Quality Improvement Plan 2018-19 by St. Michael's Hospital

QUALITY IMPROVEMENT PLAN 2018-2019

Our priorities to keep you safe and help you have a great experience

Our network

In health care our top priorities, above all else, are to keep our patients, residents and our people safe and

deliver high-quality care. As a new network, we have the opportunity to set goals to do this across three sites, Providence Healthcare est. 1857

allowing us to build off of one another’s strengths and share best practices across our teams. This Quality

Improvement Plan (QIP) is the first for our new network between Providence Healthcare, St. Joseph’s Health

Centre and St. Michael’s Hospital and it identifies measurable steps we will take over the next year to create a safer environment to deliver care.

This QIP was designed by and with our people, patients, residents and community. We conducted a broad

consultation across our sites to make sure the QIP reflected the priorities and goals of our patients/residents,

advisors, our community and our staff, physicians, learners and volunteers. Discussion and feedback at multiple levels at each of our sites ensured that this QIP’s goals and targets are achievable and that the right people were engaged from the beginning. St. Michael’s Hospital est. 1892

St. Joseph’s Health Centre est. 1921

From the initial planning stages, we wanted this QIP to be one way to unify our staff of the new network

towards a common purpose, and to demonstrate our shared commitment to our diverse patient and resident

communities. Our 2018-19 quality priorities are based on data, including our sites’ performance on past years’ QIPs and additional quality and safety data we track and examine on an ongoing basis. Patient/resident and

family experience information, trends and feedback were particularly important to ensure our targets address issues that are relevant and important for our patients and residents.

Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital have been one corporate entity since August 1, 2017.

This QIP represents a shared commitment to the tens of thousands of patients and residents who come to us for care. It provides a roadmap for us to follow over the next 12 months as we work to achieve defined and

measurable objectives to support our communities. We want to thank everyone who supported the development of this QIP and we look forward to working closely with our patients, teams and partners in making our communities healthier over the next year.

At our three sites, we serve patients and residents across the full spectrum of care; our services span primary care, secondary community care, tertiary and quaternary care services to post-acute through rehabilitation, palliative care and long-term care, supported by world-class research and education. This document is the first Quality Improvement Plan (QIP) developed jointly by Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital. As required by the 2010 Excellent Care for All Act, this document was submitted to Health Quality Ontario (HQO) on April 1, 2018. Download the full document and appendices at www.oursharedpurpose.com.

QUALITY IMPROVEMENT PLAN 2018-19

Board Chair Tom Woods

Quality Committee Chair Domenic Belmonte 3

Chief Executive Officer Dr. Tim Rutledge

Safety First As always and above all, our first priority and responsibility is to keep everyone safe. A strong safety culture protects us all: our patients and residents as well as our staff, physicians, learners and volunteers. In 2018-19, together we will: â&#x20AC;˘ Protect patients and residents from harm by making sure when a safety incident reveals a need to change our processes, these changes occur within the committed timeframe. â&#x20AC;˘ Understand the challenges our staff and physicians are facing in feeling safe at work by striving to increase reporting of workplace violence by raising awareness of these issues and designing new ways to support our people when they are impacted.

QUALITY IMPROVEMENT PLAN 2018-19

GOAL #1

GOAL #2

Protect patients and residents from harm by continuing our work on key safety priorities and making sure that when a safety incident reveals a need to change our processes, these changes occur within the committed timeframe.

Understand the challenges our stafF AND PHYSICIANS are facing in feeling safe at work by striving to increase reporting of workplace violence by raising awareness of these issues and designing new ways to support our people when they are impacted.

Our network is relentless in our commitment to eliminate unnecessary harm. However, when a patient is harmed, it’s our responsibility to investigate and make the right changes as quickly as possible. We must find the right balance between thoughtful investigation and swift action and do everything we can to prevent an incident from happening again. Here’s how we will reach our goal: Build a strong foundation: We will continue to educate and support our teams in the crucial first step of identifying and reporting all patient safety events. Look for a new way of working: We will develop and implement a consistent network approach for reporting and investigating serious safety incidents, sharing learnings and new practices network-wide to make changes to prevent incidents from happening again. Create a collective safety culture: We will work to better understand our safety culture across the network through a current-state assessment, a validated patient safety culture survey and focus groups at each site.

HOW WILL WE MEASURE SUCCESS? Our QIP target challenges us to move from recommendation to implementation. This will be measured by the proportion of serious safety events with recommendations implemented on time

75%

“Creating a safety culture means that when staff report incidents, we can see a big picture of what’s happening across the organization and respond accordingly – if we know falls are an issue, we can look at the reasons why and take steps to reduce them.” SUSAN BLUNDELL RISK MANAGEMENT SPECIALIST

QUALITY IMPROVEMENT PLAN 2018-19

HOW WILL WE MEASURE SUCCESS? Our QIP target for 2018-19 is to increase the reporting of workplace violence. While it may seem counterintuitive to aim to increase the number of incidents reported, we believe (and research supports) that violence is underreported among health-care workers. Our goal is to increase workplace violence reporting by

Keeping our people safe is necessary to patient safety. A strong safety culture protects everyone, regardless of whether they’re seeking or providing care. Working in health care is and will always be challenging in many ways, but violence should never be part of the job. When our staff, physicians, learners and volunteers encounter violence at work, we must work together to raise awareness of the issue to prevent it from happening again. Here’s how we will reach our goal: Highlight the issue: We will raise awareness of workplace violence across the network and of the commitment by our executive team to address it. Spread best practices: St. Joseph’s Health Centre made reducing workplace violence a priority on last year’s QIP, which generated important new learnings and processes. Design a roadmap to success: A new, multidisciplinary task force will develop a multi-year, network-wide Workplace Violence Prevention Plan to recognize, address and prevent physical and psychological harm at work.

“It’s important that we have a full understanding of the issues staff are facing so that we can focus on the specific policies or processes that need to be revisited. There are things we can do to prevent violence – but we have to know the extent of the problem to be able to impact change.”

MARIA MONTEIRO WORKPLACE SAFETY AMBASSADOR

The Patient Experience Our goal is to provide the best possible patient/resident experience, as defined by our patients and residents, their caregivers, our advisors and our community. In 2018-19, together we will: â&#x20AC;˘ Expand our patient/resident/caregiver/community advisory program to ensure we are incorporating whatâ&#x20AC;&#x2122;s important to patients, residents and caregivers by involving them in more projects, planning committees and other important aspects of our work across the network. â&#x20AC;˘ Provide a smoother transition home by providing patients with the right level of information as they leave the hospital. 8

GOAL #3

GOAL #4

Expand our patient/resident/caregiver/community advisory program to ensure we are incorporating what’s important to patients, residents and caregivers by involving them in more projects, planning committees and other important aspects of our work across the network.

Provide a smoother transition home by ensuring that we provide patients with the right level of information as they leave the hospital.

There is an exciting and growing movement across our organization to better capture and benefit from patients’, residents’ and family members’ unique knowledge. Each site has developed its own dynamic network of patient/resident/caregiver/community advisors who participate in projects and planning committees to shape the way we deliver care. Here’s how we will reach our goal: Grow and evaluate our program: We will recruit new advisors to expand our Patient, Resident, Caregiver and Community Engagement Program and work with them to provide education to more staff on their experiences. We will also develop and validate an evaluation tool to measure advisors’ satisfaction with their level of engagement with our network. Share success stories: We will raise staff awareness around the benefits and successes of working with advisors to increase opportunities for their participation. Create a roadmap to success: We will develop a network-based Patient Declaration of Values – a set of statements defined by our patients about what they value most in their care, in keeping with the Excellent Care for All Act.

HOW WILL WE MEASURE SUCCESS?

We will get more advisors involved in more initiatives. Our QIP target for 201819 is to increase the number of committees, activities and initiatives with patient/resident/caregiver/ community advisors by at least

By making sure our patients have enough information. Our QIP target is to increase the proportion of respondents who as patients feel they had enough information when they left the hospital by at least

40%

“We need to be more efficient, more mindful of patient needs and more inclusive in our engagement with the people we are serving. PFAs bring diverse experiences and insights into the room that might otherwise be missing.” COLIN GILLIES PATIENT FAMILY ADVISOR (PFA)

QUALITY IMPROVEMENT PLAN 2018-19

Empowering patients and caregivers with accurate, easy-to-understand information when they are discharged and leave the hospital is necessary for safe care at home, as well as preventing further Emergency Department visits and readmissions. Once a patient returns home, our routine patient experience survey asks patients, “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?” To help patients answer positively to this question in 2018-19, we will focus on: Spreading best practices: We will continue to design and implement plain-language, patient-friendly discharge instructions network-wide and share additional best practices across sites. Providing more accessible information: We will ensure our patients and families can access the support of Interpreter Services in a timely and meaningful way, including as part of their discharge preparation.

Joining forces: We will link our discharge planning initiatives to the Toronto Central Local Health Integration Network’s initiatives to reduce avoidable readmissions among patients with congestive heart failure, gastrointestinal disease, chronic obstructive pulmonary disease and pneumonia.

“At the time of discharge, it’s not really possible to explain to a patient what they’re going to feel like in the weeks after having open heart surgery. Making sure patients and families have information about what they can expect when they leave the hospital helps validate what they’re feeling – it supports a smoother transition home.” MENAKA PONNAMBALAM NURSE PRACTITIONER

Long-term Care Our new health network includes a residence that 288 people call home. The Cardinal Ambrozic Houses of Providence is a long-term care home that provides the highest standards of comfort, care and safety to its residents. Quality of life is our primary focus, with care centred on residents in a way that recognizes and respects their privacy and independence.. In 2018-19, together we will: â&#x20AC;˘ Improve resident and caregiver experience through faster acknowledgment of concerns and complaints. â&#x20AC;˘ Protect our residents from harm by preventing and reducing resident falls and pressure injuries.

QUALITY IMPROVEMENT PLAN 2018-19

GOAL #5

GOALS #6 AND 7

Improve resident and caregiver experience by acknowledging concerns and complaints faster.

Protect our residents from harm by PREVENTING AND reducing falls and pressure injuries.

When the people we care for or those who provide care have issues and concerns, we want to address them quickly. By regulation, longterm care homes are required to have complaints acknowledged within 6-10 business days. To create a standard goal across the network, we are aiming to do better than the Ontario standard by creating our own target of responding within five business days. Here’s how we will reach our goal: Collect data: We will develop a process to acknowledge complaints and concerns and begin documenting this data in an electronic system – this will help us create a baseline that we can use as a starting point to measure how we are doing. Report back regularly: We will share data monthly with the Houses leadership, our resident and family councils and management team to understand our current performance in order to be able to improve.

HOW WILL WE MEASURE SUCCESS?

By acknowledging and responding quickly to concerns. By the end of the fiscal year, our goal is to make sure concerns and complaints we receive are acknowledged within five business days. Our goal is

By reducing the We will identify percentage of potential fall risks residents who and reduce falls by develop a stage 2 to 4 pressure By reducing the ulcer to percentage of residents who develop a stage 2 ororless less to 4 pressure ulcer to

80%

“When there’s a concern or complaint brought forward, we keep our residents and their families in the loop as we investigate. We want to be open and transparent – it’s part of building positive, trusting relationships.” JUBE WALKER PROVIDENCE HOUSES DIRECTOR OF CARE

QUALITY IMPROVEMENT PLAN 2018-19

10%

10% 3.1 3.1%

We want to make our residents as comfortable as they would be in their own homes and part of that is keeping them injury-free. Here’s how we will reach our goal: Identify potential fall risks: We will start doing high risk rounds for residents identified as likely to fall, and put preventative measures in place to keep them safe. We will also trial a new Fall Risk Assessment Tool that is designed specifically for the long-term care population. Monitor skin carefully: We will review residents with high risk pressure injury scores at weekly rounds to revise and create new strategies and interventions that are customized to their care plan. We will also educate staff and physicians on new medical directives for pressure injuries.

“Falls often occur when residents have unmet needs such as using the washroom. We’ve created a new structured rounding routine that helps residents to know when their care providers will be in to see them and help them with those needs.” VIANI TROPIANO NURSING PRACTICE CONSULTANT FOR THE HOUSES

ADDITIONAL CORPORATE QUALITY PRIORITIES

Hand hygiene and hospital-acquired infections

Performing well in hand hygiene will help the network ensure that our patients and residents are protected from hospital-acquired infections, and demonstrate to our patients and residents our commitment to their safety. Washing hands prior to contact with a patient or entering the patient environment has the greatest impact on patient safety and will continue to be our priority. Our goal: Increase our staff hand hygiene rates and prevent hospital-acquired infections.

Emergency Department length of stay

We believe that in order to have a positive patient experience, our patients should be able to get the care they need as quickly as possible. Waiting to be admitted both results from and creates bottlenecks that impact a hospital’s efficiency, flow and quality of care. Improvement efforts will focus on reducing the 90th percentile length of stay for both nonadmitted and admitted patients in the Emergency Department. Our goal: Reduce ED length of stay.

In addition to our QIP goals and system priorities, we’ve identified the following areas as opportunities for our network to focus on to support high quality care. In 2018-19, together we will work on addressing these priorities to keep our patients as safe as possible. Hospital-acquired pressure injuries

Falls in hospital

Pressure injuries are common among patients in health-care organizations across Canada, yet despite how frequently they occur, they can be avoided. Hospital-acquired pressure injuries typically affect people who are bedridden or have limited mobility during their stay, and they represent a serious risk to patient safety. They are painful, can result in potentially life-threatening infections and reduce a patient’s ability to move around.

To a patient, a bad fall in hospital can mean the difference between going home to recover or weeks more of treatment. The work involved in preventing falls is complex and multi-disciplinary, and many factors including medications, physical environment, etc. all play a role. Our goal: To prevent and reduce harmful falls.

Our goal: To prevent and reduce hosptal-acquired pressure injuries. QUALITY IMPROVEMENT PLAN 2018-19

Medication reconciliation

This is a formal process in which the network works with patients, caregivers and care providers in the community to make sure all parties have the patient’s correct medication information. Evidence suggests that 30 per cent of medication errors in North America have the potential to cause patient harm. They are also a common reason for unplanned readmissions to the hospital. Our goal: Work with our patients and partners to ensure everyone has the correct medication information. 17

OUR COMMITMENT TO BROADER SYSTEM PRIORITIES

Collaboration and integration We cannot meet our goals without other health

providers across all sectors: hospital, community, primary care and long-term care. These partnerships allow us to provide our patients with a range of services that best meet their needs, enabling seamless transitions of care on their health journey and best practices to be shared across the health-care system. Our network has a wide web of partners who we are working with on everything from designing pathways for our patients who have suffered from a stroke, to helping ALC patients move to the appropriate level of care, to supporting our patients as they move from the hospital back into the community.

Reducing the use of opioids

Opioids are a group of drugs commonly prescribed to treat pain. Opioid prescribing, related adverse events and access to treatment for opioid use disorder continue to be a high priority for clinicians, policy-makers and the general public in Ontario due to the growing number of related overdoses and deaths.

Our mission is to provide safe, high quality care to everyone who comes through our doors. The following have been identified as areas of opportunity for all hospitals across the province that we as a network will work together on. Alternate level of care

Health equity

When a patient no longer requires the intensity of resources or services provided in hospital but remains at the hospital while they wait for the right level of care to become available elsewhere, they are designated “Alternate Level of Care” or “ALC.” As a broad health system, we need to do better in helping our ALC patients get to the next stages of their care journeys. Our sites each bring a long history of quality improvement initiatives to address ALC, with our own unique successes and lessons learned. Integration is an exciting opportunity for sharing strategies, best practices and community connections that can be embedded across the network so our ALC patients receive the right level of care they need, in the right place. QUALITY IMPROVEMENT PLAN 2018-19

St. Joseph’s has been a leader in addiction medicine for over 20 years, developing and implementing a number of strategies to prevent and manage opioid addiction. Some of these strategies have now been adopted by St. Michael’s as well as other hospitals across Ontario – this is the kind of system crosspollination and knowledge sharing that we will work to continue. Initiatives at both sites include introducing suboxone in the Emergency Department for patients in opioid withdrawal, the launch of Rapid Access Clinics, inpatient addiction medicine consultation services, withdrawal management services for those in acute withdrawal and courses for patients with addictions to learn strategies for cognitive- and mindfulness-based relapse prevention.

Our sites share the Sisters of St. Joseph’s legacy of caring for the most marginalized or disadvantaged in our communities. This shared commitment to serving the underserved is one of the network strengths that brought us together. Across the network, we continue to collect patients’ health equity data as part of a LHIN-wide program, which helps us better understand the populations we serve, identify gaps in our services and ensure we are providing high quality care to all. Integration is an opportunity to share strategies and best practices for using this data to its fullest potential.

QUALITY IMPROVEMENT PLAN 2018-19