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

3/30/2016

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. Reflecting the Health Links Business Plan, priorities will 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. This will build on existing hospital 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, global 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 (e.g. surveys, complaints process, partnership meetings and the future Client and Family Patient Council). 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. RVCHC, in partnership with SFMH, participates in ethics education opportunities with a focus on community cultural diversity. 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 has recently signed on to participate in Health Quality’s Primary Care Reporting Quality Indicators to better equate services and setting/achievement of targets. 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 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 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. Strength in People – Recruitment of practitioners to meet funded positions through innovative approaches including partnership with SFMH to create shared full time opportunities. Provision of 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). Continue to work with SFMH to provide

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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 was faced with some Human Resources challenges this year including losing one part-time Nurse Practitioner and two physicians decreasing clinic days due to Maternity and Paternity leaves. We were fortunate to recruit a new Part-time Nurse Practitioner and utilized the integration with SFMH to recruit one of its Emergency Room physicians who had previous CHC experience. Unfortunately, this is a short term solution as our new physician will also be utilizing a maternity leave during the upcoming year. Our goal for the upcoming year is to stabilize Human Resources in order to alieve any client anxiety about loss of practitioners. Financial Performance – Continued accountability 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 as these services are critical components of a functional care package that supports facilitated self-management for those with chronic illnesses and recurrent hospital visits. At the present time, RVCHC continues to function only on a part time basis which reduces access to primary care for community residents and limits ability to recruit professional practitioners. RVCHC and its sponsor SFMH submitted a Community Needs Assessment which reviewed the status of RVCHC and its capacity to meet primary health care priorities as identified by area residents and health and community service partners to the LHIN in 2015. Although the Needs Assessment clearly identified the necessity to invest additional funds into RVCHC in order to maximize primary care benefits to the community, no additional funding was granted. 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 (primarily in attracting health care professionals to work for the CHC) the current funding and mode of operations is not sustainable. 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. With more than half of our local physician compliment contemplating retirement over the next 1-3 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 who otherwise 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. The area residents have identified a number of priority needs related to primary health care. Specifically, access to: - Primary care locally rather than at a distance; - Mental health services and supports that include individuals who are not primary care clients of RVCHC; - Programs and services that support living and aging well, particularly if coping with chronic diseases or conditions; - ‘Just in time’ referral services and care coordination so they can access the right services and supports when they need them; and

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- Support to coordinate community efforts (both volunteer- and provider-led) to address local healthcare needs.

QI Achievements From the Past Year Previously, RVCHC utilized an “in house” satisfaction survey to gather data on client satisfaction and change/ quality improvement ideas. 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 was discussed at the team and leadership level before implementation. 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 - HQO Reports have provided us with improved “across the board” comparisons with peers and to be able to better align with HQO targets. - Satisfaction results are very high (jointly 99% would recommend services to family and friend - Provides feedback on staff performance from the client perspective - Confirms our needs assessment as we see repeated requests for additional staffing hours and improvements to the physicians space to address privacy, confidentiality and accessibility to the 2nd floor - 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

Integration & 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. 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. At this time the Health Links has doubled their anticipated client load. RVCHC will partner with regional hospitals to support the reduction of ER visits and hospital admissions for the identified client population through timely follow-up and a focus on facilitated self-management and health promotion. In February of 2016, the RVCHC team met 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

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and group counseling. A regional partnership has been formed to provide classes throughout the area and support seniors' exercise classes. RVCHC continues to partner with regional paramedical services to offer home visits to isolated clients to promote wellness and reduce crises. 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. 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.

Engagement of Leadership, Clinicians and 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. Staffs 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 attends meetings either in person or via teleconference and minutes are shared. Additionally, 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. In the future, we will be inviting Directors to attend team meetings to engage staff directly in order to build greater understanding and trust in the linkages we have established. During the past year, we have focused on building engagement between staff, clinicians and Leadership. Attendance by the Chief Operating Officer, VP of Finance and Executive Director of the Foundation at team meetings have provided opportunity to strengthened 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

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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).

Patient/Resident/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: - 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 by Physician, Nurse Practitioner, Registered Nurse 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. In addition, our partner, St. Francis Memorial Hospital, has very recently developed a Patient and Family Advisory Council. Following the direction set out by HQO, we have begun discussions with SFMH to include representation from clients of Rainbow Valley CHC on this council to better engage clients in the development of QIP activities and ongoing quality feedback. 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.

Other One of our areas of focus for the upcoming year is to stabilize staffing at Rainbow Valley CHC. With only part time positions available, staff retention is difficult and recruitment problematic. Over the last year we have experienced the following Human Resource struggles: - hired a new part time Nurse Practitioner in January. NP was offered full time work elsewhere so adjusted budget to increase time to two days per week in order to retain. NP spouse is employed in the Military and was transferred un-expectantly to the US. NP resigned. -Part time Social Worker on a personal leave, then required extended sick leave for spouse. Submitted retirement notice in December. Have not replaced -Executive Director resigned. New COO of St. Francis Memorial assumed duties and new administrative structure developed resulting in a part time Manager of Health Services (3 days per month) created -One physician on leave due to a Maternity leave, second physician on leave due to a paternity leave (married couple)

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-Was able to replace physician for some portion of maternity leave, but locum physician is also expecting. In an effort to be proactive with regards to upcoming privacy requirements, RVCHC implemented monthly privacy audits of access to client records through out EMR. These are completed by our IT specialist and submitted to the Privacy Officer. To date, there has been no unauthorized activity. The physical environment continues to be a source of concern for clients and staff. During the recent client satisfaction survey, 73% of respondents noted that if funding allowed, changes to improve privacy, waiting room space, accessibility and confidentiality at the reception desk would be appreciated. A request for funding to plan a redevelopment of the space was submitted to the LHIN but was unsuccessful. 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. 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 Jasna Boyd Quality Committee Chair or delegate Darcy Lacombe Executive Director / Administrative Lead Greg McLeod CEO/Executive Director/Admin. Lead _______________________ (signature) Other leadership as appropriate _______________________ (signature)

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2016/17 Quality Improvement Plan for Ontario Primary Care"Improvement Targets and Initiatives"

Rainbow Valley Community Health Centre 49 Mill Street, Killaloe, ON K0J 2A0

AIM Measure Change

Quality dimension Objective Measure/Indicator Unit / Population Source / Period

Organization Id

Current perfor Target

Target justification

Planned improvement initiatives (Change Ideas) Methods Process measures

Goal for change ideas Comments

1)Continue to meet or exceed target

Participation in the HQO Primary Practice reports will increase comparators. Until then, continue tracking through the EMR

Ensure practitioners are accurately documenting in the EMR

Continue to meet or exceed target

Above LHIN average - plan to maintain high performance

1)Continue to meet or exceed target

Maintain correct identification and documentation in the EMR

Distribute and review reports generated through EMR by practitioner to team members

Meet or exceed current target

Meeting both Ontario and CLHIN targets

1)Improve process to document encounters and referrals within the EMR

Discussed at monthly team meeting. Will meet with IT support to formalize how practitioners can best document encounters and referrals. This information will be shared with staff at next team meeting.

Increase in the Inter-professional Diabetes Care rate

By the end of the 2016 year, show a 10% increase to be better aligned with the CLHIN average

It is felt by the team that high quality care is being provided in this aspect, but

1)Advertise flu shot clinics in local newspapers, on social media, website (ours and the Public Health Units),on local information boards.

Advertise flu shot clinic information in local newspapers, on social media, website (ours and the Public Health Units),on local information boards.

Increase the % of patients over the age of 65 to receive a flu shot in 2015 to 18%. Ensure practitioners continue to accurately enter data into the EMR

Increase the % of patients over the age of 65 to receive a flu shot in 2015 to 18%.

Influenza rates were down all across our area this year. Public Health held only

1)due to our low numbers of admissions, our reporting information in this sector has been suppressed. RVCHC has signed up with

These reports will be reviewed at monthly team meetings

decreased % of readmissions to acute in-patient hospital

If measurable (not suppressed) we hope to be within targets of comparable CHC's.

As per the CHC Practice Profile report for the Champlain CHC Region, dated

1)If funding allowed, increase days of operation. Currently patients are without CHC access from Thursday evenings till

Increase Nurse Practitioner and physician hours.

"% of visits best managed elsewhere" Decrease from present 14.8 to provincial average of 11.4

Provincial Average for Ontario is 11.40% as per the CHC Practice Profile

1)Ensure staff are provided with education opportunitie4s and training on AODA, Human Rights and Cultural Sensitivity.

All new staff are provided training during orientation. Additional materials are made available online, through the LMS, or distributed via email.

% of staff who have received the above noted training

100 % of all new staff are provided training on AODA, Human Rights and Cultural Sensitivity.

Maintain high performance standard. 0% of patient responded

1)Use team meeting venue to discuss strategies to support dialogue with clients.

Place as standing agenda item for all team meetings

# of team meeting agendas that include discussion of strategies to support interface with clients/barriers to interface

100% of team meeting agendas include relevant discussion as standing item

Note that RVCHC has very small staff complement and majority of team meetings

Improve rate of HbA1C testing for diabetics

Improve rate of cancer screening.

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

% / All patients with diabetes

Ontario Diabetes Database, OHIP / Annually

92241*

71.00 CHC Practice Profile for Champlain CHC Region states the Ontario average

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* 72 72.00 CHC Practice Profile for Champlain CHC Region indicates the average for

Percentage of patients aged 50-74 who had a fecal occult blood test within past two years,

% / PC organization population eligible for screening

See Tech Specs / Annually

92241* 70.25

Percentage of people/patients who report having a seasonal flu shot in the past year

% / PC organization population eligible for screening

EMR/Chart Review / Annually

92241* 15.75

78 85.00 Average of the CLHIN CHC

14.8 11.40 Provincial Average for Ontario is 11.40% as per the CHC Practice

Decrease Emergency Department visits for conditions best managed elsewhere (BME)

Effective

Percentage of patients or clients who visited the emergency department (ED) for

% / PC org population visiting ED (for conditions BME)

DAD, CAPE, CPDB / April 2014 – March 2015

92241*Efficient

18.00 Average for CLHIN CHC's is 20%. However the clientele of the RVCHC is

Improve seasonal Immunization rates

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

% / PC org population discharged from hospital

DAD, CAPE, CPDB / April 2014 – March 2015

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

Reduce hospital readmission rate for primary care patient population

% / PC organization population (surveyed sample)

In-house survey / April 2015 - March 2016

92241* 94

98.00 Equity is about consistency across all settings and all nations. It requires nothing

OtherEquitable Percentage of respondents who responded positively to the question: "Thinking about the

% / PC organization population (surveyed sample)

In-house survey / April 2015 - March 2016

92241* 98

Patient Experience

94.00 Continue to provide high quality care in order to meet or exceed target

Improve Patient Experience: Opportunity to ask questions

Percent of respondents who responded positively to the question: "When you see your

2)Maintain scheduling processes that recognize adequate time requirement for client and practitioner discussion

standing agenda at monthly team meetings # survey responders meet or exceed current target within the next year

3)Ensure all team members are working to scope and that non-medical needs are being addressed by administrative support staff

Standing agenda item for all team meetings # of team meeting agendas that include discussion of strategies to support interface with clients / barriers to interface

100% of team meeting agendas document relevant discussion as a standing item

1)Continue to ensure scheduling process recognizes time requirement for client and practitioner discussion

Adjust scheduling to reflect individual client or practitioner needs (e.g. palliative client may require more time for discussion)

Currently achieving high levels of satisfaction (90th percentile) 0% responded "Never" and "Rarely" within the client satisfaction survey

Maintain high performance target

Currently achieving high levels of satisfaction

1)Continue to ensure scheduling process recognizes time requirement for client and practitioner discussion.

Continue to adjust scheduling as per client and practitioner needs.

98% responded "Often" and "Always" 0% responded either "Never" and

Maintain high performance

Continue to meet and maintain high performance targets

1)Given our small numbers (suppressed data in the CHC Practice Profile for the Champlain CHC Regions) we have recently signed on to

review reports when available Continue education of the reception staff on the importance of patients having a office appointment within 7 days post-discharge from hospital.

Share the results with the staff. Encourage access to appointments for these patients within 7 days.

develop change ideas when detailed reports are available

Given our small numbers (suppressed data in the CHC Practice Profile

1)Administration will investigate and review the possibility of changing days of operation to more equitable coverage across

-Add item to team meeting agendas -Discuss possibility with team -Survey clients for acceptance -Implement

Increase patient survey satisfaction rate to 20% by next year (combined "Same day" and "next day"

Increase patient survey satisfaction rate to 20% by next year (combined "Same day" and

Although studies have shown that access to a regular primary care provider can

97.03 With our result in the high ninetieth percentile, we will continue

Improve Patient Experience: Primary care providers spending enough time with patients

Percent of patients who responded positively to the question: "When you see your doctor or

% / PC organization population (surveyed sample)

In-house survey / April 2015 - March 2016

92241* 97.03

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 2015 - March 2016

92241* 95.05 95.05 With our result in the high ninetieth percentile, we will continue

Improve Patient Experience: Patient involvement in decisions about care

doctor or nurse practitioner, how often do they or someone else in the office give you an opportunity to ask questions about recommended treatment?"

Timely 0.00 Due to our small patient roster, this information was suppressed in the recent CHC

Improve 7 day post hospital discharge follow-up rate for selected conditions

Percent of patients/clients who responded positively to the question: "The last time you were

% / PC organization population (surveyed sample)

In-house survey / Apr 2015 – Mar 2016 (or most recent 12-month period available)

92241* 19.15 20.00 Rainbow Valley CHC operates 3 days per week (Tuesday, Wednesday and

Improve timely access to primary care when needed

Percent of patients/clients who see their primary care provider within 7 days after discharge

% / PC org population discharged from hospital

DAD, CIHI / April 2014 – March 2015

92241* X