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
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
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
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
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
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
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, ONNorth 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, ONEngagement 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, ONPopulation 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, ONIn 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, ONAccess 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, ONOpioid 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, ONEducation 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, ONWorkplace 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, ONSeniors’ 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, ONAccess 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, ONPerformance 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, ONContact 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, ONSign-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, ONYou can also read
