Download Indicator Progress 2015

Excellent Care for All
Quality Improvement Plans (QIP): Progress Report for the 2015/16 QIP
The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and
gain insight into how their change ideas might be refined in the future. The new Progress Report is mostly automated, so
very little data entry is required, freeing up time for reflection and quality improvement activities.
Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread
successful change ideas, and inform robust curriculum for future educational sessions.
ID
1
2
3
Target
Current
as
Current
Measure/Indicator from Org Performance
stated Performance
Comments
2015/16
Id as stated on
on QIP
2016
QIP2015/16
2015/16
“Overall, how would you rate 653 0.00
0.00
0.00
Due to the cost and the
the care and services you
low response rate
received at the ED?”, add the
resulting in no reports
number of respondents who
in house surveying is
done.
responded “Excellent”, “Very
good” and “Good” and divide
by number of respondents
who registered any response
to this question (do not
include non-respondents).
( %; ED patients; October
2013 - September 2014;
NRC Picker)
“Overall, how would you rate 653 0.00
0.00
0.00
Due to cost and low
the care and services you
response rates which
received at the hospital?”
result in no report in
(inpatient), add the number
house surveying is
of respondents who
done.
responded “Excellent”, “Very
good” and “Good” and divide
by number of respondents
who registered any response
to this question (do not
include non-respondents).
( %; All patients; October
2013 - September 2014;
NRC Picker)
“Would you recommend this 653 0.00
0.00
0.00
Due to cost and slow
ED to your friends and
turnaround times NRC
Picker is not used. In
family?” add the number of
respondents who responded
house surveying is
“Yes, definitely” (for NRC
done.
Canada) or “Definitely yes”
(for HCAHPS) and divide by
number of respondents who
registered any response to
this question (do not include
4
5
6
7
non-respondents).
( %; ED patients; October
2013 - September 2014;
NRC Picker)
“Would you recommend this
hospital (inpatient care) to
your friends and family?” add
the number of respondents
who responded “Yes,
definitely” (for NRC Canada)
or “Definitely yes” (for
HCAHPS) and divide by
number of respondents who
registered any response to
this question (do not include
non-respondents).
( %; All patients; October
2013 - September 2014;
NRC Picker)
In-house survey (if
available): provide the %
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).
( %; Other; October 2013 September 2014; In-house
survey)
Total Margin (consolidated):
% 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.
( %; N/a; Q3 FY 2014/15
(cumulative from April 1,
2014 to December 31, 2014);
OHRS, MOH)
Readmission within 30 days
for Selected Case Mix
Groups
( %; All acute patients; July
1, 2013 - Jun 30, 2014; DAD,
CIHI)
653 0.00
0.00
0.00
Due to cost and slow
turnaround time NRC
Picker is not used. In
house surveying is
done.
653 0.00
0.00
0.00
In house surveys
completed for ER and
inpatients.
653 -8.95
-8.37
-3.02
Budget continues to be
an issue.
653 20.00
22.00
8.00
The current
peroformance is based
on our internal data
from coding sent to
CIHI.
8 CDI rate per 1,000 patient
653 X
days: Number of patients
newly diagnosed with
hospital-acquired CDI during
the reporting period, divided
by the number of patient
days in the reporting period,
multiplied by 1,000.
( Rate per 1,000 patient
days; All patients; Jan 1,
2014 - Dec 31, 2014;
Publicly Reported, MOH)
9 ED Wait times: 90th
653
percentile ED length of stay
for Admitted patients.
( Hours; ED patients; Jan 1,
2014 - Dec 31, 2014; CCO
iPort Access)
0.00
X
Monthly reporting to
MOH is generally at a
consistent value of
zero.
0.00
0.00
10 Medication reconciliation at 653 97.00
admission: The total number
of patients with medications
reconciled as a proportion of
the total number of patients
admitted to the hospital
( %; All patients; most recent
quarter available; Hospital
collected data)
11 Number of times all three
653
phases of the surgical safety
checklist were performed
(‘briefing’, ‘timeout’ and
‘debriefing’) during the
reporting period, divided by
the total number of surgeries
performed in the reporting
period, multiplied by 100.
( %; All surgical procedures;
Jan 1, 2014 - Dec 31, 2014;
Publicly Reported, MOH)
12 Number of times that hand
653 90.00
hygiene was performed
before initial patient contact
during the reporting period,
divided by the number of
observed hand hygiene
opportunities before initial
patient contact per reporting
period, multiplied by 100.
100.00
97.00
EDH is not part of
ERNY. There has not
been any wait time for
ER patients that are
admitted to hospital.
An ER Patient Flow
Plan outlines
processes should this
change.
One quarter was 100%
with the rest at 95 to
97%.
0.00
0.00
EDH does not do
surgical procedures
and thus this indicator
is not applicable.
80.00
90.00
Exceeded the target.
Reporting period is Jan
1, 2015 to Dec 31,
2015 as most recent
available.
( %; Health providers in the
entire facility; Jan 1, 2014 Dec, 31, 2014; Publicly
Reported, MOH)
13 Percent of complex
653
continuing care (CCC)
residents who fell in the last
30 days.
( %; Complex continuing
care residents; Q2 FY
2014/15 rolling 4 quarter
average (October 1, 2013 September 30, 2014);
CCRS, CIHI (eReports))
14 Percent of complex
653
continuing care (CCC)
residents with a new
pressure ulcer in the last
three months (stage 2 or
higher).
( %; Complex continuing
care residents; Oct 1, 2013 Sep 30, 2014 -Q2 FY
2014/15 rolling 4 quarter ave;
CCRS, CIHI (eReports))
15 Percentage of ED patients
653 85.00
who respond positively to the
question "Would you
recommend this facility to
family and friends?" Tick box
choices are Definitely Yes,
Yes, Neutral, No and
Definitely No
( %; ED patients; 2015/16 Q1
to Q4; In-house survey)
16 Percentage of in patient
653 93.00
acute care population that
respond Definitely yes, or
Yes to the question "Would
you recommend this facility
to family and friends?". Tick
off choices are Definitely
Yes, Yes, Neutral, No,
Definitely No
( %; All acute patients;
2015/16 Q1 to Q4; Hospital
collected data)
17 Physical Restraints: Number 653
of admission assessments
where restraint use occurred
0.00
NA
With occupancy rate of
CCC at 1 or 2 patients
the data is not valid
and thus not a target
indicator. All fall's data
within the organization
is collected.
0.00
NA
Occupancy of CCC
beds is at 1 or at the
most 2 patients and
results would be
skewed.
85.00
77.00
Target lower than set
however response rate
continues to be low so
that data reliability is
questioned. Data is
from 2014/15 Q4 to
105/16 Q3.
85.00
99.00
Consistently good
response rate with high
satisfaction. Will
continue to monitor for
the comments section
on the survey. Data is
from Q4 2014/15 to Q3
2015/16.
0.00
0.00
N/A
in last 3 days divided by the
number of full admission
assessments in time period
( %; All patients; Oct 1, 2013
- Sep 30, 2014; OMHRS,
CIHI)
18 Rate of central line blood
653
stream infections per 1,000
central line days
( Rate per 1,000 central line
days; ICU patients; Jan 1,
2014 - Dec 31, 2014;
Publicly Reported, MOH)
19 The percentage of all ED
653 85.00
patients with a LOS of 3
hours or less
( Hours/ED patient; ED
patients; Q1 to Q4; HCD,
DAD, NACRS)
20 Total number of discharged 653 CB
patients for whom a Best
Possible Medication
Discharge Plan was created
as a proportion the total
number of patients
discharged.
( %; All patients; Most recent
quarter available; Hospital
collected data)
21 Total number of inpatient
653 23.25
days where a physician (or
designated other) has
indicated that a patient
occupying an acute care
hospital bed has finished the
acute care phase of his or
her treatment, divided by the
total number of inpatient
days in a given period x 100.
( %; All acute patients;
October 2014 – September
2015; DAD, CIHI)
22 Ventilator-associated
653
pneumonia (VAP) rate per
1,000 ventilator days: Total
number of newly diagnosed
VAP cases in intensive care
0.00
0.00
Central lines are not
inserted or used at this
facility.
75.00
79.00
0.00
CB
Those with Length of
Stay from
registration,triage,
physicians and
assessment of less
than 3 hours continue
to be Triage levels 4
and 5 (less emergent
cases).
Focus has been on
medication
reconciliation at
admission. No on site
Pharmacist has
presented challenges.
25.00
38.30
Was not a priority issue
for the facility last year.
0.00
0.00
No ventilators at this
facility.
units (ICU) after at least 48
hours of mechanical
ventilation during the
reporting period, divided by
the number of ventilator days
in that reporting period,
multiplied by 1,000.
( Rate per 1,000 ventilator
days; ICU patients; Jan 1,
2014 - Dec 31, 2014;
Publicly Reported, MOH)