Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - St. Joseph's Health Centre Toronto
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Quality Improvement Plan (QIP) Narrative for
Health Care Organizations in Ontario
3/28/2018
This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement
Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and
organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement
plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents,
provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.
Our Shared Purpose 1
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospital
Overview
In health care, our top priorities, above all else, are to keep our patients, our 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, allowing us to build off of one another’s strengths and share best practices across
our teams. This Quality Improvement Plan (QIP) identifies measurable steps we will take over the next
year to create a safer environment to deliver care and to find more ways to have our patients,
residents and caregivers at the table, advising alongside us as we plan, build and improve our care
together.
The 2018-19 plan: Our goals and the work ahead
We have developed a very broad plan that addresses many areas where we want to improve care and
overall experience. The following are a few key areas that will be monitored and measured in the
coming year.
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:
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 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 people when they are impacted.
Our goal for everyone who walks through our doors is to provide them with the best possible
experience, as defined by our patients, our residents, their caregivers, our patient, resident, caregiver
and community advisors and our community. In 2018-19, together we will:
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 providing patients with the right level of information as
they leave the hospital.
Our network also includes a long-term care facility that residents call home. In 2018-19, together we
will:
Improve resident and caregiver experience through faster acknowledgment of concerns and
complaints.
Protect our residents from harm by preventing and reducing resident falls and preventing and
reducing pressure injuries.
Our Shared Purpose 2
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s HospitalA brief overview of the targets, initiatives and rationale for each of these goals is listed below.
Patient/resident priority: Keep me safe
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.
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 staff 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 and 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 with a goal of at least 75 per cent.
Understand the challenges our staff 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.
Keeping our people safe is necessary to patient and resident 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.
Our Shared Purpose 3
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospital 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.
How will we measure success? Our QIP target for 2018-19 is to increase the reporting of violence by at
least 5 per cent. 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 so we can fully understand the scope of
the problem. Prevention is the ultimate and urgent goal.
Patient/resident priority: Provide the best-possible experience
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.
There is an exciting and growing movement across our organization to better capture and benefit from
patients’, residents’ and caregivers’ 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 more staff
education 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 2018-19 is to increase the number of committees, activities and initiatives with
patient/resident/caregiver/community advisors by at least 40 per cent.
Provide a smoother transition home by ensuring that we provide patients with the right level of
information as they leave the hospital.
Empowering patients and caregivers with accurate, easy-to-understand information when they are
discharged and leave the hospital is key to safe care at home, as well as preventing further Emergency
Department visits and readmissions.
Our Shared Purpose 4
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s HospitalOnce 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 caregivers can access
the support of Interpreter Services in a timely and meaningful way, including as part of their
discharge preparation process.
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.
How will we measure success? By making sure our patients have enough information. Our QIP target
is to increase the proportion of respondents to our discharge survey/calls who as patients feel they had
enough information when they left the hospital by at least 2 per cent.
Additional targets for long-term care homes
Our new health network includes a residence that 288 people call home. The Cardinal Ambrozic
Houses of Providence is a long-term care (LTC) 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 we plan to improve
resident and caregiver experience in the Houses of Providence by acknowledging concerns and
complaints faster and protecting residents from harm by preventing and reducing falls and pressure
injuries.
Improve resident and caregiver experience by acknowledging concerns and complaints faster.
When the people we care for or those who provide care have issues and concerns, we want to address
them quickly. By regulation, long-term 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 to
complaints.
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.
Our Shared Purpose 5
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s HospitalHow will we measure success? By acknowledging and responding quickly to concerns. By the end of
the fiscal year, our goal is to make sure that at least 80 per cent of the concerns and complaints we
receive are acknowledged within five business days.
Protect our residents from harm by preventing and reducing falls and pressure injuries.
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 pilot 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 on a
regular basis at weekly rounds to revise and create new strategies and interventions that are
customized for them and to their care plan. We will also educate staff and physicians on new
medical directives for pressure injuries.
Describe your organization's greatest QI achievements from the past year
Although 2018-19 is the network’s first QIP, our three sites have developed and submitted individual
QIPs for the past several years. Our successes illustrate our unique strengths – together, we are well-
positioned to learn from each other and continue to improve our patients’ and residents’ experiences.
Here are some stories of the impact our improvements from the last year are having:
St. Michael’s Hospital has made major strides in staff increasing their hand-washing to protect
patients from hospital-acquired infections. The success has resulted from piloting a new real-time,
hand hygiene data feedback system that provides quick access to how well our teams are cleaning
their hands – allowing participating units to see how the changes they were making resulted in
improvements almost immediately. Other successful initiatives included dedicated local support from
Infection Prevention and Control, frequent hand hygiene-focused huddles, monthly data scorecards,
staff champions and initiatives to encourage friendly reminders and feedback between staff members.
All of this resulted in an increase from 63.6 per cent of staff washing hands before contact with a
patient or the patient’s environment at baseline to 78 per cent (as of December 31, 2017), exceeding
the 2017-18 QIP target by more than 14 per cent.
St. Joseph’s Health Centre was a trailblazer in including workplace violence as a 2017-18 QIP focus
area. We introduced new levels of support by a senior leader connecting directly with any staff
member who reported workplace violence that resulted in lost time and/or the need for medical care.
A review and refresh of the Code White (violent person) policy created better processes to support
staff at risk. A review playbook was created by the Joint Centres for Transformative Healthcare
Innovation to help better track and more deeply understand the issues and predictors related to
violent incidents. In 2016-17, there were 17 incidents of workplace violence that resulted in workers
requiring healthcare. To date in 2017-18 (as of December 31, 2017), there have been 12 incidents The
Our Shared Purpose 6
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospitalnew framework will provide an important foundation and lessons learned that will be applied to the
2018-19 goal of addressing workplace violence across our network.
In 2017-18 Providence Healthcare helped more rehabilitation patients reach their recovery goals.
Overall there was an increase in Functional Independence Measure (FIM) scores from 1.49 at baseline
to 1.79 to date in 2017-18 (as of December 31, 2017), exceeding the 2017-18 QIP target of 1.64. Our
improvement efforts included increased opportunities for more consistent and self-directed
rehabilitation by developing an “activity hub” where patients have 24-7 hour access to a variety of
activities to improve their cognitive status and communication. This opportunity for self-directed
rehab was well-received among patients, who often used the hubs outside of their scheduled therapy
time. A rehab nursing mentorship program was also designed and implemented which evolved into a
“Hope Coaching” pilot – a program that teaches nurses effective communication techniques to use
with patients that instills hope in achieving rehab goals.
In the Houses of Cardinal Ambrozic (LTC home), Providence Houses successfully reduced falls among
residents. Fall prevention in long-term care continues to be a major focus for quality improvement in
patient safety. Falls can result in disability, functional decline, reduced quality of life, and even death.
In addition, fear of falling can cause further loss of function, depression, feelings of helplessness, and
social isolation. To support the goal of reducing falls, Providence Houses trialed a satellite station to
help staff better monitor patients in the hallways. The satellite station is a computer work station for
staff to complete required documentation that is located at the entry to resident hallways, closer to
residents’ beds. The halls at Providence Houses are very long and it can be difficult for staff to see all
the way to both ends as normally all staff sit in a “nursing station” that is about 20 feet away from the
resident hallway, to complete their documentation. The result: more falls were prevented from
happening. Overall there was a decrease in the percentage of residents who fell in the last 30 days
from 15.81 per cent at baseline to 12.64 per cent to date in 2017-18 (as of December 31, 2017),
exceeding the 2017-18 QIP target of 15.01 per cent
Resident and Patient, Engagement and Relations
How we engaged patient, resident, caregiver and community advisors in 2017-18
We have a shared commitment across our three sites to continuously seek and benefit from the
unique knowledge and experience of our patients, residents, caregivers and communities. Over the
past year we purposefully sought ideas and advice from these sources as part of our quality
improvement initiatives. Below are a few highlights of these activities.
Patient and family advisors at St. Joseph’s are members of the Intensive Care Unit (ICU) Advisory
Council, a group that meets to help shape and enhance the patient-centered care approach in the ICU.
Patient advisors also worked with our facilities and foundation teams in the planning of our new Breast
Cancer Centre – ensuring flow and design is patient-focused and patient-friendly for the best possible
experience.
At St. Michael’s, patient and family advisors were involved in the development and implementation of
the Family Presence policy, which replaced our historical patient visitor policy and now provides for
and supports the option for patients to have a support person stay with them overnight. Patients and
Our Shared Purpose 7
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospitaltheir families have also been engaged in helping us design and deliver information technology
solutions for our new patient care tower – set to open in 2018-19.
Providence is in the third year of our strategy to improve the overall patient and resident experience
while working towards achieving a gold designation award through Planetree. Planetree is an
international non-profit organization that works with health-care organizations to achieve excellence in
patient-centered care across the care continuum. Patient and resident advisors were an integral part of
this work as members of the Patient Experience Steering Committee and helped with initiatives
including wayfinding improvements and the planning of a multi-faith room which provides a quiet
environment for prayer, reflection and healing for staff, patients, residents and families.
We also work with community members who represent our local neighborhoods and bring their
perspective to various initiatives aimed at improving patient and visitor experience. This past year St.
Joseph’s Community Engagement Council supported the development of the smoke-free campus
policy, providing insight on community members’ views of the shift to being completely smoke-free. At
Providence, the Council developed questions that advisors could ask during staff interviews and over
the last year, three community advisors have participated in staff interview panels.
St. Michael’s took some initial steps in 2017-18 to intentionally reach into its marginalized populations
to create longer term engagement opportunities. The hospital started an exciting partnership with the
Supporting Transitions and Recovery (STAR) Learning Centre, working together to engage patients and
community members experiencing homelessness and mental illness.
These examples from the past year create an exciting opportunity and foundation to build on as a
network and in how we work together to engage with our marginalized communities.
Collaboration and Integration
Our network is part of a broader health system – we cannot meet the needs of our patients, our
residents and their caregivers without collaboration with 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. 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 Alternative Level
of Care (ALC) patients move to the appropriate level of care, to supporting our patients successfully as
they move from the hospital back into the community.
Both St. Joseph’s and St. Michael’s have strong partnerships with their Family Health Teams (FHTs)
that support rapid access to primary care for unattached patients seen at the hospital, as well as the
opportunity for improved access for referrals from the clinics to specialty services in the hospital.
As one of the largest post-acute hospitals providing rehabilitation services in Ontario, Providence has
taken a leading role with the Rehabilitative Care Alliance to develop pathways and programs that
Our Shared Purpose 8
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospitalsupport this patient population. Through this partnership, we have been able to work on initiatives
that are strengthening rehab care across the province, including best practice frameworks and ongoing
evaluation tools to continually assess performance.
St. Joseph’s Health Centre remains a member of the Joint Centres for Transformative Healthcare
Innovation which is a unique partnership between seven large community hospitals. This partnership
reflects the network’s commitment to improving care through collaboration to develop, implement
and spread leading practices and innovative solutions. The member hospitals have worked on a
number of improvement initiatives that have focused on clinical and administrative process changes
including reducing the number of workplace violence incidents and hospital-acquired infections.
In partnership with the Toronto District School Board’s Model Schools for Inner Cities Program, St.
Michael’s is helping deliver care in communities where it’s needed most. Two paediatric clinics offer a
wide variety of medical services to hundreds of children and their families in the Regent Park area, with
a focus on developmental and mental health care. The initiative was started as a response to a concern
that many children in the hospital’s neighborhood faced barriers to accessing health care. These clinics
now allow children to conveniently access medical care right inside their school.
Engagement of Clinicians, Leadership & Staff
In developing this QIP, we conducted a broad consultation across our sites to ensure that our plan
reflects the priorities and goals of our patients, residents, our community and our staff, physicians,
learners and volunteers. The process included engagement of executive, practice and program
leaders, clinicians, physicians and staff and consultation with operational, quality and medical
leadership at each site of the network to choose priorities, change ideas and set targets.
Population Health and Equity Considerations
Our sites share the Sisters of St. Joseph’s legacy of caring for the most marginalized or disadvantaged in
our communities. More than a century later, a cultural assessment revealed in 2017 that our people
still strongly believe that this core value is what makes our sites unique and special – it must be
nurtured and preserved through the integration. 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.
This data also helps us to 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. At Providence, data showing the socioeconomic
information about our patient population has been used to better understand factors that can drive
ALC issues. This data has helped teams design a discharge follow-up phone calls in languages that are
most commonly spoken among patients at Providence (Cantonese, Italian and Greek are the top
languages in addition to French and English).
Better supporting disadvantaged patients is a stated priority in St. Michael’s 2015-18 strategic plan and
through a partnership with Well Living House, St. Michael’s has introduced San’yas Indigenous Cultural
Our Shared Purpose 9
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s HospitalSafety Training for staff and leadership. A comprehensive eight-hour program designed for use in
health care, the training increases Aboriginal-specific knowledge, enhances individual self-awareness
and strengthens skills that support culturally sensitive services and care. In 2017-18, 30 members of
our management team completed the training.
Understanding our community and creating opportunities for patients, caregivers and residents to be
involved in creating a healthier west end Toronto is a priority for St. Joseph’s. Our Community
Engagement Council has brought together a dynamic group of people from neighborhoods we serve to
help make sure there is a community voice in our planning. The Council includes representation from
diverse cultural and ethnic backgrounds, education and vocational experiences. One of the Council’s
main objectives is to ensure that we apply a diversity and equity lens to all aspect of our services.
Access to the Right Level of Care - Addressing ALC
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.
St. Michael’s data shows a longer length of stay for ALC patients who have mental health and/or
behavioural components to their care. In response, teams are working with Bridgepoint Health and
Providence to increase capacity for taking these patients, through education sessions with St. Michael’s
nurses and physicians with expertise in mental health and addictions. We also provide psychiatrist
support to LOFT Community Services in exchange for a dedicated bed at their facility.
St. Joseph’s works closely with community partners, the CCAC and the LHIN to identify opportunities
for better alignment and communication. We are part of a west-end group of organizations who
together provide a complete range of services for patients, ensuring seamless transitions for them as
they move to the appropriate care facility. These west-end organizations meet bi-weekly to work
together on complex cases and address systemic issues such as overcapacity during flu season, which
allows the group to put processes into place to support one another during busy times.
In addition to the capacity building partnerships described above, Providence leaders co-chair both the
Wait Time Information System ALC Committee and the TC LHIN ALC Avoidance Working Group. The
hospital’s acute care, home and community partners continue to participate in weekly
Reducing/Avoiding ALC Rounds and co-design processes. Although ALC is a constant challenge for
Providence given the complexity of its patient population, CCAC data indicates that Providence’s
number of long-term-care applications continues to decrease annually surpassing its target of 82.5%,
Our Shared Purpose 10
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospitalwith over 85 per cent of patients discharged home and to community destinations as of January 31,
2018.
Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder
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.
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 cross-
pollination 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 (non-medical – e.g. programming and counseling) for clients in acute withdrawal, and courses
for patients with addictions to learn strategies for cognitive- and mindfulness-based relapse
prevention.
Providence approaches pain management with an integrated addictions and palliative care
perspective. For example, our Palliative Care Unit Attending Physician is also the Pain Management
Consultant across the entire organization. We have been moving increasingly to non-opioid pain
management strategies for all patients, residents and clients, and best practice guideline adoption
recommendations are under development by the Medical Best Practices Committee for Opioid
Withdrawal.
Over the coming year, all three sites will be working closely together to further spread best practices
and develop a network-wide approach to better support inpatients and outpatients at risk of opioid
addiction.
Workplace Violence Prevention
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 highlight the issue to prevent it from happening again.
St. Joseph’s Health Centre was a trailblazer in including workplace violence as a 2017-18 QIP focus
area. We introduced new levels of support by an executive or senior leader connecting directly with
any staff member who reported workplace violence that resulted in lost time and/or the need for
medical care. A review and refresh of the Code White (violent person) policy created better processes
to support staff at risk. A review playbook was created by the Joint Centres for Transformative
Healthcare Innovation to help better track and more deeply understand the issues and predictors
related to violent incidents. In 2016-17, there were 17 incidents of workplace violence that resulted in
workers requiring healthcare. To date in 2017-18 (as of December 31, 2017), there have been 12
Our Shared Purpose 11
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s Hospitalincidents The new framework will provide an important foundation and lessons learned that will be
applied to the 2018-19 goal of addressing workplace violence across our new network.
In addition to spreading these best practices network-wide, our 2018-19 QIP activities to address
workplace violence will include creating a new multidisciplinary task force to develop a multi-year,
network-wide Workplace Violence Prevention Plan to recognize, address and prevent physical and
psychological harm at work.
Performance-Based Compensation
In accordance with the requirements of the Excellent Care for All Act 2010, executive accountability for
the overall performance of the network is embedded in our management philosophy and practice. Our
executives’ compensation for 2018-19 is linked to performance in a graduated manner based on the
following QIP indicators:
INDICATOR WEIGHTING
Incidents of workplace violence 25%
Serious safety event recommendations 25%
implemented within committed
timeframe
Discharge satisfaction 8.33% Providence
8.33% St. Joseph’s
8.33% St. Michael’s
Activities patient/resident/caregiver/ 25%
community advisors are involved in across
the network
The amount awarded per metric will be based on the Board of Directors’ evaluation, set out in the
table below:
PROGRESS AGAINST QIP TARGETS FOR ALL PERCENT OF AVAILABLE
FOUR INDICATORS INCENTIVE
Worse than previous year’s performance with Zero
no special considerations
Worse than previous year’s performance with Up to 20
special considerations
Maintained previous year’s performance with Up to 40
special considerations
Better than previous year’s performance but Up to 60
did not meet target
Achieved target 100
Our Shared Purpose 12
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s HospitalOther
Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital have been one
corporate entity since August 1, 2017. At our three sites, we serve patients, residents and clients 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.
Contact Information
For QIP inquiries, please contact:
Sean Molloy
Senior Director, Quality, Safety & Innovation
St. Michael’s Hospital
30 Bond Street
Toronto, ON M5B 1W8
Tel: 416-530-6486 x 4531
Email: smolloy@stjoestoronto.ca
Sign-off
We have reviewed and approved our network’s 2018-19 Quality Improvement Plan and are pleased to
submit to Health Quality Ontario. Thank you to the staff, physicians, learners, volunteers, patients,
residents and families who contributed their expertise and energy to the development of this plan.
Together, we can provide the best possible experience for our patients, residents and families.
Our Shared Purpose 13
Providence Healthcare St. Joseph’s Heath Centre St. Michael’s HospitalYou can also read
