Download [Insert Hospital Name/Logo] - Sunset Country Family Health Team

Quality Improvement Plan (QIP) Narrative for
Health Care Organizations in Ontario
4/1/2014
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 HQO (if required) in the format described herein.
1
Overview
The Sunset Country Family Health Team (SCFHT) commenced operations in 2007, and currently has 14.5 FTE
interprofessional health providers (IHPs), including 3 nurse practitioners. Our 23 FP physicians are signatories to the
Sunset Country Family Health Network.
Besides working in primary care, all of our FP physicians provide other services in the community and the region including
ER coverage + second on-call, Obstetrics, GP Anaesthesia + on-call, Fracture Clinic, Hospital On-Call (HOC), Surgical
Assist, Colonoscopy, Hospital inpatient care of orphaned patients, weekly medical clinics in surrounding First Nation
communities, LTC support at two Nursing Homes, Coroner duties, Hospital in-patient care, ICU coverage, Chemotherapy
support, physician coverage for Kenora Area Health Access Centre, Creighton Youth Services, Northwestern Health Unit,
Kenora Jail, Minaki Nursing Station, Sioux Narrows.
SCFHT currently operates out of 4 sites. The majority of programs and services are located at the Paterson Medical
Centre site. We have a panel size of approximately 18,500 patients,17,600 who are rostered. We continue to roster
patients on the principal of equity & access. In addition most patients identified as needing continuing “follow-up” care are
rostered by a FHN physician (eg. Diabetes and Asthma Programs)
We service a large and widely dispersed geographical area with a catchment population estimated at 28,000. Census
Canada 2011 shows that there are 15,348 people living in the City of Kenora, of which 2800 are identified as First Nation.
We also service Unorganized Territories (East & West), Minaki, Redditt, Sioux Narrows/Nestor Falls and 11 surrounding
First Nations communities with a population of approximately 8000.
SCFHT participated fully in the first QIIP Learning Collaborative beginning in May 2008. This “Learning Community” was
most helpful to our team in learning the foundations of Quality Improvement in primary care.
The SCFHT QIP will focus on system and organizational-wide improvements in:
Timely access to primary care, when needed by improving data collection at the PMC site and initiating data collection at our other 3
sites. This will include training staff at all 4 sites in consistent data collection and patient education. We will also collect information
via a Patient Experience Survey regarding patients perception of receiving a visit or appointment on the same day or when needed.
1.
2.
3.
4.
5.
Reduce ER Use – we will work collaboratively with Lake of the Woods District Hospital to reduce the percent of
patients who visit the ER for conditions best managed elsewhere (BME)
Timely access to primary care appointments post discharge. We will strive to maintain the current level of 91% by
improving on receiving discharge information from both the hospital and CCAC in a more reliable and consistent
manner. We have developed and implemented, on a trial basis, a central referral and intake process for access to
FHT Programs and Services.
Reduce unnecessary hospital readmissions - we will work collaboratively with Lake of the Woods District Hospital
to reduce the percent of patients who are readmitted to hospital after they have been discharged
Receiving and utilizing feedback regarding patient experience with the SCFHT. We have updated our Patient
Experience Survey to include physicians, NPs and IHPs. Surveys were conducted in February-March at 2 of our
sites. We plan to implement this survey at our other 2 sites in 2014-15. Our goal for 2014-15 is to survey 10% of
all patients seen by a SCFHT provider between April 2014 and March 2015.
Population Health – included in our 2014-15 initiatives will be increasing access to influenza vaccine with a focus
on patients over 65 and those with chronic disease; reducing the incidence of cancer by improving our screening
rates for breast cancer, colorectal cancer and cervical cancer.
2
Integration & Continuity of Care
SCFHT’s 2014-15 QIP will continue to focus on integration and continuity of care. We recognize, in our community, the
need to enhance partnerships, communication and data sharing. This will require leadership and innovation to ensure our
patients receive continuous comprehensive and integrated care. This will be facilitated, in part, by new initiatives and
partnerships that include Physician Office Integration (POI), (allows for the almost immediate transmission of patient
information from hospital information systems to the EMR located in our physician offices), Community Health Portal
(CHP), (allows health service providers across the North West LHIN to view valuable patient information from the
NWCCAC electronic record, also known as CHRIS or Patient Health Record Information System.
Challenges, Risks & Mitigation Strategies
SCFHT recognizes the challenges and complexity in establishing baselines. A primary focus for the 2014-15 QIP will be to
establish and provide more relevant baseline data and numerical scores for the Population Health “quality dimensions”
influenza vaccination rates and cancer screening rates. Our most problematic challenge has been data extraction from
our EMR. Three of our sites use P & P Data but utilize different versions and are not integrated or connected between
sites, while the fourth site uses OSCAR for their EMR. This challenge should be somewhat mitigated as we develop and
implement the QIDSS initiative. Another significant challenge lies with the current data that only captures physician visits
within the rostered population and does not include other interprofessional providers. The SCFHT intends to capture data
that reflects patient centered interprofessional collaborative care. The risk, and challenge in timely sharing and transfer of
patient information are the limitations of communication infrastructure (in our community), lack of sector level data sharing
agreements and privacy issues. Again, this may be somewhat mitigated through the QIDSS initiative (and the POI & CHP
projects).
The development and maintenance of Health Maintenance Plans (HMPs) has been particularly challenging. Our goal for
2014-15 will be to determine the best method/vehicle for following patient screening, review current methods of input and
identify methods of receiving information, determine tracking mechanisms and establish baseline data. We have applied
for a grant through NOAMA, which if successful, will provide us with the necessary resources to fully develop, implement
and maintain a consistent process (that may or may not include using HMPs).
We anticipate encountering continuing difficulties (due to lack data accuracy and management, standardization, and
irretrievability of meaningful data) in implementing and enhancing quality improvement initiatives organization wide.
Information Management Systems
The functionality of our EMR is limited in meaningful data extraction and accuracy. While the SCFHT participated in Wave
1 of QIIP (in May 2008), we have since struggled with implementing many of the “lessons learned” and Quality
Improvement Initiatives. Basically we have struggled with the lack of expertise and resources to utilize the limited
functionality of our EMR. We continue to struggle with standardization of data, data extraction and analysis, enhancing
data and information management. Other than on a very limited basis, we are unable to extract and analyze data to create
reports that would help inform managers and clinicians in decision making processes. We recognize the need for good
data to support clinical staff (including physicians and IHPs) with clinical process change and improvement.
SCFHT is a host FHT for a Quality Improvement Decision Support Specialist (QIDSS). The QIDS Specialist will be
responsible for supporting SCFHT and its partner sites in their quality improvement planning, decision making and
implementation activities. This includes reviewing data quality, supporting teams in the implementation of data quality
initiatives, improving the flow and use of information, developing queries and analytical products to support boards and
leaders in their quality improvement goals and teams engaged in clinical process change.
The current process to create and update HMPs (Health Maintenance Plans) to include PAP, Mammogram, FOBT is not
working well. We have also created “Registries” for Hypertension Management, INR, Smoking Cessation, COPD, Asthma
and Diabetes Programs. A new CDM “flowsheet” for Diabetes Management and INR have been developed.
3
We will continue to work on processes to enable improved data accuracy and standardization of data input by our team
resulting in enhanced retrievability of data to support quality improvement.
Engagement of Clinical Staff & Broader Leadership
SCFHT recognizes the need to engage both clinical and administrative support staff and, patients in quality improvement.
We intend to form a Quality Improvement Committee to include the QIDS Specialist, SCFHT ED, FHT support staff and
IHPs, clinic support staff and physician representation. This group will be responsible for the continuing development and
implementation of our 2014-15 QIP. We propose that the physician on the committee also be a SCFHT Board member
who will be responsible for reporting on quality improvement at each Board Meeting. As part of our plan for broader
representation and leadership, we will formalize the Terms of Reference, membership and reporting relationships of our
three current quality improvement committees (Office Practice Redesign, Integrated Cancer Screening and Diabetes
Working Group).An Interprofessional Best Practice Team has also been formed. The intent of this team is to look at scope
of practice, competencies and interests of team members to have the most appropriate provider(s) providing timely quality
patient care. It is intended as a forum to communicate, network and collaborate to exchange information related to
evidence-based patient-centered primary care practice and programming. Our “team” will begin a new quality initiative in
April 2014. This will include a team review of “interesting cases” on a monthly basis.
Accountability Management
While accountability for quality improvement ultimately rests with the SCFHT Board of Directors, we plan to develop, over
the coming months, a “culture” of quality improvement within all four sites and with our community partners. Our Quality
Improvement Committee along with the OPR, Diabetes, ICS and Interprofessional Best Practice teams, will continue to
advance our quality improvement initiatives in 2014-15.
The SCFHT Board will be engaged directly in the advancement of our organizational wide Quality Improvement Plan.
Other
Key opportunities and challenges in 2014-15 will include:





Implementation of POI and enhancing our partnership with Lake of the Woods District Hospital
Partnering with the NWCCAC in the CHP initiative
Partnering with CCO and utilization of the Screening Tool Kit to assist with planning, implementing, monitoring
and reporting cancer screening rates
Using our EMR(s) to identify high risk populations and at risk patients
Improve communication with Northwestern Health Unit and community pharmacies to share information on
immunization status
4
Internal QI note
place 8
Sign-off
It is recommended that the following individuals review and sign-off on your organization’s Quality Improvement Plan (where
applicable):
I have reviewed and approved our organization’s Quality Improvement Plan
Board Chair
Clinician Lead
Executive Director / Administrative Lead
Instructions: Enter the person’s name. Once the QIP is complete, please export the QIP from Navigator, and have each participant
sign on the line. Organizations are not required to submit the signed QIP to HQO. Upon submission of the QIP, organizations will be
asked to confirm that they have signed their QIP.
5