Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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)