2013/14 Quality Im

provement Plans for O

ntario Hospitals

Improvem

ent Targets and Initiatives

Please do not edit or modify provided text in Colum

ns A, B &

CA

IMM

EASU

RECH

AN

GE

Quality D

imension

Objective

Measure/Indicator

Current Perform

anceTarget for 2013/14

Target JustificationPriority

levelPlanned im

provement initiatives

(Change Ideas)M

ethods and process measures

Goal for change

ideas (2013/14)Com

ments

Safety1) M

onitor health care provider hand hygiene com

pliance with the

provision of timely feedback.

A) Conduct direct observations for hand hygiene com

pliance in selected areas. B) Create new

signage as reminders for good hand

hygiene practices. C) D

evelop recognition program to rew

ard areas that m

eet the target compliance rate quarterly.

Feedback to be provided w

ithin 30 days of availability

2) Educate health care providers and patients annually on hand hygiene indications, products, techniques and hand care

A) Completion of eLearning m

odules by staff Modules

include: Hand hygiene for Clinical and N

on-Clinical staff and Routine Practices and Additional Precautions B) Conduct short in-person education for new

em

ployees, medical/nursing students and for individual

departments upon request

75%

3) Ensure environmental controls

and systems support allow

for hand hygiene to be perform

ed

Perform w

orkflow pattern and risk assessm

ent to facilitate placem

ent of products and stationsBased on com

pletion

1)D

evelopprophylactic

antibioticcriteria-protocol

A) Order set established

B) Chart audits via PICIS data Monthly report

2) PQAC w

ill lead the initiativeA) Audit results B) M

onitor set guidelinesM

onthly reporting to PQ

AC or Com

mittee

3) Develop roll-out strategy

PQAC to review

rollout planRollout plan approved

Effectiveness1) M

onitor performance daily,

weekly, m

onthlyPerform

ance documented in PICIS

Reports completed

and reviewed

2) Monitor com

plianceD

ata presented regularly to OR Com

mittee

OR Com

mittee

reviews data

regularly

3) Monitor and evaluate outliers

Evaluate for ongoing improvem

ents Im

provements

made as necessary

1) Information gathering to

understand variables impacting

current rate

Review curent users ordering patterns and capacity of

systemClear understanding of current state

2) Improvem

ent strategy confirm

ed Stakeholder inform

ed improvem

ent strategy is critical to success

Improvem

ent strategy com

plete

3) Monitor im

plementation of

strategy M

onior utilization rates monthly as w

ell as user feedback

Monthly reports

reviewed

1) Complete a literature review

of existing benchm

arks for wait tim

es.Benchm

arks will be established based on literature

search findingsBenchm

arks determ

ined for Q1

2) Complete a process m

apping exercise to determ

ine areas that lead to long w

ait times (both

administrative processes and

provider scheduling)

Review current patient flow

patterns and capacity w

ithin the systemIm

provement

strategy complete

3) Implem

ent suggested im

provements

Identification of failure points and solutions for change to be established and im

plemented.

Changes monitored

routinely for impact

and revision

4) Continuously monitor and

improve.

Wait tim

es will be collected, m

onitored and reported.85%

of patients will

be seen within 20

mins

Majority of

Wom

en's College Hospital, 76 G

renville Street, Toronto, Ontario M

5S 1B2

Improve provider hand hygiene

compliance

Hand hygiene com

pliance before patient contact: The number of tim

es hand hygiene perform

ed before initial patient contact divided by number of observed hand hygiene

opportunities before initial patient contact, multiplied by 100. D

ata will be provided by a direct

observer.

Implem

entation of Antimicrobial

Stewardship Program

Antim

icrobial Stewardship: to m

onitor the appropriate administration of antim

icrobial therapy to achieve the best patient outcom

es, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and prom

ote patient safety. % of patients w

ho receive their appropriate antibiotic therapy w

ithin 45 minutes prior to incision for ACL reconstructions

100%99%

90%92%

3Increase hand hygiene

compliance to 92%

with the

longer term goal of reaching

100 %

A) Collect survey cards and calculate percentage of

2Increase com

pliance to 100%

Improve O

perating Room first

case start time accuracy

% First Case O

n-time (O

RBC): Percent of first OR cases that start on tim

e or early84.4%

90%Set target is sustainable

1

24%Im

prove procurement process: Im

prove the procurement process by increasing the percent of

requisitions submitted electronically. The percentage of e-requisitions divided by the total

number of requisitions that are subm

itted through the procurement process.

Improve procurem

ent processTarget has been set based on

current performance

50%

Improve patient engagem

ent in

Improve w

ait times in Specialized

Medicine Program

Access

1) Patients in FPHT w

ill be invited

Patient Engagement in FH

T: To increase patient engagement in the Fam

ily Health Team

by

75%1 1

78%Target has been set based on

Improve patient w

ait times from

arrival for appointment to provider contact: Im

prove wait

between patient scheduled appointm

ent time and the tim

e the first provider sees the patient: Percentage of patient (target 85%

) visits that meet w

ait time of 20 m

inutes benchmark.

Inclusion criteria: patients that arrived on time for their appointm

ent in a pilot project in Endocrine clinics.

76%85%

Target has been set based on evidence-based literature

1

Patient-centred

AIM

MEA

SURE

CHA

NG

E

2) Educate patients and staff about the initiative and the im

portance of hand hygiene

A) Conduct information session for staff at the

beginning of the project B) Share data, patient com

ments and progress w

ith staff and patients in various venues (i.e. staff m

eetings, patient education nights, etc.) C) Create signage to inform

/remind patients and staff of

hand hygiene initiative

Venues to share inform

ation TBD by

FPHT An increase

in return rate as a result of visual rem

inders

Monitor patient satisfaction

during transition to new facility

Patient Satisfaction : To monitor patients' perceptions of their care during the transition

"Overall how

would you rate the care and services you received at the hospital." Percent of

those who responded Excellent, Very G

ood and Good.

New

initative75%

Target has been set based on previous perform

ance through N

RC Picker

21) Patients receiving care in the new

facility will be invited to

provide feedback on their experience

A) Collect survey cards and calculate percentage of survey cards returned B) Collect feedback from

trained volunteers with

regards to experience interacting with patients in this

initiative

Majority of

feedback from

volunteers to be positive

Compliance w

ith TASHN

Research Q

ualifications Com

pliance with TA

HSN

Components: A) all individuals listed on an active research ethics

protocol will com

plete the "Responsible Conduct of Research" module and achieve a certificate

of completion, indicating a satisfactory m

ark on all required courses. B) All prinicpal investigators leading or are responsible for an active research ethics protocol w

ill complete the

"Responsible Conduct of Research" module and achieve a certificate of com

pletion, indicating a satisfactory m

ark on all required courses.

New

initiative - no m

odules completed

A) 50%

B) 65%Targets reflect the phased

approach to module

completion, coinciding w

ith protocol renew

als and subm

issions

31) Ensure inidividuals across the organization are aw

are of the new

educational opportunity and required courses.

A) Presentations to relevant hospital groups for team

dissemination

B) Individual notification from the research ethics boad

to principatl investigators with open research protocols

Online account

creation indicating the course m

odule has been started.

1) Work w

ith WCH

clinicians to identify key inform

ation-sharing requirem

ents for improved care

transitions between clinical

provider partners.

A) Tasks associated with developing the integration

approach for WCH

's aEPR will be reflected in the project

plan. B) Progress w

ill be tracked through project m

anagement structures and reported through project

governance structures.2) W

ork with W

CH's clinical

provider partners (e.g., UH

N, PM

H,

CCAC, SMH

, SHSC) and clinicians to

identify key information-sharing

requirements for im

proved care transitions w

ith WCH

Key information sharing requirem

ents will be identified

and documented

3) Confirm integration approach

for electronic exchange of key inform

ation identified.

Project plan will be developed inclusive of integration

approach for electronic exchange of key information

Confirmed aEPR

integration approach for electronic exchange of inform

ation with

clinical provider partners.

Integrated

Integration and implem

entation of an Am

bulatory Electronic Patient Record

Care Transitions: Defined integration requirem

ents for electronic exchange of information w

ith W

CH's clinical provider partners in support of im

proved care transitions (e.g., Virtual Ward,

After Cancer Treatment Clinic, Fam

ily Health Team

)

New

initiative By D

ec 31, 2013

integration requirem

ent defined

Target reflects required tim

ing 1

feedback from

volunteers to be positive

survey cards returned B) Collect feedback from

trained volunteers with

regards to experience interacting with patients in this

initiative

the Family H

ealth Team

to observe and provide feedback on health care provider hand hygiene com

pliance

involving them in providing hand hygiene com

pliance feedback. a) The num

ber of survey cards returned divided by the total number of survey cards

distributed.

current performance