Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital

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Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital
Quality Improvement Plan (QIP) Narrative for
Health Care Organizations in Ontario

 03/05/2018

         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.

North York General Hospital                                                                                                                              1
4001 Leslie Street, Toronto, ON
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital
Overview

         A Quality Improvement Plan (QIP) is a formal, documented set of commitments that a health care
         organization makes to its patients, staff and community on an annual basis to improve quality through
         focused targets and actions.

         This narrative contains the summary of North York General Hospital’s (NYGH) QIP journey over the
         past year. It shows how our culture of quality and safety has evolved while maintaining our focus on
         patient- and family-centred care. NYGH’s QIP was developed through the hospital’s QIP committee.
         The committee is comprised of an interdisciplinary group of staff, physicians and a patient and family
         advisor. The NYGH 2018/19 QIP includes feedback from our Patient and Family Advisory Council,
         Quality of Care Committee, Quality Committee of the Board, Board of Governors, and hospital
         performance data.

         In 2018/2019, NYGH will continue to work with the Joint Centres for Transformative Health Care
         Innovation (The Joint Centres), which is a unique partnership between seven large community hospitals
         including Mackenzie Health, Markham Stouffville Hospital, Michael Garron Hospital, North York
         General Hospital, Southlake Regional Health Centre, Humber River Hospital and St. Joseph’s Health
         Centre. The inclusion of the work of the Joint Centres in our QIP is intended to reinforce our
         commitment to improvement through collaboration and to leveraging the knowledge, expertise and
         experience of our partners to maximize the benefits across all of our hospitals.

         The Joint Centres will continue to work together to spread quality, safety, and value improvement
         initiatives across the participating hospitals and affiliated primary care practices. For 2018/2019, all
         seven hospitals are sharing leading practices for the prevention of workplace violence. This work
         includes creating a common approach to identification and flagging incidents of violence, risk
         assessment, and care planning for patients at risk for violence. An additional area of focus for the Joint
         Centres will be on reduction of harm through an applied learning approach.

         This year, NYGH has retired five indicators from the 2017/18 QIP that have either met their target
         performance, are no longer identified as a priority issue, or are monitored and reported through
         avenues other than the QIP. They include: reduction of 30-day readmissions for patients with
         Congestive Heart Failure (CHF), increase in the rate of home support referrals for discharged palliative
         patients, reduction in avoidable C-Section rate, access to the right level of care – Alternate Level of
         Care (ALC), and reduction of 90th percentile Emergency Department (ED) wait times for complex
         patients.

North York General Hospital                                                                                           2
4001 Leslie Street, Toronto, ON
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital
Describe your organization's greatest QI achievements from the past year

         Over the past year, a number of quality improvement projects have been implemented and sustained to
         continually improve the quality of care delivered to our patients. In the Medical Imaging Program, hours
         of operation have expanded for the ultrasound and interventional radiology departments, allowing better
         access to care for patients. The ultrasound department is also improving access for patients by booking
         weekend out-patient appointments, which will provide patients with additional options for coming to the
         hospital for their examinations and will help reduce wait times for patients. The magnetic resonance
         imaging (MRI) unit underwent a substantial upgrade in 2016, which has led to reduced scan times for
         patients and has allowed for increased access to our MRI during operational hours.

         Since 2012, the Surgical Program continues to be the provincial leader for wait times in four specific
         areas: hips & knees, cataracts and cancer surgery. In 2016/17, NYGH was awarded for the fourth year
         in a row the Cancer Care Ontario (CCO) award for top performing hospital for Wait Times 2 (decision to
         treat to treatment) and for the second year in a row, the Cancer Care Ontario (CCO) award for meeting
         all targets for Wait Times 1(time from referral to consult), a new CCO quality indicator. The Surgical
         Program additionally has reduced its total Urinary Tract Infection rate from 5.3% to 1.5% through
         standardized education and orientation material for staff, standardized catheter insertion criteria, and
         updates to order sets.

         To improve medication reconciliation on discharge, NYGH provided targeted training to the
         gynecological surgery physician group in May 2017 and generated a memo and checklist to support
         process improvements. The training strategy was effective in increasing the rate of medication
         reconciliation on discharge in this program from 9% in February 2017 to 75% in December 2017,
         raising surgery overall from 65% to 76% over the same time period.

         Positive patient feedback has been collected around two initiatives supporting information provided at
         discharge:
              Follow-up phone calls to discharged Medicine patients: 95% of 641 patients surveyed received
                 a departure summary and only 6% had questions regarding their hospitalization
              Post-operative phone calls to Ophthalmology patients: 98% of 177 patients surveyed indicated
                 that they had received "adequate discharge instructions” regarding their care after cataract
                 surgery

         The follow-up process has had high engagement among the staff making the phone calls, who see the
         process as valuable in supporting effective transitions. NYGH will be looking into spread these
         practices across the Medicine and Surgical Programs.

North York General Hospital                                                                                       3
4001 Leslie Street, Toronto, ON
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital
Resident, Patient, Client Engagement and relations

         In 2012, the NYGH corporate strategy launched the patient- and family-centred care initiative through
         the strategic initiative “Culture”, building on our culture of quality, safety and patient-centred care. The
         resulting success of this initiative has established the hospital as a noted leader in patient- and family-
         centred care. Successes include:
              Development of a Patient and Family Advisor Program, through which more than 50 PFAs have
                 gifted over 4000 hours of their time
              Formation of a Patient and Family Advisory Council (PFAC) composed of 12 Patient and Family
                 Advisors and two co-Chairs
              Integration of Patient and Family Advisors on over 70 hospital committees, including quality
                 improvement, accreditation, new employee orientation, staff education, capital and renovation
                 planning, program quality committees, and policy development and review.
              Participation of Patient and Family Advisors on all hiring panels for management and Clinical
                 Chiefs
              Creation of the Patricia Mackey Patient- and Family-Centred Care Educational Award, of which
                 12 staff, physicians and volunteers have received
              Creation of an innovative education program, teaching the four foundational pillars of patient-
                 and family-centred care adopted from the Institute for Patient- and Family-Centred Care, which
                 has been used to train 1500+ staff, physicians and volunteers
              Implementation of over 12 patient- and family-centred care focused projects, led by staff and
                 physician Chiefs

         Our Patient and Family Advisors play an important role in helping develop a patient- and family-centred
         care culture at NYGH. Patient and Family Advisors are volunteers who provide important perspectives
         and have a direct impact across a wide range of hospital initiatives, programs, services and policies to
         improve the experience of care. We partner with our Patient and Family Advisors to offer them a forum
         for sharing their unique thoughts and perspectives and to help ensure that the voice of patients,
         families, and caregivers are heard, considered, and included in programs and plans. Our aim is to
         ensure a Patient and Family Advisor’s voice is consistently included at the table in the majority of
         decision making around new and ongoing initiatives. The Patient and Family Advisory Council has also
         had input into and will continue to work towards the creation of the 2018/2019 Plan.

         Developing patient- and family- centred care continues to be an organizational priority. Since May
         2017, the Patient- and Family-Centred Care Office has been working collaboratively with the PFAC,
         Patient and Family Advisors, staff, physicians and volunteers to develop a strategy on patient- and
         family-centred care for the next three years. The strategy (refer to Figure 1) was created in partnership
         with and input from NYGH’s patients, families, caregivers, internal and external stakeholders, staff,
         physicians and volunteers. The Strategy reflects the voice of the North York Community, and has been
         reviewed and approved by the Patient and Family Advisory Council.

North York General Hospital                                                                                          4
4001 Leslie Street, Toronto, ON
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital
Figure 1: 2017-2020 Patient- and Family-Centred Care Strategy

         Six themes emerged in Strategy. Most central is the theme entitled “Deliver Engaged Care”, which
         highlights the importance of harnessing the partnerships in care among health care providers and
         patients and families to deliver exceptional, compassionate care. One important initiative is the hospital-
         wide implementation of the Communicate with H.E.A.R.T.TM. Adopted from the Cleveland Clinic, the
         program teaches communication and relationship-building skills to staff, physicians, and volunteers that
         impact the patient experience, which is delivered in collaboration with Patient and Family Advisors and
         staff.

North York General Hospital                                                                                        5
4001 Leslie Street, Toronto, ON
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario - North York General Hospital
Collaboration and Integration

         Joint Centres for Transformative Healthcare Innovation
         The Joint Centres represents a dynamic partnership between hospitals, where collaboration leads to
         better patient care. The objectives of the Joint Centres are to: seek and share innovative ideas that
         improve service delivery and / or value across the system, serve as a living laboratory to demonstrate
         innovation, provide a forum for the rapid execution of new ideas, technologies, products and processes
         to improve system performance and create opportunities for shared innovation, learning and knowledge
         transfer among the member organizations, their staff and physicians.

         The Joint Centres hospitals have worked on a number of improvement initiatives that have focused on
         clinical and administrative process changes designed to improve care through collaboration and
         innovation. Past projects include reduction of C-difficile infections and reduction of C-Sections, which
         as of 2017-18 have moved into a sustainability and monitoring phase at each hospital supported by
         Joint Centres’ communities of practice. In addition, Choosing Wisely – an Adopting Research to
         Improve Care (ARTIC) Program supported project that has targeted the reduction of unnecessary tests
         will conclude at the end of March 2017.

         Active projects that the member hospitals will continue to collaborate on in 2018-19 include:
              The prevention of workplace violence through development and implementation of a common
                approach to risk identification and care planning (alert for behavioural care protocols and
                processes)
              The reduction of harm classified as never events beginning with prevention and management
                of pressure injuries through awareness raising, reliable application and auditing of an agreed
                upon set of “Always Events” and patient and family engagement

         These on-going projects continue to reflect the commitment of the Joint Centres hospitals to working
         together to develop, implement and spread leading practices and innovative solutions to improve care
         for the patients and families they serve.

         Health Links
         Health Links are part of Ontario’s Action Plan for Health Care to provide faster access “to the right care,
         at the right time, in the right place”. Health Links is an integrated approach to care that brings a team of
         care providers together along with patients and caregivers to provide coordinated, efficient and effective
         care for patients with complex needs. NYGH is the lead for the North York Central Health Link
         (NYCHL), working with many local partners to support our patients. As one of our key partners, the
         Central Local Health Integration Network (LHIN) Home and Community Care provides NYCHL patients
         with a Care Coordinator who arranges a case conference with the patient and his/her care team,
         documents a Coordinated Care Plan focused on the patient’s goals, and provides care coordination to
         help the patient navigate the health care system. NYCHL currently enrolls about 50-60 patients a
         month. As of December 31, 2017 NYCHL is supporting 700 patients and has developed 478
         Coordinated Care Plans this fiscal.

North York General Hospital                                                                                         6
4001 Leslie Street, Toronto, ON
North York Central Integrated Care Collaborative
         In 2015, NYGH was selected to be one of six sites to implement an Integrated Funding Model (IFM) by
         the Ministry of Health and Long-Term Care. An innovative “Test of Change” project was fully
         implemented in 2016 – 2017. The IFM services pathways were designed by inter-professional,
         interagency and Patient and Family Advisors for persons with mid to late stage CHF and chronic
         obstructive pulmonary disease (COPD).

         The IFM project secures early identification of the respective patient cohort on admission to hospital
         and provides smooth transitions home across health care sectors for 60 days providing community
         services post-hospital discharge. The premise of the IFM is to support patient self-management of their
         chronic disease. Each patient receives detailed education modules designed specifically for their
         condition. Education modules are delivered at specific times within the 60 day pathway for each IFM
         patient by the inter-professional team.

         IFM patients have consistent coordination throughout the IFM pathway via clinical experts in CHF and
         COPD – a nurse educator (CHF) and a respiratory therapist (COPD), access to 24 / 7 helpline, an
         individualized Action Plan, Pulmonary Rehab and access to the Heart Function Clinic. The
         interdisciplinary, interagency team of project partners including Saint Elizabeth Health Care, ProResp,
         Circle of Care and Central Home and Community Care participate in weekly rounds to discuss patients’
         progress to established goals.

         Results for COPD patients who completed Pulmonary Rehab showed significant improvement in their
         ability to control emotional function and achieve mastery of respiratory techniques as measured by the
         Chronic Respiratory Questionnaire. The CHF patients who completed the IFM demonstrated an
         improved ability to follow self-care instructions and have new confidence in their ability to manage their
         diuresis regime as measured by the Self Care of Heart Failure Index.

         The IFM patient population has decreased hospital length of stay, decreased ER visits and hospital
         admissions during the time on the IFM pathway. The results demonstrate that the project has been
         successful and the project team is developing plans to transition this project to a permanent program at
         NYGH.

North York General Hospital                                                                                           7
4001 Leslie Street, Toronto, ON
Engagement of Clinicians, Leadership & Staff

         In order for the staff of NYGH to put patients and families first in everything we do, it is crucial that
         we have engaged employees, physician and volunteers. High quality care requires conditions that
         support all members of an organization to give of their best, remain aligned to the organization’s
         goals and to practice its values.

         NYGH has continued to be recognized as having highly engaged staff and physicians. At NYGH,
         employee engagement is measured through anonymous employee and physician engagement surveys
         delivered through the National Research Corporation Canada (NRCC). The survey is sent out to staff,
         volunteers and physicians on a yearly basis. NRCC analyses the results and shares the final scores
         with the hospital.

         Data collected between 2014-17 from participating hospitals show that NYGH continues to rank highly
         for employee and physician engagement, health and safety, patient care, and trust in the organization.
         NYGH’s overall employee engagement score was 78.4% and our physician engagement score was
         91.1%. Responses to the survey indicated that 95% of physicians were “proud to tell others they are
         part” of the hospital.

         Both medical and administrative leadership is central to reaching this level of achievement. NYGH
         consistently surpasses its comparator groups in questions relating to the commitment of leadership and
         management to act on feedback, improve workplace safety and promote high quality care. Physicians
         indicate a 91.7% level of positive satisfaction with medical leadership.

North York General Hospital                                                                                          8
4001 Leslie Street, Toronto, ON
Population Health and Equity Considerations

         NYGH is located in the North York Central sub-region, and is an active participant in the North York
         Central sub-region planning table. Demographically, the sub-region:

                   Is home to almost 400,000 residents, with close to 60,000 of those being senior residents
                   Has low rates of diabetes, asthma and hypertension
                   Has the highest percentage of newcomers (58.6%) and recent newcomers (12.5%).
                   Is well educated, with 79.4% of adults having a post-secondary education

         Through the development of sub-region planning we will work with our community partners to improve
         the ways we provide care to meet the needs of our residents.

         Embracing and celebrating the diversity of our community
         is an important component of our Patient- and Family-
         Centred Care culture at NYGH. We encourage patients
         and families to share with us the information about their
         cultural beliefs, their values, their preferences, and
         religious background as they relate to their care so that we
         can make their experience the best it can be. Guided by a
         conceptual Diversity Framework (Figure 2), members of
         Diversity Working Group have come together from different
         areas in the hospital to work collaboratively to identify
         opportunities and provide recommendations on programs
         and initiatives to meet the needs of NYGH’s diverse
         communities.
                                                                              Figure 2. Diversity Framework

         Highlights of the work include:

                  114 Diversity Champions graduated through Diversity Champions Training, which trains
                   employees to act as a role model in the area of diversity, and provides champions with the
                   opportunity to share their experiences and insights in a Quarterly Diversity Champions gathering
                  Developed and implemented an Annual Diversity Strategic Plan that is envisioned as a roadmap
                   to lead the NYGH’s efforts on diversity and inclusion
                  Enhanced diversity workshops for staff and volunteers covering topics that in 2017 included:
                   Managing a Diverse Workforce, Working with Chinese patients, Deaf- Blindness 101, and Islam
                   and Caring for Muslim Patients
                  Created an online education forum on the subjects of Mental Health in the Workplace, Hinduism
                   and Health Care, LGBTQ Emotional and Mental Health

North York General Hospital                                                                                       9
4001 Leslie Street, Toronto, ON
In order to build awareness and sensitivity toward the unique differences of our patients and families,
         our Religious Diversity Guide was created in 2015 to help facilitate understanding of different cultural
         observances. Our Diversity pamphlet provides information on offerings available to patients and
         families, as well as instructions on how to access language services at NYGH. Recognizing that one
         aspect of providing high-quality care is being able to communicate effectively with patients and families
         from our diverse communities in their native languages, we have provided more than 1,300 hours of on-
         site interpretation and nearly 200 hours of phone interpretation services in 41 different languages this
         calendar year. We also continue to make available a customized communication tool at nursing stations
         to assist patients in both our aphasia unit and our Seniors’ Health Centre. Through our Spiritual and
         Religious Care department, we provide direct patient and family supports during the most difficult
         moments by accessing community religious partners and internal chaplaincy services.

         NYGH will continue to focus on enhancing supports and addressing the needs of under-represented
         and marginalized communities in our quality improvement efforts. In partnership with the Central LHIN,
         we are engaged in learning and access opportunities for our indigenous community, as well as
         identifying potential supports that will further advance the care environment for the francophone
         community. Overall, our objectives remain to strengthen the delivery of diversity education, collaborate
         with other areas of the hospital to incorporate diversity into every aspect of the hospital and, support
         our staff, physicians and volunteers to create a positive, inclusive and respectful hospital for our
         patients and families.

North York General Hospital                                                                                     10
4001 Leslie Street, Toronto, ON
Access to the Right Level of Care - Addressing ALC

         At a given time, approximately 15% to 17% of NYGH inpatient beds are occupied by patients who no
         longer require acute hospital care but are not able to return to their home. These patients require a care
         setting that provides an alternate level of care (ALC) and as such are identified as ALC patients. The
         risk of deconditioning, nosocomial infections and iatrogenic injury increases with ALC patients, who are
         generally over the age of 75. These patients often benefit from lower intensity, restorative care
         programs and therapies that are not typically available in acute hospital settings.

         ALC is a system-wide issue and impacts hospital flow. The prevalence of ALC patients in acute care
         settings is intensified by:
              limited availability of interim beds in the community,
              challenges in accessing rehabilitation beds for complex patients,
              stringent qualifying criteria for accessing convalescent care beds, and
              bed closures in Long-Term Care due to influenza outbreaks or other contagions.

         NYGH has on average approximately 65 ALC patients at any given time. It is being forecasted that over
         the next 20 years the patient population over the age of 75 will increase by 108% and will account for
         11% of the population of the Central LHIN, thus increasing the challenges for the ALC population and
         patient flow across the system. Addressing ALC requires system engagement across the journey of
         care to ensure that patients are receiving the right care, at the right time, in the right place.

         A call for action has resulted in reopening of the Humber Finch Hospital as a temporary solution for the
         Central LHIN’s growing ALC problem. The Central LHIN hospitals worked collaboratively to open a
         hospital unit-based Reactivation Care Centre which opened on December 10, 2017, of which 30 beds
         were allocated to NYGH. A key benefit of this innovative service delivery model is the opportunity to
         provide specialized programming for patients waiting for their next destination. It will include enhanced
         activation, social, cognitive and physical programs to benefit NYGH patients. This model is closely
         aligned with the MOHLTC’s guidelines for the Assess and Restore program.

         It is anticipated that the addition of 30 new patient beds will improve hospital flow, and models the
         philosophy of having the right patient, in the right bed, provided care by the right team.

North York General Hospital                                                                                      11
4001 Leslie Street, Toronto, ON
Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder

         Health Quality Ontario (HQO) publishes quality standards that inform clinicians and organizations about
         what high quality health care looks like. The standards are based on the best available evidence. In
         light of the recent opioid crisis, HQO has published three quality standards on opioid use:

                   1. Opioid Prescribing for Acute pain (for people 15 years of age and older)
                   2. Opioid Prescribing for Chronic Pain (for people 15 years of age and older)
                   3. Opioid Use Disorder (for people 16 years of age and older)

         The quality standards provide guidance on the appropriate prescribing of opioids and include
         considerations such as using multimodal therapies, optimizing non-opioid therapies and harm reduction
         from opioid use.

         NYGH had already started to address pain management practices prior to the publication of the HQO
         standards with the formation of the NYGH Interprofessional Pain Steering Committee. This committee
         helps to develop, implement, monitor and promote the use of evidence-based information and patient-
         and family-centred pain management. NYGH also has specialized pain management teams such as
         the Acute Pain Service, the Chronic Pain Service and the Palliative Care team. These consult teams
         help to educate patients on pain awareness, prevention and management. Most recently, NYGH
         published a systematic literature review of evidence around post-surgery discharge prescriptions. From
         this review, an initial research project was conducted that examined opioid prescribing practices and
         the use of opioid medications by NYGH patients post-appendectomy and cholecystectomy surgeries.

         NYGH continues to develop new initiatives around pain management, incorporating the new HQO
         standards to address opioid prescribing and provider and patient education on opioid use. Several of
         these initiatives generated by the initial research project are outlined below:

                  A standardized post-operative pain management protocol that reduces the amount and duration
                   of opioid medication being prescribed and maximizes the use of non-opioid pain medications
                  An education pamphlet for patients on post-operative pain management
                  Survey patient’s response and satisfaction to the pain management protocol implementation
                   (planned second phase of research study)

         Since NYGH has computerized physician order entry (CPOE), evidence-based content can be
         incorporated into pain management order sets to guide prescribing. One objective is to incorporate the
         use of multi-modal therapies and streamline options for opioid medications such as removing
         combination products. Other areas to explore would be to continue developing standardized discharge
         prescriptions for various surgeries and patient populations that would limit the quantity and duration of
         opioid medications and/or provide recommendations for tapering of opioid medications, where
         appropriate.

North York General Hospital                                                                                      12
4001 Leslie Street, Toronto, ON
Education is also key in addressing opioid use and preventing its misuse, including the education of
         NYGH staff done during National Pain Week. Topics included the results of the research study to
         medical staff at NYGH Surgical/Medical Grand Rounds, the use of naloxone kits, and a presentation on
         the new Canadian Guidelines for pain management. Future educational initiatives include development
         of more patient information sheets on pain management for various types of pain or specific for certain
         populations (e.g. post-surgical, orthopaedic, chronic pain, and others), identification and education of
         patients that would warrant naloxone kits, and patient pain education during Pharmacy Awareness
         Month in the NYGH Outpatient pharmacy.

         Collaboration and sharing of experience with other institutions will also help with ensuring the HQO
         quality standards are being met across Ontario. NYGH is partnering with the Institute for Safe
         Medication Practices (ISMP) in the development of patient information pamphlets and with London
         Health Sciences Centre and Michael Garron Hospital for prescribing initiatives.

North York General Hospital                                                                                     13
4001 Leslie Street, Toronto, ON
Workplace Violence Prevention

         Incidents of workplace violence are being increasingly recognized as a trend in health care
         organizations. At NYGH, incidents of workplace violence have been reported to the Senior Leadership
         Team and the Board through Occupational Health, Safety and Wellness and the Quality Improvement
         Plan (QIP) for a number of years. NYGH has an active Workplace Violence Prevention (WVP)
         Committee and Occupational Health, Safety and Wellness team that have been working on a plan to
         address the new legislative and reporting changes regarding workplace violence and strengthen our
         own reporting. With continuing support and active involvement in our initiatives from Senior Leadership,
         WVP is being interwoven into all levels and disciplines of care to ensure that we have a safe
         environment for staff, visitors, and patients.

         To date the reporting has consisted of the following: 1) number of workplace violence incidents that
         resulted in lost time; and 2) how lost time as a result of workplace violence has impacted our New
         Experimental Experience Rating, which looks at lost time, sick time, short- and long-term disability, and
         Workplace Safety and Insurance Board claims. In the 2017/2018 fiscal year, Occupational Health
         began reporting the total number of incidents of workplace violence to all levels of leadership. To align
         with the new reporting requirements, this total number will become the new indicator for workplace
         violence in our QIP. The incidents will also be stratified based on categories of escalating severity. The
         categories are as follows:

                  Hazardous situation – the communication and reporting of an unsafe situation, environment or
                   practice that could contribute towards an incident or accident occurring
                  Near Miss – an incident of workplace violence that occurred but did not result in an injury or
                   illness, such as an item thrown at Health Care Worker (HCW) that made no contact
                  First Aid – an incident requiring medical attention but with no lost time for injury or illness
                  Lost Time for Injury or Illness – an injury or illness due to an incident of workplace violence
                   that results in days not worked after the day of the incident
                  Critical – an incident of the highest severity that may require reporting to the Ministry of Labour

         The WVP committee is working on a number of initiatives within NYGH to enhance safety and add
         additional levels of support for staff. These initiatives have been in progress since 2017 and many will
         come to fruition in the 2018/2019 fiscal year, including:
             Corporate signage for prevention of workplace violence poster campaign (Phase 2)
             Safety alert system whereby patients with a potential to harm themselves or those around will
                 be identified in the electronic patient record and with visual cues
             “Train the Trainer” education model for the education of staff in the prevention of workplace
                 violence that will then be brought to frontline staff

         The Occupational Health, Safety and Wellness team, along with Senior Leadership and key
         stakeholders across the organization, have the ultimate goal of working towards a supportive NYGH
         community that fosters reporting of incidents and ultimately results in a reduction in the number of
         workplace violence incidents that occur.

North York General Hospital                                                                                         14
4001 Leslie Street, Toronto, ON
Seniors’ Health Centre QI Achievements

         Seniors’ Health Centre (SHC) is part of NYGH (NYGH’s long-term care home). It is a licensed 192-bed
         long-term care home operating under the Ministry of Health and Long-Term Care legislation and
         regulations. SHC priorities are as follows:

                  Reducing the number of transfers of residents to the Emergency Department
                  Reducing the use of antipsychotics for residents without psychosis
                  Pressure ulcer prevention
                  Reducing falls among residents
                  Improving Resident experience and likeliness to recommend Seniors Health Centre to others

         These 5 priority indicators share alignment with the organizations strategic plan, our Long-Term Care
         Service Accountability Agreements and accreditation standards. Our restraint usage indicator will be
         retired as our restraints reduction initiative has been sustained and successful in maintaining restraint
         use at less than 3% for the last two years. Our current performance as of Q2 was 1.7%, as compared
         to the HQO benchmark of 3%.

         Quality Improvement achievements from the past year
            The acquisition in January 2017 of a full time Nurse Practitioner (NP) at SHC has helped reduce
                avoidable transfers to hospital this year
            Overall resident satisfaction was 89%, exceeding our target of 85%
            Prescription of antipsychotics has been reduced from 20.2% in Q3 2015 to 14.2% currently – a
                29% reduction. SHC has exceeded provincial average, which is currently at 20%
            Overall, 8 of the 9 publically-reported quality indicators are reporting better than provincial
                averages, and SHC exceeds the provincial average for 28 of 35 indicators reported by CIHI.

         Collaboration and Integration
         Many of our residents are dealing with physical deficits in addition to cognitive impairments, including
         dementia. SHC collaborates with our local Behavioural Supports Ontario outreach team, and our
         Psychogeriatric Resource Consultants in addressing the unique needs of residents dealing with mental
         health diagnoses. In addition, our Nursing Led Outreach Team available from NYGH will assist us in
         2018 with support and education on Intravenous (IV) therapy maintenance and assessments,
         Gastronomy-tube replacements and other clinical issues to help reduce our residents’ transfers to
         hospital. NYGH continues to partner with SHC to bring many volunteers in many areas into our home
         enhancing the quality of life of our residents.

         Population Health/Equity Considerations
         SHC serves the traditional seniors population and also residents dealing with addictions, mental health
         diagnoses and history of homelessness. SHC partners with organizations such as the Toronto
         Rehabilitation Institute and the Center for Addiction and Mental Health to ensure these residents
         receive the highest quality of care. SHC also works closely with Public Guardian and Trustee in
         advocating for the optimal care of those individuals who don’t have family to support them.

North York General Hospital                                                                                          15
4001 Leslie Street, Toronto, ON
Access to the Right Level of Care – Addressing ALC Issues
         SHC provides 12 convalescent care beds. This is an initiative that provides nursing care and services
         with additional programs and therapies focused on returning seniors to their home within 90 days. This
         service helps prevent or delay admissions to long-term care.

         Engagement of Clinicians, Leadership & Staff
         SHC holds a quarterly Professional Advisory Committee meeting to collaborate with our clinical
         partners and service providers, such as physicians, physiotherapy, pharmacy, and others. This is also
         our forum to consult on our QIP, strategic plan and quality initiatives.

         Resident Engagement and Relations
         Resident and family feedback is obtained through admission and annual care conferences as well as
         Resident Council/Family Council and annual satisfaction surveys. Their input is also sought in annual
         program evaluations and strategic planning. Areas of improvement are identified and positive ideas for
         change are brought forward and incorporated into the development of our operating plan and this
         annual QIP.

North York General Hospital                                                                                      16
4001 Leslie Street, Toronto, ON
Performance Based Compensation

         NYGH’s Senior Leadership Team are accountable for achieving the targets for the following indicators:

                  Dimension                             Indicator
                                                               Improve patient experience (Did you
                                                                receive enough information when you
                  Effective Transitions
                                                                left the hospital)

                                                               Improve patient satisfaction (Would
                                                                you recommend – inpatient (surgical
                  Patient-Centred
                                                                and medicine programs) and ED)

                                                               Increase in the number of workplace
                                                                violent incidents that are reported
                                                               Sustain proportion of patients receiving
                  Safe
                                                                medication reconciliation upon
                                                                discharge

         The following roles from our Senior Leadership Team are included in this process:

                  President and Chief Executive Officer (10%)
                  Chair, Medical Advisory Committee (5%)
                  Vice President, Medical & Academic Affairs (5%)
                  Vice President, People, Strategy and Clinical Support (5%)
                  Vice President, Clinical Programs, Quality & Risk, Chief Nursing Executive (5%)
                  Vice President, Information & Corporate Services, Chief Financial Officer (5%)
                  Vice President, Planning, Facilities & Support Services (5%)

North York General Hospital                                                                                  17
4001 Leslie Street, Toronto, ON
Contact Information

         For QIP inquiries please contact:

                   Jennifer Quaglietta
                   Director, Patient Experience and Quality Transformation
                   T 416.756.6216
                   E Jennifer.Quaglietta@nygh.on.ca

                   North York General Hospital
                   4001 Leslie Street, Toronto, ON M2K 1E1
                   nygh.on.ca

North York General Hospital                                                  18
4001 Leslie Street, Toronto, ON
Sign-off

         I have reviewed and approved our organization’s Quality Improvement Plan

         Mr. Murray Perelman               Dr. Louise Lemieux-Charles         Mrs. Karyn Popovich
         Chair, Board of Governors         Chair, Board Quality Committee     Interim, President and CEO

North York General Hospital                                                                                19
4001 Leslie Street, Toronto, ON
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