Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - St. Joseph's Health Centre Toronto

 
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - St. Joseph's Health Centre Toronto
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
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - St. Joseph's Health Centre Toronto
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 Hospital
A 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 Hospital
Once 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 Hospital
How 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 Hospital
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 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 Hospital
their 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 Hospital
support 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 Hospital
Safety 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 Hospital
with 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 Hospital
incidents 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 Hospital
Other
         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 Hospital
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