Peterborough Regional Health Centre 2020/2021 - Quality Improvement Plan (QIP) Narrative - PRHC
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Peterborough Regional Health Centre – 2020/2021 – Quality Improvement Plan (QIP) Narrative Peterborough Regional Health Centre 1 1 Hospital Drive, Peterborough, Ontario, K9J 7C6
Overview At Peterborough Regional Health Centre (PRHC) our mission is to be a regional hospital, building healthier communities with our patients and partners, and to achieve this by investing in our people and technology with a focus on performance. We are driven and supported by our values: "Guided by You", "Doing it Right", and "Depend on Us", with the vision of “Exceeding your expectations, every day”. Our leaders, staff, physicians, volunteers, patients and families define our path to improvement by ensuring that we remain focused on providing outstanding, high-quality care and a first-class experience. Our 2020-2021 Quality Improvement Plan (QIP) supports the commitments made in our 2017-2020 Strategic Plan and is being considered as we refresh our Strategic Plan for 2020-2023. The QIP continues to be about our patients. We are proud that many of our Patient and Family Partners (PFPs) are engaged in informing our work, and that for the fifth consecutive year we have used a subset of our PFPs in the development of our QIP. These PFPs have been an important voice, informing and validating our plan and monitoring progress and improvements throughout the year. Our focus on patients and families is evident in the approach we have taken over the last three years and the change initiatives we continue to support to improve the quality of care we provide at PRHC. A key focus is the standardization of daily patient safety and experience best practices, including Bedside Nursing Shift Report, daily Safety Huddles, daily Patient Experience Rounding, and Interprofessional Patient Care Rounds across the organization. This approach ensures that structured methods and processes are in place to collect and respond to critical patient care information and feedback in real time. We have made progress in many of our quality indicators in 2019-2020, and we are confident that we will continue to sustain and build upon these improvements in 2020-2021. Peterborough Regional Health Centre 2 1 Hospital Drive, Peterborough, Ontario, K9J 7C6
Describe your organization's greatest QI achievement from the past year The success of our Quality Improvement efforts is best demonstrated by direct feedback from our patients. This year we achieved new highs in the percentage of patients who would “definitely recommend PRHC to friends and family,” with an all-time monthly high of 98% in December 2019 and greater than 94% for the year overall. This achievement is particularly remarkable given that PRHC saw considerably higher patient volumes across the board in 2019, with the hospital at or above capacity on a year-round basis. Our approach to quality improvement continues to be refined as we focus on the systems within our organization. A critical part of this journey continues to involve the direct inclusion of clinicians in our quality and collaborative practice project cycles. We have built a model that offers developmental opportunities for our clinical staff to leave their patient care roles on a temporary basis to support a specific quality or collaborative practice project. Using a hands-on approach, participants are mentored on change management skills and the science of improvement. The knowledge they gain is building our organizational capacity for quality improvement while providing unique personal and professional development opportunities. Our patient care staff return to their work areas with the ability identify new opportunities and support their teams through quality improvement initiatives. In 2019, PRHC was awarded an Impact and Innovation Bursary from the Registered Practical Nurses Association of Ontario (RPNAO) to support the development of a framework for our staff quality improvement developmental program. This opportunity is supporting the expansion of this program to all departments in the hospital. Over the past three years, we have welcomed and supported 19 clinical staff members who have provided leadership on many quality improvement projects, including enhanced communication with patients, developing a diabetes education program and the prevention of falls with harm. Their feedback highlights that the time spent with the Quality and Collaborative Practice department has enhanced their understanding of how to lead change in the hospital setting. These staff members have shared that they return to the clinical environment with a renewed confidence to make improvements in their own work environments, and that organizationally we are working on the right things for patients and staff. Also in 2019, PRHC took the first steps in implementing a new clinical information system. The system, which will replace paper-based documentation processes with electronic charting, will offer valuable tools and technology to support improved patient care, safety and health outcomes. Patients will have access to a personalized electronic “portal” to access and track their own health information, among other features. For healthcare providers, it will provide easy access to information when and where it is needed, allowing them to work more efficiently and collaboratively to meet the needs of our patients and their families. Peterborough Regional Health Centre 3 1 Hospital Drive, Peterborough, Ontario, K9J 7C6
Collaboration and integration Peterborough is excited to be among the first communities in the province to be announced as an Ontario Health Team (OHT). The 22 providers and organizations of Peterborough OHT have chosen to partner because together we have the capacity, knowledge, and leadership to improve population health outcomes in Peterborough and the surrounding region. Our OHT partners have been collaborating for many years, both formally and informally, to provide care for patients in the Peterborough community and region. As an OHT, we are committed to building on these partnerships to ensure the patients we serve can navigate through the healthcare system in a seamless and coordinated way. Patient/client/resident partnering and relations To ensure shared decision-making in partnership with patients and families, we continue to build and expand our network of Patient and Family Partners (PFPs). These individuals are key members of many groups, including the Patient and Family Steering Committee, Program Quality Councils, Unit-Based Councils, Work Groups, and the Post-Discharge Phone Call Program. To ensure we listen to and act on the needs of patients every day, we continue to implement Daily Patient Experience Rounding across the organization. As part of this new process, managers and charge nurses round directly with patients and family every day, providing us with better opportunities to hear and respond to the needs of each patient in real time. Workplace Violence Prevention Workplace violence prevention is a strategic priority for our organization, as staff safety is critical to achieving our vision of “exceeding your expectations, every day.” This can only be achieved when staff feel safe and cared for in the work environment. Following an in-depth review of our existing supports, we are refreshing our violence prevention program. We have maintained the integration of Workplace Violence as a key dimension within our Integrated Risk Model and QIP, with a focus on risk identification, communication and staff training. Virtual care As we establish Peterborough Ontario Health Team (OHT) we will enhance and expand our virtual care programs. Currently the Peterborough Family Health Team (PFHT), Canadian Mental Health Association (CMHA), Haliburton, Kawartha Pine Ridge District Health Unit (HKPR), and Peterborough Regional Health Centre run a variety of virtual care clinics. PRHC provides virtual services via the Ontario Telemedicine Network (OTN) and has successfully implemented this practice in a multitude of inpatient and outpatient programs and services, including mental health, stroke care and telestroke initiatives, nephrology, orthopedics, geriatric services, diabetes and wound care, and neurology. OTN visits over the last five years have doubled in number, with more than 2000 virtual patient visits in 2018/19. This volume represents approximately one per cent of PRHC’s total of 176,000 ambulatory care visits for that year. In addition, PRHC provided 16,445 clinical telephone visits, including intake assessments and nurse teaching. Given the decreased travel time and time to access a specialist, we anticipate increased satisfaction for those who receive care through virtual visits. Peterborough Regional Health Centre 4 1 Hospital Drive, Peterborough, Ontario, K9J 7C6
Executive Compensation
The Excellent Care for All Act (ECFAA) requires that the compensation of the CEO and executives reporting to the CEO be
linked to the achievement of the performance improvement targets laid out in the QIP. The purpose of the performance-
based compensation related to ECFAA is to drive accountability for the delivery of the QIP, enhance transparency and
motivate executives. ECFAA mandates that hospital QIPs must include information about the manner in and extent to
which executive compensation is linked to achievement of QIP targets.
Contact Information
Dr. Nancy Martin-Ronson, VP, CNE, CIO
705-743-2121 x 2307
nronson@prhc.on.ca
Other
We thank you for taking the time to review our 2020-2021 Quality Improvement Plan, and thank all those who have
supported our quality improvement efforts in 2019-2020.
Sign-off
I have reviewed and approved our organization’s Quality Improvement Plan:
Position
Name Signature
Board Chair
Board Quality Committee Chair
Chief Executive Officer
Other leadership as appropriate
Peterborough Regional Health Centre 5
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