UHN Quality Improvement Plan for 2014

2014/15
Quality Improvement Plan
April 1, 2014
University Health Network
190 Elizabeth Street, Toronto, M5G 2C4
1
Overview
At University Health Network (UHN) our vision is to achieve global impact and our mission is to provide
exemplary patient care, research, and education. Our Quality Improvement Plan (QIP) is directly aligned to the
goals we set out in our Strategic Directions 2016: Global Impact. Specifically, the following goals and objectives
within our Caring domain guided the selection of our priority measures:




Become a world leader in documenting and improving patient outcomes
Transform "patient-centered care" to "patients as partners in care"
Measure and improve the value of care
Lead health system integration
This year we included all seven HQO priority measures designated by the Ministry of Health and Long Term
Care (MOHLTC) on our QIP. We will aim to ‘improve’ performance on three of the measures, and we will aim to
‘maintain’ our performance on the remaining four. In addition, as part of our commitment to ongoing quality
improvement, we have selected four additional UHN key priority measures.
UHN Priority
HQO Priority
Measure
Baseline
Target
ED wait times
24.1
24.1
Maintain current performance
ALC rate
9.3%
9.3%
Maintain current performance
30-day readmission
16.2%
17.0%
Maintain current performance within corridor
Med reconciliation
NA
70%
Patient experience
89.6%
90.1%
Aim to increase by 0.5%
C. difficile
0.47
0.42
Aim for last year’s target
Total margin
2.0%
0%
Maintain current performance
Surgery to rehab LOS
32.4
31.0
Aim for best practice benchmark
Surgical cancellations
4.6%
4.5%
Aim to decrease by 0.1%
Central line infection
1.04
0.9
Discharge summary completion
84.7%
85.0%
University Health Network
190 Elizabeth Street, Toronto, M5G 2C4
Target Justification
Aim for Accreditation Canada’s standard
Aim for TAHSN hospital average
Maintain current performance
2
For all of the measures on our QIP we have developed a comprehensive set of change ideas. The change
ideas for each of the measures where we will aim to ‘improve’ performance are summarized below.
Patient-centered care is a fundamental value on which we form our journey to excellent patient engagement,
satisfaction, and outcomes. This year, UHN will launch a 2-year roadmap to transform to “Partners in Care” and
have set a target to increase our patient satisfaction rate by 0.5%. One major component of this roadmap will
be to engage patients and care givers as advisors in our activities and initiatives.
To enhance patient safety, we are aiming to reduce our C. difficile rate by 0.05. Change ideas include switching
to a sporicidal cleaning agent that defends against C. difficile and implementing C. difficile guidelines.
Moreover, we will begin to develop the process to track and measure urinary tract infections as these infections
have been shown to have an impact on C.difficile rates.
At UHN, reconciling medications at admission is indeed part of our practice; however, we have not been
actively tracking this practice. We are aiming to have medication reconciliation occur upon admission at least
70% of the time in our first year measuring this outcome. This year we will focus on developing sustainable
tracking mechanisms for both paper-based and electronic data capture.
Reducing avoidable surgical cancelations remains an area of focus for 2014/15. While we have made progress
in previous years, we continue to aim to decrease avoidable surgical cancelations by 0.1%. Various change
ideas include, opening a general internal medicine unit to increase flex capacity, expanding the number of flex
days available, redesigning our current OR booking system and evaluating implementations from last year's
rapid improvement events to ensure improvements are sustained and changes are made, where necessary.
We continue to aim to reduce our central line infection rate this year. Our change ideas include furthering
education initiatives for staff, improving response time for bed side peripherally inserted central catheters at
TGH, implementing vascular access assessments in daily huddles, trialing CHG baths in MSNICU, and
implementing a vascular access committee.
To continue our efforts on improving system integration between acute and primary care, we continue to focus
on our performance for discharge summary completion. Change ideas include sending incompletion letters
within 72 hours and enabling web-based online editing for our Most Responsible Physicians.
To improve transitions in care between acute and rehab, we aim to reduce the length of stay from surgery to
rehab for fractured hip and rapid assessment treatment patients at Toronto Western from 32.4 days to 31 days.
A thorough set of change ideas has been collated between Toronto Western and Toronto Rehab that will be
pursued over the year to help us achieve this target.
University Health Network
190 Elizabeth Street, Toronto, M5G 2C4
3
Integration & Continuity of Care
Through evaluation of 2013/14 data to inform our current plan, we reviewed patient and employee surveys, patient
complaints and staff reports of critical incident information. The common themes emerging from our analysis include
integration of care throughout a patient's journey. That is why discharge planning remains a focus in our QIP. We
continue to build partnerships with other organizations such as Bridgepoint Health, St. Hilda's and continue to connect
patients with appropriate services such as CCAC, Telehomecare, Virtual Ward, ICCP, and SCOPE. Moreover, our
leadership role in the Mid-West Health Link has informed our QIP and we continue to identify areas for opportunity
improvement to improve coordination and information sharing.
Challenges, Risks & Mitigation Strategies
There are a few external and internal challenges and risks to achieving our QIP goals. Externally, there are significant
and recurring program pressures and patient demand that require funding to balance these pressures. To maintain
patient volumes, we continue to request volume funding from the MOHLTC and TCLHIN. We also continue to review
tertiary factors and HBAM adjustments to ensure funding appropriately matches high patient acuity in acute, rehab,
and CCC. In addition, we are in the process of implementing new Advanced Clinical Documentation (ACD) and
therefore more focus will be on gathering requirements to begin preparation for implementation. As a result, tracking
improvements and implementing IT solutions within the current IT infrastructure will be difficult as the new ACD will be
the main priority. To mitigate the risks and challenges presented to us, regular review of our QIP by our Executive
Team and Senior Management Team are scheduled to occur throughout the year.
Engagement of Clinical Staff & Broader Leadership
In developing this QIP, clinical staffs were engaged to develop improvement strategies and come up with change
ideas. Assigned Measure Leads met with their various teams and staff to identify appropriate change ideas
and measures for 2014/15. Moreover, we engaged our Operations Committee and Collaborative Academic Practice
Committee to ensure that various targets were aligned and synergies were leveraged, where possible. Senior
Management and the Board provided their oversight and approval for the engagement process.
University Health Network
190 Elizabeth Street, Toronto, M5G 2C4
4
Accountability Management
Executive compensation will be linked to the achievement of the following five 'improve' measures: patient
experience, C.difficile, medication reconciliation, central line infection and surgery to rehab length of stay.
The following portions of variable compensation will be linked:
President and Chief Executive Officer
25%
Executive Vice President and Chief Financial Officer
20%
Senior Vice President, Human Resources and Organizational Development
20%
Vice President, Health Professions and Chief Nurse Executive
20%
Vice President, Quality and Medical Affairs
20%
Vice President and Chief Information Officer
20%
Senior Clinical Vice Presidents
20%
Physiatrist in Chief
20%
Physician in Chief
20%
Surgeon in Chief
20%
The five targets will be equally weighted. The following incentives will be available for each target:
Target achieved
100%
Improvement over previous year (target not achieved)
80%
Same as previous year (minimum threshold achieved)
50%
University Health Network
190 Elizabeth Street, Toronto, M5G 2C4
5
Accountability Sign-off
I have reviewed and approved our organization’s Quality Improvement Plan and attest that our organization fulfills the
requirements of the Excellent Care for All Act.
Mr. John Mulvihill
Dr. Dhun Noria
Dr. Robert Bell
Board Chair
Quality Committee Chair
Chief Executive Officer
University Health Network
190 Elizabeth Street, Toronto, M5G 2C4
6
2014/15 Quality Improvement Plan
Improvement Targets and Initiatives
Aim
Quality
dimension
Access
Measure
Objective
Definition
Reduce wait
times in the
ED
ED Wait times: 90th percentile ED length of stay
for Admitted patients.
Change
Current
performance
Target
24.1
24.1
Target
justification
Priority
Change Ideas
level
Q3 YTD is 24.1 Maintain 1)Conduct improvement
and we will aim
initiatives to improve
discharge planning and
to maintain this
performance
implement quality based
procedures (QBPs)
2)Improve ED
consultation and decisionmaking for patient
disposition
3)Resolve technology
issues with pre-triage
assessment using iPads
for escalating patients
4)Open an additional GIM
unit at TWH; Develop a
plan for additional unit at
TGH
5)Place emphasis on
internal flow strategies
6)Continue partnership
with Bridgepoint Health
and expand flow of
patients to Toronto Rehab
Increase
access to
surgery
Avoidable Surgical Cancellations: The number of
avoidable OR cancellations within 48 hours (on the
scheduled day of surgery or the day prior) out of
all scheduled OR cases.
4.6
4.5
Aim to decrease Improve 1)Open a GIM unit at
by 0.1%
TWH & TGH to increase
flex capacity and mitigate
cancellations because of
no beds
2)Expand number of flex
days to 4 rooms per week
to increase flex capacity
at TGH
3)Redesign OR booking
system (ORSOS codes) to
minimize case overload
cancellations; 2 year
project; goal in 2014/15 is
to define project team
and scope
Improve
organizational
financial
health
Total Margin (consolidated): % by which total
corporate (consolidated) revenues exceed or fall
short of total corporate (consolidated) expense,
excluding the impact of facility amortization, in a
given year.
1.94
0
Integrated
Reduce
unnecessary
time spent in
acute care
Percentage ALC days: Total number of acute
inpatient days designated as ALC, divided by the
total number of acute inpatient days.
9.3
9.3
Goal
Number of improvement
events
5
Hours between
registration and physician
assessment
Hours from ED consult to
decision to
admit/disposition
Percent of project
complete
2.9
Percent of project
complete to open unit on
4B Fell
Percent of project
complete to develop a
plan to open new unit on
12 Eaton South
Monthly monitoring and
reporting of Pay for
Results dashboard
Decrease % of ALC days
(acute)
7
100%
100%
100%
Ongoing
9.3%
Percent of cancellations
due to no bed decreased
30%
Percent of project
complete (50% - add 2
rooms in June )
100%
Percent of project phase
complete
100%
4)Decrease the number of Percent of cancellations
cancellations for more
decreased
urgent, priority 1A, and
priority 1A transplants
50%
5)Evaluate
implementation from
process improvement
event in TWH Ortho to
streamline information
patients receive that
enables patient to arrive
on time
Effectiveness
Process measures
Number of
implementations
evaluated
2
Aim for
Maintain
theoretical best
Q3 YTD is 9.3% Maintain 1)Pilot new CCAC role
and we will aim
embedded within TWH
to maintain this
GIM for early
performance
identification of ALC
patients
Completion of pilot
May 2014
2014/15 Quality Improvement Plan
Improvement Targets and Initiatives
Aim
Quality
dimension
Measure
Objective
Definition
Change
Current
performance
Target
Target
justification
Priority
Change Ideas
level
2)Develop revised
discharge planning
approach for complex
patients
Process measures
Implementation of new
approach
3)Focus on partnership
Number of incremental
with Bridgepoint Health to patients transferred by
expedite transfer for
March 2015
rehab, LTC, and CCC
patients
4)Develop strategies to
refer patients from GIM
to the Transitional Care
Program at St. Hilda’s
5)Apply lean process
improvement
methodologies across the
continuum of care (acuteto-rehab ) for specific
populations
Monitor number of
patients transferred
Reduce
unnecessary
hospital
readmission
Readmission to any facility within 30 days for
selected CMGs for any cause: The rate of nonelective readmissions to any facility within 30 days
of discharge following an admission for select
CMGs.
16.2
17
May 2014
195
Ongoing
Completion of plan for
June 2014
GIM to include number of
opportunities for
improvement
6)Develop a strategy to
Completion of strategy
increase utilization at UC
and Bickle Sites, focusing
on LTLD and CCC patients
7)Renew focus on ALC
performance at the unit
level
Q3 YTD is 16.2 Maintain 1)Enhance recovery after
and we will aim
surgery (ERAS) pathway
to maintain this
for colorectal surgery
performance
patients
Goal
Implementation of unitlevel targets
March
2015
June 2014
Percent of colorectal ERAS
patients re-admitted
within 30 days
0%
2)Provide follow-up
support to general
surgery patients with use
of nurse navigators
Percent of general surgery
patients who receive a
follow-up from a nurse
navigator post-discharge
70%
3)Regular follow-up
phone calls post-discharge
to post-surgical patients
in Thoracics, Urology, ENT,
Gyane oncology
Number per week in
Thoracics
Number per month in
Urology, ENT, Gynae
Oncology
10
40-50
4)Resident and NP run
Number of clinics per
1 per
clinics to provide access to week in Thoracics and ENT service
any ambulatory follow-up
for discharged patients
5)Identify opportunity for Number of improvement
improvements in ED/GIM events
6)Pilot Transitional Care Percent complete
role in GIM TWH with
focus to: A. Establish
process to identify and
develop care plans for
complex patients B.
Confirm all patients have
PCP and link those who do
not to a PCP C.
Standardize workflow for
complex patients to have
a follow-up 7-days post
GIM discharge D.
Establish a standardized
process to discharge
planning to connect
appropriate patients with
services
Improve
Surgery to rehab length of stay (LOS) for Fractured
integration
Hip & Rapid Assessment Treatment (FHRAT)
between
patients
acute care and
32.4
31
Aim for best
practice
benchmark
Improve 1)Implement clinical
Percent patients on 9A
pathway for fractured hip are on a clinical pathway
patients on 9 A Fell
5
100%
100%
2014/15 Quality Improvement Plan
Improvement Targets and Initiatives
Aim
Quality
dimension
Measure
Objective
Definition
Change
Current
performance
Target
acute care and
rehab
Improve
integration
with primary
care
Patientcentred
Improve
patient
satisfaction
Target
justification
Priority
Change Ideas
level
2)Conduct daily huddles
to identify potential
opportunities for
improvements and model
of care enhancements at
TWH & TR
Discharge Summary Completion: Percent of
discharge summaries completed within 7 days of
inpatient discharge
From NRC Picker: "Would you recommend this
hospital (inpatient care) to your friends and
family?" (add together % of those who responded
"Definitely Yes" or "Yes, definitely").
84.7
89.6
85
90.1
Process measures
A. Acute: Monitor LOS
against target- 5 days
(and monitor outliers) B.
Rehab: Functional
Independence Measure
(FIM) efficiency target
Goal
A. 5 B.
1.15
3)Develop process to
Percent of rehab
maintain and/or increase appropriate patients
number of rehab patients referred
referred from TWH to TR
100%
4)Develop a consistent
Percent of RM&R referrals
approach to ensure RM&R sent by day five increased
referrals are completed
and sent properly
80%
5)Increased RM&R
submission authority to
more staff
Percent of staff with
RM&R submission
authority
20%
Percent of patients ‘ready
for surgery’ within 48
hours
90%
Percent of incompletion
letters sent within 3 days
90%
6)Develop standard
approach to ensure
patients move from ER to
OR within 48 hours of
admission
Maintain current Maintain 1)Send incompletion
performance
letters within 72 hours (3
days) providing physicians
with 4 days to complete
and meet the 7 day
requirement
2)Enable web-based
All MRPs have access to
online editing Clinician
CLiP
Portal (CLiP) to allow
Most Responsible
Physicians (MRPs) to signoff on discharge
summaries online
March
2015
3)Start pilot on front-end
voice recognition to
increase speed of
transcription of notes,
discharge summary etc.
4)Track, validate, and
develop change ideas for
2015/16 for TR inclusion
on QIP discharge
summary completion
Percent of pilot project
complete
100%
Percent project complete
to include TR
100%
Percent of lean process
improvement initiatives
100%
Engagement at all sites
Report back to UHN
Operations group on
progress
4
3)Once each Hospital has
identified their top three
Goals & Objectives;
recruit patient & caregiver
advisors to act as
committee members for
these initiatives
Number of
patients/caregivers
recruited (2 pts /
caregivers x 3 goals x 4
hospitals)
24
4)Engage patients &
caregivers in the ACD
project
Patient engagement
process to be developed
Aim for 0.5%
Improve 1)Capture patient
increase
voice/experience to
(Toronto Rehab
inform clinical process
included in
improvement initiatives
overall UHN
2)Engage patients &
results)
caregivers as advisors to
each site’s Goals &
Objectives Days
5)Implement the Four A’s Percent of areas
Customer Service Model implemented
across UHN
March
2015
50%
2014/15 Quality Improvement Plan
Improvement Targets and Initiatives
Aim
Quality
dimension
Safety
Measure
Objective
Increase
proportion of
patients
receiving
medication
reconciliation
upon
admission
Reduce
hospital
acquired
infection rates
Definition
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.
CDI rate per 1,000 patient days: Number of
patients newly diagnosed with hospital-acquired
CDI, divided by the number of patient days in that
month, multiplied by 1,000 - Average for Jan-Dec.
2013, consistent with publicly reportable patient
safety data.
Change
Current
performance
NA
0.47
Target
70
0.42
Target
justification
Priority
Change Ideas
level
Process measures
Goal
6)Embed Four A’s into
Percent of project
new employee orientation complete
50%
7)Implement report at the Percent of areas
bedside across UHN
implemented
50%
Aim for
Improve 1)Increase awareness
All team, forum and
through organization wide leadership meetings
Accreditation
Canada standard
communication
reached
Aim for last
year's target
2)Develop a sustainable Audit and review data
tracking mechanism for
manual tracking and
reporting at TR and PMH
(paper-based hospitals);
streamline process to
obtain accurate
admissions data at TGH &
TWH to identify
compliance
Quarterly
3)Revitalize / update local
practice models for
clinical areas not meeting
target
Ongoing
Provide reminders for
areas with low
compliance on best
practices
Improve 1)Switch to a sporicidal
Percent of units assessed
cleaning agent that
to utilize new cleaning
defends against C. difficile agent
100%
2)Educate housekeeping Percent of housekeeping
staff on updated cleaning staff
best practices
100%
3)Implement C. difficile
antimicrobial treatment
guidelines
100%
Percent of project
complete
4)Track inpatient catheter Ability to track and
use (both time in and out) measure UTI for 2015/16
QIP
Rate of central line blood stream infections per
1,000 central line days: total number of newly
diagnosed CLI cases in the ICU after at least 48
hours of being placed on a central line, divided by
the number of central line days in that reporting
period, multiplied by 1,000 - consistent with
publicly reportable patient safety data.
1.04
0.9
June 2014
Aim for TAHSN Improve 1)Review/remind staff of
hospital average
line maintenance impact
including sterile access
has on CLI rates
A. Percent of patients
where needed have
swabcaps in place B.
Percent ICU nurses
educated on line
i t
2)Include vascular access Daily assessment on
assessment, date/site and vascular access for every
in daily patient
patient
huddle/rounds
March
2015
A. 80% B.
100%
Dec-14
3)Increase response time
for bedside PICCs in
Critical Care and MOT
step-down at TGH
Response time of
48 hours
insertions and
interventions related to
beside insertion from time
of referral
4)Trial CHG baths at TWH Track compliance on
100%
for all patients in MSNICU usage of CHG wipes,
unless contraindicated
product evaluations and
(skin irritation, allergy or correlating infection rates
rash/open wound)
with usage
5)Implementation of
Vascular Access
Committee to discuss new
policies, and standardize
best practice in carecollaborate with 3M to
improve dressing
alternatives & alternate
securement devices
Percent of project
complete for trial
evaluation and audit
dressing duration
100%

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