Manager. Ensure the nurse practitioners are listed as primary care providers

1)Review the CHC Practice Profile report with staff

Monthly team meetings

1)Continue to meet or exceed target

Track through primary practice reports and MSAA indicators and discuss with team at monthly meetings

1)Follow up with clients to ensure the test is scheduled

Letters to clients, notes in the EMR

1)Audit compliance of completion

track rates of test offered against rates of those who have received test/procedure to audit whether more education and follow-up is need to ensure compliance

1)Continue to improve process of documenting encounters and referrals in the EMR.

EMR documentation and discussion at team meetings.

1)Continue to maintain scheduling processes that recognize adequate time requirement for both client and practitioner discussion

standing agenda item at 100% monthly team meetings97.4 97.40 Continue to meet or exceed high target

Person experience

Effective

Percent of patients who stated that when they see the doctor or nurse practitioner, they or someone else

% / PC organization population (surveyed sample)

In-house survey / April 2016 - March 2017

92241*Patient-centred

92241*

Percentage of women aged 21 to 69 who had a Papanicolaou (Pap) smear within the past three years

% / PC organization population eligible for screening

See Tech Specs / Annually

92241*

Effective transitions

Percentage of Ontario screen-eligible women, 21-69 years old, who completed at least

% / PC organization population eligible for screening

CCO-SAR, EMR / Annually

92241*

Population health - colorectal cancer screening

Percentage of patients with diabetes, aged 40 or over, with two or more glycated

% / patients with diabetes, aged 40 or over

ODD, OHIP-CHDB,RPDB / Annually

92241* 85.75 87.00 Met previously set target. Striving to meet provincial average of 91%

Population health - diabetes

Percentage of screen eligible patients aged 50 to 74 years who had a FOBT within the past two years, other

% / PC organization population eligible for screening

See Tech Specs / Annually

78.7 79.00 Continue to meet or exceed target and CLHIN average

92241*

68

78.7 79.00 Attain 90 percentile among peers

69.00 Provincial average is currently 67.9

X

Population health - cervical cancer screening

0.00 ICES CHC Practice Profile number <5

Percentage of acute hospital inpatients discharged with selected HIGs that are readmitted to any

% / Discharged patients with selected HIG conditions

CIHI DAD / April 2015 - March 2016

92241* X 0.00 due to our low numbers, this information has been supressed

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

CIHI DAD / April 2015 - March 2016

1)Investigate with staff the possibility of clinic being open different days to offer more equitable coverage (ex Monday, Wednesday,

Add a question into the next client satisfaction survey to see if proposed change would be preferable.

2)Increase access to physician appointments

Increased physician coverage

35.00 Rainbow Valley operates 3 days per week (Tuesday, Wednesday and Thursday) so often, same day or even next day appointments are not a

Timely access to care/services

Timely 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)

In-house survey / April 2016 - March 2017

92241* 31.43

Process measuresTarget for process measure Comments

track numbers to see if % improved or remain suppressed

Have 100% of practitioners place notices in their exam rooms by May 2017

Small numbers (suppressed data in the CHC Practice Profile) Human Resource

Discuss at monthly team meetings to ensure information is being documented and transferred

Have Hospital Report Manager in place by Fall of 2017

decreased % of readmission to acute in-patient hospital At the time when our numbers are not suppressed, we hope to be within targets of

Information suppressed for privacy reasons

Increase in percentage rates Distribute monthly EMR reporting to practitioners and discuss at 100% of team meetings

Currently meeting both Ontario and CLHIN targets

Increase in rates for those who have had test/procedure vs. test/procedure offered but not completed

5% increase in those having test completed by March 2018

EMR and MSSA indicators will be compared to CHC Practice profile report which has the appropriate numerator in place already

Decrease in the difference between the MSAA and CHC practice profile report of 2%

Discuss monthly MSAA indicator rates at monthly team meetings

Increase the inter-professional diabetes care rate by 2% over the next year.

# survey responders and complaints meet or exceed current target within the next year

Annual client satisfaction results 50% of respondents would need to be in favour 100% of Physician, NP and

Due to the nature of part-time staff with positions elsewhere, this may not be

Annual client satisfaction survey Increase same day or next day appointments by 5% over the next year

Changes in Human Resources may see an increase in dedicated