2019-20 Quality Improvement Plan Work Plan
Primary 2020 Strategic Plan Alignment Quality Dimension Objective Measure/Indicator Planned Improvement Initiatives (Change Ideas) Methods Process Measures Targets for Process Measures Most Responsible
1 Patient Experience Safe Medication reconciliation at admission The total number of patients with medications reconciled as a proportion of the total number of patients admitted to the hospital 1) Improve participation and completion of medication reconciliation by physicians at admission.
2) Allocate resources and develop work flow process for medication reconciliation audits.
1) Engage physicians in medication reconciliation process.
2) Monitor daily reports and follow up with care team and physicians.
3) Report and monitor compliance to Med Rec Working Group, Chief of Staff and Medical Advisory Committee.
4) Pharmacy develop workflow process to complete medication reconciliation audits in the Emergency Room
5) Commit dedicated resource (Nurse/Pharmacy Tech) in Emergency to ensure completion and quality of Best Possible Medication History (BPMH) assessments.
6) Train dedicated resource(s) on BPMH assessments and work flow process in the Emergency Department.
7) Targeted communication and education.
1)% BPMH complete with quality standard met
2)% physicians engaged
3)% Medication reconciliation audits complete
1)100%
2)90%
3)100%
Deborah Emery
2 Patient Experience Safe Overall Incidents of workplace violence Number of overall workplace violence incidents (verbal, physical contact, no physical contact, those requiring medical aid). 1) Enhance current workplace violence prevention program 1) Create a culture that supports reporting, including an understanding that reporting of incidents and hazards are done without reprisal; supervisors act on those reports and support the staff involved and assist in mitigating risk of future incidents.
2) Develop processes for the identification and evaluation of patient specific workplace factors.
3) Provide education and training to staff in order to ensure they have the knowledge and tools required to protect themselves and others in the workplace.
4) Coordinate the prioritization of security and facility enhancements to improve facility security for all.
1) Process for identification and evaluation developed
2) % of identified staff educated on how to protect themselves
3) % of identified security and facility enhancements implemented
1) Process developed
2) 100%
3) 100%
Rose Lazinski
3 Comprehensive Clinical Care Safe 30-day in-hospital deaths following major surgery 30-day in-hospital deaths following major surgery 1) Determine root cause of in-hospital deaths following major surgery 1) Chart review and analysis on in-hospital deaths occurring within 30 days following major surgery
2) Review with Chief of Surgery
3) Determine if there are trends that need to be addressed
1) % of chart reviews complete
2) Review process developed
1) 100%
2) Process developed
Laura Lee Barrie
4 Seniors Health Safe Fall rate per 1,000 patient days Fall rate per 1,000 patient days 1) Identify and implement fall prevention initiatives.
2) Ensure fall risk assessments are completed on patients and that identified patients have appropriate arm bands.
1) Reconvene the Falls Committee
2) Create focused education for front line staff and audit compliance.
3) Review falls data and develop action plans based on top identified priorities.
1) Number of fall prevention initiatives implemented. 1) 100% of identified initiatives implemented. Dawna Maria Perry
5 Comprehensive Clinical Care Timely Time to Inpatient Bed 90th %tile wait from disposition to inpatient bed for admitted patients. 1) Ensure the new policy and procedures are facilitating timely transfer of patients from the Emergency Department to inpatient units.
2) Optimize the use of the Meditech Bed Board System.
1) Monitor and Evaluate the new Interdepartmental Transfer Process from Emergency Department Policy.
2) Automate bed requests from the Emergency Department.
3) Utilize P4R initiatives.
1) % of identified improvement strategies implemented 1) 100% Lisa Beck
6 Comprehensive Clinical Care Efficient Average Length of Stay ALOS (excluding ALC) 1) Improve Data Quality for tracking Consult Delays in Patient Flow Software.
2) Optimize the use of the Meditech Bed Board System.
3) Provide real time ELOS tracking for Physicians and engage on improvement strategies.
1) Complete a process improvement 'Design Event' to ensure all members of the care time are aware of physician consults.
2) Automate bed requests from the Emergency Department.
3) Develop Reports for Physician Groups and provide reports to physician chiefs/ section meetings.
1) % of identified improvement strategies implemented 1) 100% John Ross
7 Comprehensive Clinical Care Efficient Alternative Level of Care ALC days to Rehabilitation Services or Complex Continuing Care 1) Develop a clear pathway for geriatric patients to Assessment Beds/ Rehab Services. 1) Develop patient pathway between the hospital & SJCG.
2) Ensure the quality of data reported on the patient populations.
1) 90th percentile Days Wait for Assessment Beds from date of referral to date of admission. 1) 3 Days John Ross
8 Patient Experience Equitable Respect training Experience and treatment scores under custom questions on CPES 1) Create a culture that supports Respect 1) Develop continuous improvement processes to ensure adoption of the Respect Campaign
2) Provide education and training to staff in order to ensure they have the required knowledge and understanding.
1) % of Staff that have received Respect training in all in all clinical and non clinical areas 1) 60% Kelly Meservia-Collins
9 Patient Experience Effective Discharge summaries sent within 48hrs of discharge Process Indicator 1) Develop strategies to improve discharge summary completion
2) Ensure collection of reliable data
1) Investigate current use of Discharge Report Form and implement required improvements
2) Implement education on discharge summary best practices
3) Develop reliable and sustainable data collection methods
1) % of identified improvement strategies implemented 1) 100% Zaki Ahmed
10 Comprehensive Clinical Care Effective Patients with complex health needs (Health Links) Process Indicator 1) Ensure TBRHSC patients meeting Healthlinks criteria are identified and communicated to the NWLHIN

2) Seek support from NWLHIN in ensuring required services for Healthlinks patients are readily available and that patients are referred to appropriate providers for care
1) On a quarterly basis, source TBRHSC patients who meet Healthlinks criteria (including recent hospital inpatient and ED encounters; primary & secondary diagnoses; demographic info), and forward listing to NWLHIN for referral to appropriate care providers.
2) For patients referred on to appropriate providers, source post referral data and evaluate success of support services.
3) Measure percentage of patients referred to appropriate support services.
1) Compliance with Healthlinks patient reporting

2) % of Healthlinks patients referred to supportive services
1) 100%

2) % of Healthlinks patients referred to supportive services is dependent on capacity of Community Care Division of the NWLHIN and supportive services, so target cannot yet be set
Michael Del Nin
11 Patient Experience Effective Staff satisfaction Engagement Score (TBRHSC Employee and Professional Staff Experience Survey (EPSES) 2021) 1) Develop Department and Corporate EPSES action plans 1) Engagement with staff on action plan development and creation of SMART goals
2) Collection and analysis of feedback for Corporate initiatives, action plan development and creation of SMART goals
3) Developed actions embedded into Operational Plans
4) Quarterly updates from HR/Communications to SLC and to staff
1) % of Departments with developed action plans by April 1, 2019.
2) % of Corporate action plans by April 1, 2019.
3) % of Action Plans completed within deadlines.
1) 100%
2) 100%
3) 75-100%
Amy Carr
12 Patient Experience Patient-Centred Patients receiving enough information on discharge % of respondents who responded "completely" to the question: Did you receive enough information from the hospital staff about what to do if you were worried about your condition after you left the hospital? 1) Increase patient understanding on discharge through PODS and include specific condition PODS where applicable. 1) Evaluate process and modify PODS tool as appropriate (based on results).
2) Evaluate appropriate time when giving education on PODS tool.
1) % of discharged patients to home receiving PODS.
2) % of patients who say the PODS was explained in a way they understood.
1) 100% for medicine and surgery
2) Improve 5% per quarter
Bonnie Nicholas
13 Comprehensive Clinical Care Safe Infection Control Process Indicator 1) Identify an effective surveillance system of processes and outcomes that drive quality improvement in how we prevent and control infection.

2) Define key indicators to measure the clinical and cost effectiveness of the IPAC program
1) Assess and identify most appropriate process measures to allow us to better control and prevent infection (Process Surveillance) https://www.publichealthontario.ca/en/eRepository/BP_IPAC_Ontario_HCSettings_2012.pdf

2) Assess and identify chosen options for infection measurement (Outcome Surveillance), which is consistent with PIDAC.
https://www.publichealthontario.ca/en/eRepository/Surveillance_3-3_ENGLISH_2011-10-28%20FINAL.pdf
1) % of identified Process and outcome surveillance strategies committed to 1) 100% Katherine Bell