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Improvement Targets and Initiatives
PART B
MARKHAM STOUFFVILLE HOSPITAL - 2013/14 Quality Improvement Plan (QIP)
Please do not edit or modify provided text in Columns A, B & C
AIM
MEASURE
Quality dimension
Safety
Objective
CHANGE
Measure/Indicator
Current perf.
Reduce hospital acquired infection Clostridium Difficile (CDI) rate per 1,000 patient days: Number of patients newly diagnosed
rates
with hospital-acquired CDI, divided by the number of patient days in that month, multiplied by
1,000 - Average for Jan-Dec. 2012, consistent with publicly reportable patient safety data
Hand hygiene compliance before patient contact: The number of times that hand hygiene was
performed before initial patient contact divided by the number of observed hand hygiene
indications for before initial patient contact multiplied by 100 - Jan-Dec. 2012, consistent with
publicly reportable patient safety data
Jan - Dec 2012:
0.74
Jan - Dec 2012:
87.4%
Ventilator Acquired Pneumonia (VAP) rate per 1,000 ventilator days: the total number of
Jan - Dec 2012:
newly diagnosed VAP cases in the ICU after at least 48 hours of mechanical ventilation, divided 0%
by the number of ventilator days in that reporting period, multiplied by 1,000 - Average for JanDec. 2012, consistent with publicly reportable patient safety data
Target for
2013/14
< 0.60
Markham Site
Target
justification
Priority
level
2012-13 Target
not achieved
3
Planned improvement
initiatives (Change Ideas)
Methods and process measures
We will continue to focus on Number of CDI cases.
reducing the number of
strategies
patients with newly
diagnosed, hospital acquired
clostridium difficile (C.
Difficile) across the
Organization. We will
achieve this through ongoing
corporate wide focused
efforts to achieve compliance
with best practice guidelines
for hand hygiene,
environmental cleaning and
a dedicated focus on
antibiotic stewardship.
See also hand hygiene
Goal for change
ideas (2013/14)
Markham Site:
< 44 cases per year
Uxbridge Site:
< 6 cases per year
> 90% yearly
average
Achieve at or
above
provincial
average
1
1) Attain hand hygiene
% of units that achieve 80% compliance with Moment 1 90%
compliance rate for Moment
1 (before initial contact) of
90% across both sites. We
will achieve this through the
involvement of hand hygiene
champions, monthly auditing
and follow-up with staff, a
focused education program,
and a standard monitoring
process. We will Identify and
develop strategies to address
hospital specific barriers
through use of a survey of
staff related to knowledge
and barriers to compliance.
2) Reinforce hand hygiene
audit processes including
minimum number of
audits/month and
accountability for reporting
and monitoring of audit
results.
0%
Maintain better
than provincial
average
3
Renew education on VAP
bundles with all ICU staff to
ensure ongoing compliance
Markham Stouffville Hospital 2013/14 QIP - Page 1
Comments
AIM
Quality dimension
CHANGE
MEASURE
Objective
Measure/Indicator
Current perf.
Rate of central line blood stream infections per 1,000 central line days: total number of newly Jan - Dec 2012:
diagnosed CLI cases in the ICU after at least 48 hours of being placed on a central line, divided by 0%
the number of central line days in that reporting period, multiplied by 1,000 - Average for JanDec. 2012, consistent with publicly reportable patient safety data
Target for
2013/14
Target
justification
Priority
level
Planned improvement
initiatives (Change Ideas)
0%
Maintain better
than provincial
average
3
We will maintain Central Line
Infections (CLI) at a rate of
0% through the continued
application and monitoring
of Safer Health Care Now
(SHCN) best practice
guidelines.
100%
Theoretical Best
Benchmark
3
We will achieve a rate of
completion of all 3 phases of
the surgical safety checklist
of 100% by monitoring
compliance with checklist.
> 90% by Dec
2013
Accreditation
2
Enhance compliance with
med rec on admission on 3E,
ED, 1Wf and SAC through
education and
publishing/discussion of
audit results
2
Continued focus on inpatient
falls prevention, risk
assessment and
implementation of patient
specific interventions and
follow-up
Reduce incidence of new pressure Pressure Ulcers: Percent of complex continuing care residents with new pressure ulcer in the
ulcers
last three months (stage 2 or higher) - Q2, FY 2012/13, CCRS
Avoid patient falls
Falls: Percent of complex continuing care residents who fell in the last 30 days - Q2, FY 2012/13,
CCRS
Reduce use of physical restraints
Physical Restraints: The number of patients who are physically restrained at least once in the 3
days prior to the initial assessment divided by all cases with a full admission assessment - Q4 FY
2009/10 - Q3 2010/11 OMHRS
Reduce rates of deaths and
complications associated with
surgical care
Rate of in-hospital mortality following major surgery: The rate of in-hospital deaths due to all
causes occurring within five days of major surgery - FY 2011/12, CIHI CHRP eReporting tool
Surgical Safety Checklist: number of times all three phases of the surgical safety checklist was
Jan-Dec 2012
performed (‘briefing’, ‘time out’ and ‘debriefing’) divided by the total number of surgeries
100%
performed, multiplied by 100 - Jan-Dec. 2012, consistent with publicly reportable patient safety
data
Medication reconciliation at admission: The total number of patients
with medications reconciled as a proportion of the total number of patients admitted to the
hospital - Hospital-collected data, most recent quarter available (e.g., Q2 2012/13, Q3 2012/13) Increase proportion of patients
Medication reconciliation at admission: The total number of patients
receiving medication reconciliation with medications reconciled as a proportion of the total number of patients admitted to the
upon admission
hospital - Hospital-collected data, most recent quarter available (e.g., Q2 2012/13, Q3 2012/13)
Reduce inpatient Falls
Medication reconciliation at admission: The total number of patients
with medications reconciled as a proportion of the total number of patients admitted to the
Emergency Department (ED), Medicine/Telemetry (3E), Inpatient Mental Health (1Wf) and the
Surgical Assessment Clinic (SAC)
Jan 2013
Average: 73%
Rate of inpatient falls per 1000 patient days
Fiscal YTD (Dec) < 4.3
2012: 4.9
Standards
2012-13 target
not achieved
Markham Stouffville Hospital 2013/14 QIP - Page 2
Methods and process measures
Goal for change
ideas (2013/14)
Comments
AIM
Quality dimension
Effectiveness
CHANGE
MEASURE
Objective
Reduce unnecessary deaths in
hospitals
Improve organizational financial
health
Measure/Indicator
Current perf.
Hospital Standardized Mortality Ratio (HSMR): number of observed deaths/number of
expected deaths x 100 - FY 2011/12, as of December 2012, Canadian Institute for Health
Information (CIHI)
Target for
2013/14
Fiscal Year
79
2011/12 (as
publicly reported
in Dec 2012):
79 with a
Confidence
interval (CI) of 70
- 89
Total Margin (consolidated): Percent by which total corporate (consolidated) revenues exceed
or fall short of total corporate (consolidated) expense, excluding the impact of facility
amortization, in a given year. Q3 2012/13, OHA's Ontario Healthcare Reporting Standards
(OHRS)
FYTD Q3: 1.06
0
Target
justification
with a
Confidence
interval of 70 89
Provincial
mandate
Markham Stouffville Hospital 2013/14 QIP - Page 3
Priority
level
Planned improvement
initiatives (Change Ideas)
1
Reduce hospital acquired
positive culture Urinary Tract
Infections (UTIs) through
comprehensive initiative
entitled “ Holy Moly My
Patient has a Foley”, which
includes 1)
implementation of best
practice standards regarding
insertion of Foley catheters.
2) Developing criteria for
removal of indwelling
Urinary Tract catheters
3) Implementation of postcatheter care plans
4) Continued education and
discussion at bullet rounds
5) Improved processes
related to proper
documentation of hospital
acquired UTIs.
% of IP indwelling urinary tract catheters in place that do < 30% by Jan 2014 not meet insertion criteria (as a % of patients with
based on monthly
catheters audited)
audits
% IP indwelling urinary tract catheters removed within
48 hours of insertion – in keeping with criteria
> 60% by Jan 2014
Continue with
implementation of
Antibiotic Stewardship best
practices including daily
rounding and ongoing
education and awareness
Defined Daily Dose (DDD) [Antibiotics usage per 100
patient days measured by defined daily dose based on
pharmacy drug dispensing information]
<45 %
Total Antibiotic usage/expenditure
< $3.31/patient day
Susceptibility of pseudomonas to Ciprofloxacin
> 80%
Maintain achievements
related to Sepsis best
practices
Sepsis Mortality Rate
< 20%
We will put in place
enhanced process controls
and early warning systems to
facilitate improved budget
management both
departmentally and
corporate-wide
Financial reports reviewed and discussed monthly at
Senior Management meeting.
100%
Financial reports reviewed and discussed quarterly by
Leadership Team at LPC meetings
100%
Continue efforts to reduce
sick time hours through a
focus on Return to Work,
and implementation of a
renewed staff Wellness
Program
sick time hrs as a % of total worked hours
< 3%
2
Methods and process measures
Goal for change
ideas (2013/14)
Comments
AIM
Quality dimension
Access
Patient-centred
CHANGE
MEASURE
Objective
Reduce wait times in the ED
Improve patient satisfaction
Measure/Indicator
Current perf.
ER Wait times: 90th Percentile ER length of stay for Admitted patients. Q4 2011/12 – Q3
2012/13, iPort -
2011/12 Q4 2012/13 Q3:
47.4 hours Markham Site
Target for
2013/14
Target
justification
Priority
level
Planned improvement
initiatives (Change Ideas)
< 40.3 hours
2012-13 target
not achieved
1
1) Streamline and
standardize patient flow
related roles, develop
standard work for patient
flow, bed flow meetings and
Daily Access and Reporting
Tool (DART)
2) Incorporate an assessment
tool into the discharge
process to identify patients
at higher risk for readmission and to work with
our community partners and
primary care physicians to
have appropriate supports in
place post-discharge.
Methods and process measures
Goal for change
ideas (2013/14)
90th Percentile Wait from decision to admit to
Emergency Department (ED) discharge - Markham Site
< 35 hrs
% medical cases discharged on weekend as a % of all
medical discharges per week - Markham Site
> 20%
# scheduled surgeries canceled related to no inpatient
bed available to support post-op admission due to
increased in-patients (INEs) in the Emergency
Department – excluding ICU and paediatric beds.
< 4 cases in one
year
2011-/12 Q4 < 20 hours
2012/13 Q3: 20.6
hours - Uxbridge
Site
2012-13 target
not achieved
2
From NRC Picker / HCAPHS: "Would you recommend this hospital to your friends and family?"
(add together percent of those who responded "Definitely Yes" or “Yes, definitely”)
Oct 2011 - Sep
2012:
74.4% YTD
> 75%
Exceed
provincial
community
average of 71%
2
Ongoing unit/department
% pts who feel that the time to call bell is reasonable
focused attention on
based on NRC survey results
purposeful rounding on all
inpatient units and
anticipated improvement of
patients who answer that
the “time to call bell is
reasonable”.
> 60% based on NRC
survey results
From NRC Picker:" Overall How would you rate the care and services you received at the
Oct 2011 - Sep
2012:
91.6% YTD
> 95%
Exceed
provincial
community
1
1) Continue to do Just In
Time (JIT) patient experience
surveys on inpatient units to
provide real time patient
satisfaction info and assess
impact of focus on patient
flow and discharge planning.
2) survey 10 acute
medical/surgical/ maternal
child inpatients per week
3) Identify and address
factors related to why
patients would or would not
“recommend our hospital to
others".
# inpatient JIT surveys completed per week
10 /week
% pts completing JIT IIP survey who indicate that they
had discharge plans discussed with them
> 75%
JIT IP Survey response to "would you recommend this
hospital to your friends and family?" - Definitely Yes
> 75%
JIT IP Survey response to "Overall, how would you rate
the care you received at the Hospital?"
> 95%
Develop JIT Survey for ED
and Diagnostic Imaging
patients
# ED and DI JIT Surveys combined completed/week
starting in Sept 2013
10/week - starting
in Sept 2013
Hospital."
Markham Stouffville Hospital 2013/14 QIP - Page 4
Comments
AIM
Quality dimension
CHANGE
MEASURE
Objective
Measure/Indicator
Current perf.
Target for
2013/14
Target
justification
Priority
level
Planned improvement
initiatives (Change Ideas)
Maintain or
exceed current
performance
1
1) Promote No Place Like
Home Philosophy and
culture
2)Work with CCAC to identify
patients appropriate for
CCAC's Home First Program
3) Enhance communication
and coordination with two
on-site Family Health Teams
(FHTs) for highly complex
admitted patients
4) Develop profile of MSH's
most complex /high cost
patients and potential to
provide more coordinated
care
Methods and process measures
Goal for change
ideas (2013/14)
In-house survey (if available): provide the percent response to a summary question such as the
"Willingness of patients to recommend the hospital to friends or family" (Please list the question
and the range of possible responses when you return the QIP)
Integrated
Reduce unnecessary time spent in Percentage Alternate Level of Care (ALC) days: Total number of inpatient days designated as
acute care
ALC, divided by the total number of inpatient days. Q3 2011/12 – Q2 2012/13, Discharge
Abstract Database (DAD), Canadian Institute for Health Information (CIHI)
Reduce unnecessary hospital
readmission
2012/13 YTD Q3 < 11%
Corporate: 11%
Readmission within 30 days for selected CMGs to any facility: The number of patients with
select CMGs readmitted to any facility for non-elective inpatient care within 30 days of
discharge, compared to the number of expected non-elective readmissions - Q2 2011/12 – Q1
2012/13, DAD, CIHI
Markham Stouffville Hospital 2013/14 QIP - Page 5
ALC Days as a % of Total acute patient days - Markham
Site
< 10%
ALC Days as a % of Total acute patient days - Uxbridge
Site
< 17%
ALC - Average Length of Stay (ALOS) - Markham Site
< 20 days
ALC ALOS - Uxbridge Site
< 20 days
# pts discharged on Home First - Markham Site
> 6 per month
# pts discharged on Home First - Uxbridge Site
> 4 per month
Consider selecting process indicators such as:
Percentage of discharged patients for whom a
comprehensive discharge summary was completed.
Refer to the 2013/14 QIP Guidance Document for
Ontario Hospitals more information on this.
Comments