2021/22 Quality Improvement Plan Work Plans - Performance Monitoring & Quality Committee
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2021/22 Quality Improvement Plan
Work Plans
Performance Monitoring & Quality Committee
2 March 2021 Create Health. Build Community.2021/22 QIP Work Plans | Table of Contents
The following pages contain a work plan for each of the improvement initiatives. Work Plans articulate the: 1)
improvement objective; 2) measure to track improvement; 3) improvement target; and 4) change ideas that will drive
the improvement.
Page
Medication Reconciliation on Discharge …. 1
Transfer of Care …………………………………….... 2
Patient Experience (PODS) .…………………….. 3
ETHP Collaborative………………………………….. 4
Workplace Violence Prevention ............... 5
ED Length of Stay (Time to Bed) ……………… 62021/22 QIP Work Plans | Medication Reconciliation on Discharge
Increase the proportion of patients receiving medication reconciliation on discharge
Unit of measure/ Target for
Indicator Data Source/Period Baseline Target Justification
Patient population 2021/22
Percent of Unit of Measure Data Source • Score will continue to include Complex Care and
discharged Percent Hospital collected Maternal Newborn Child in addition to Medicine,
patients for whom data Surgery, & Mental Health
a Best Possible Patient Population 61.5% > 64%
• Baseline is based on FY 2019/2020 YTD average
Medication All in-patients excl. Reporting Period
Discharge Plan was deceased, LOS < Q1-Q4 2021/2022 • Target is based on 5% improvement on baseline
created. 24hrs, newborns score
# Change Idea Methods Measure Target
1. Include Discharge Med Rec stats as part of the required Discharge
Summary dashboard
1. Q2
Improve reporting and Completion
1 2. Introduce Discharge Med Rec for all COVID-19 vaccine recipients 2. Q1
visibility of Med Rec stats date
3. Q2
3. Review reporting post-Cerner upgrade to enhance automation
1. Continue supporting CCC and MNC in sustaining their targets
Sustain Med Rec in areas 1. Q1-Q4
Completion
2 where it has previously been
2. Incorporate PODS Discharge Form completion as part of Med Rec date 2. Q1-Q4
rolled out
monitoring for MNC
Page 12021/22 QIP Work Plans | Transfer of Care
Improve quality of information transfer at patient transition points
Unit of measure/ Target for
Indicator Data Source/Period Baseline Target Justification
Patient population 2021/22
The target represents a 10% increase from
Unit of Measure Data Source
last year’s target. Given that COVID-19 will
Percentage Hospital collected data
% correct continue to be a top organizational priority
(i.e. observational audits
completion of for the remainder of the 21/22 FY, a 10%
Patient Population of verbal handover) 77% > 85%
IPASS at shift increase is reasonable. Specific work on the
All inpatient areas
handover final component of IPASS (i.e. Synthesis by
where IPASS has Reporting Period
Receiver) will need to be completed to reach
been implemented April 2021 – Mar 2022
this target.
# Change Idea Methods Measure Target
1. Transition TOA QIP oversight from the TOA project team to clinical
operations.
1. Q1
Sustain and improve upon the 2. Continue to support teams in completing the required 10 audits per Completion
1 2. Q1-Q4
changes made last QIP cycle month. Date
3. Q2-Q4
3. Provide support to teams who have found the synthesis portion of
IPASS challenging.
1. Create interdisciplinary committee whose goal is improving
physician handover.
Develop standardized practice Completion 1. Q2
2 2. Work with IT to explore potential solutions for a standardized
for physician handover Date 2. Q2-Q4
physician handover tool in PowerChart.
Page 2Patient Experience
2021/22 QIP Work Plans | Patient Oriented Discharge Summary (PODS)
Improve patient experience
Unit of measure/ Target for
Indicator Data Source/Period Baseline Target Justification
Patient population 2021/22
Percent of top box Unit of Measure Data Source
responses (“Completely”) For the purpose of aligning with OHT priority populations
Percent Canadian Institute
to the question “Did you (seniors with chronic illnesses and their caregivers) this
for Health
receive enough year we will continue implementing PODS for patients
Information (CIHI),
information from hospital Patient Population with chronic respiratory conditions .
NRC Health
staff about what to do if 61% ≥ 61%
All survey Although the change ideas were not fully implemented
you were worried about Reporting Period
respondents due to the COVID 19 pandemic, the target was achieved.
your condition or
discharged from January 2021- Our target reflects a small increase from last year (58%)
treatment after you left
Respiratory Unit December 2021 that should be sustained once our change ideas are fully
the hospital”? (with a focus
implemented.
on Respiratory patients)
# Change Idea Methods Measure Target
% of patients who have a warm follow up
Post Discharge Phone Fully implement the automated Post Discharge Phone Call
phone call to address the flagged issues
1 calls (PDPCs) using the (PDPC) process , using the PODS framework ,for patients 100%
identified during the automated PDPCs
PODS framework being discharged to home
by end of March
% of staff who complete d iLearn module
1. Verify /complete staff training including NRT staff: and attended didactic and simulation 100%
a) iLearn module on health literacy
Build staff capacity in sessions by end of May
b) Didactic session on health literacy and teach back
2 the area of health c) Simulation session using teach back and PODS frame work
literacy and teach back 2. Observe staff during PODS conversations and documentation
and provide in the moment coaching and feedback. # of staff who have had in the moment 100%
coaching by end of June
Create the ideal Work with staff, patients and families to refresh the ideal
discharge conversation discharge process including PODS (pamphlet, expected
3 using the PODS date of discharge (EDD) on whiteboard, daily conversation, Completion Date Oct 2021
framework preparing to go home conversation and day of discharge
conversation)
Page 3East Toronto
2021/22 QIP Progress Report | ETHP Collaborative Health Partners
Improve Patient Engagement in their Care Partners: Providence, WoodGreen, VHA, SRCHC, SETFHT and Bridgepoint FHT
Unit of measure/ Target for
Indicator Data Source/Period Baseline Target Justification
Patient population 2021/22
Unit of Measure
Organizations will continue to use their
Percent Data Source
Percent of persons own organizational data in their QIP and
CIHI CPES Survey
satisfied with their can set an internal target if they feel
Patient Population question 35 & 36
they are ready to do so.
involvement in their Seniors with (TBC) 60 % > 60 %
planning of care and complex/chronic needs
Our baseline is based on last year’s
and their caregivers Reporting Period
treatment actual performance (Jan to Dec), and our
(focus on integrated care, 2021/22
target is a 5% improvement.
eg: H2D)
# Change Idea Methods Measure Target
1. Continue to roll out PFCC eLearning module across ETHP
1. Q1-Q3
Introductory Training on Person 2. Leverage BPSO Steering Committee to ensure regular meetings for Complete
1 and Family-Centred Care for Staff knowledge sharing 2. Q1-Q4
& Providers Activity
3. Support Champions to receive and provide on-going coaching and 3. Q1-Q4
support to support PFCC in their organization
1. Phase 1: literature search and finalizing interview questions and
consent forms 1. Q1
Completion of Advanced Clinical Complete
2 2. Phase 2: Through interviews and observation, study experiences of 2. Q1
Practice Fellowship Activity
PFCC across the ETHP integrated system of care
3. Q2-Q3
3. Phase 3 disseminate findings and develop action plan
1. Jointly submit indicator through the Enquire database and leverage
BPSO champions to share learnings and improvement opportunities
1. Q1-Q4
2. Jointly implement or expand data collection in two ETHP initiatives: Complete
Data collection & Quality
3 1. Home2Day initiative 2. Q2
Improvement Activity
2. HUBS
3. Q3
3. Develop and implement one Quality Improvement initiative based on
the data within the HUBS & H2D initiatives
Page 42021/22 QIP Progress Report | Workplace Violence Prevention
Reduction in workplace violence incidents
Indicator 1 Unit of measure/ Target for
Data Source/Period Baseline Target Justification
(Mandated) Patient population 2021/22
Number of workplace
Unit of Measure Data Source
violence incidents 25.8/month >26/mthly Target will remain the same, as we were
Count Hospital collected data
reported by hospital
workers (as by defined
unable to completely implement our change
Patient Population Reporting Period ideas.
by OHSA) within a 12 232/year >312/year
All patient care units April 2021– March 2022
month period.
Indicator 2 Unit of measure/ Target for
Data Source/Period Baseline Target Justification
(Custom) Patient population 2021/22
Number of workplace Unit of Measure Data Source
violence incidents Count Hospital collected data Target will remain the same, as we were
reported resulting in 13 < 13 unable to completely implement our change
Lost Time within 12 Patient Population Reporting Period ideas.
month period. All patient care units Jan 20201- Dec 2021
# Change Idea Methods Measure Target
Behavioural Care Plan Alert
1. Full implementation of the care plan alert in PowerChart
for Patient & Worker Safety 1. TBD *associated
2. Full implementation of the tool, staff education in one 1. Completion Date with Powerchart
Continue implementation of unit, prioritizing high risk to patient and staff. upgrades
1 2. Completion Date
the Behavioural Care Plan 3. Modelling the success of the one unit implementation, 2. May 2021
increase spread of implementation through dedicated 3. Completion Date
Alert for Patient and 3. September 2021
resources and/or unit level champions.
Worker Safety
Zero Tolerance Campaign & 1. Completion date of campaign
Strategy 1. Implement campaign for patients, hospital visitors and 1. September 2021
staff 2. % of staff feel action is taken 2. TBD (Pulse survey
Design and implement when attacked, bullied, or 2021 Employee
2. Develop communication and education materials to
communication , education harassed by Engagement
2 support workplace violence prevention (i.e. Close loop
and proactive solutions to patients/public/staff survey)
communication on reported incidents)
support our vision of a zero
tolerance work environment 3. Regular risk assessments (JHSC audits & identified high risk 3. # of safety audits completed 3. 80% by Q3.
areas prioritized using recently adapted tool) 4. 80% by Q4
4. # assessments completed
Page 52021/22 QIP Work Plans | ED LOS (Time for Inpatient Bed)
Reduce the time interval between the Disposition to Patient Left ED for admission to an inpatient bed or operating room
Unit of measure / Target for
Indicator
Patient population
Data Source / Period Baseline
2021/22
Target Justification
Data Source
Unit of Measure P4RHospital data; To recognize the impact of COVID-19 we have
Hours from Disposition National Ambulatory increased the target to ≤ 16 hr – however we aim
90th Percentile Care Reporting System
to Left ED for all to achieve ≤ 14 hr in the following year (F2022/23).
Emergency (NACRS); Data provided
admitted patients
Department Wait to HQO by Cancer Care 16.8 hr ≤ 16 hr COVID-19 has further highlighted the importance
Times for In- Ontario of moving patients quickly from the ED once
Patient Bed
Patient Population Reporting Period admitted, to ensure there is adequate space to
safely care for those patients arriving to the ED.
All admitted patients Dec 2020 to Nov 2021
(P4R cycle)
# Change Idea Methods Measure Target
1. Interdisciplinary facilitated workshop in June to map patient 1. Interdisciplinary
journey and identify pain points Participation in Workshops
Identify opportunities to 1. 100%
1 streamline the patient 2. Prioritize top 3 patient flow pain points, and develop and 2. Inter-Timestamp
flow journey implement interventions 2. TBD
improvements on priority
patient flow steps
1. Identify & automate at least 3 key metrics from Teletracking
for performance monitoring to inform changes 1. Completion date 1. September
2 Maximize Teletracking 2. Train users on new system 2. % of users trained 2. TBD
3. Increase visibility of key information for key users (e.g. ED 3. Time to access key info 3. Decrease by 50%
Charge Nurse, Portering, IP Clerks)
1. Leverage available funding to support offsite bed operations
to offset significant increase in ALC patients in acute care
1. ALC rate in acute care (%)
beds.
Focus on ALC 1. TBD
3 2. LOS for patients discharges
Management 2. Reduce LOS for acute medical patients through the
to community with home 2. TBD
implantation of creative discharge models, including short
care services
term comprehensive discharge support (e.g. HISH – High Page 6
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