Quality Improvement Plan 19/20 Conversations with …...Quality Improvement Plan 19/20 Conversations...

Quality Improvement Plan 19/20

Conversations with Patients – Engaging Patients to Enhance their Experience

AIM MEASURE

Quality dimension Objective Indicator Current performance Target for 2019/20 Target justification

Patient-Centred

Enhance patient reported experience of staff acting on what is important to them

% of patients who respond always to the question ‘How often did staff act on what was important to you’

Numerator: Number of always responses Denominator: Total number of responses

61% (Average positive response in Q4 2017/18)

Average positive response in Q4 2019/20 = 64.05%

Year 1 of a 3 year incremental target

This indicator is aligned to the hospital Strategic Plan as a Year 1 Operational Excellence Indicator. The target has been established at a 5% annual increase. This annual increase is considered a stretch target based on the high degree of variability in patient perspectives, and the historic impact of previous hospital-wide Person Centred Care improvement initiatives.

CHANGE

Change Ideas Methods Process Measures Goal for Change Ideas

Increase the number and frequency of conversations with patients

Interprofessional Practice will collaborate with program leadership to develop an implementation plan for Conversations with Patients that expands beyond quarterly Nursing Council meetings. The plan will include:

Development and sharing of tools to include paper template,web form, script, thank you for patients

Development and sharing of resources (education tool and video) to achieve consistency in the process of engaging patients

Commitment from programs to engage with a specific numberof patients monthly

The number of Conversations with Patients occurring quarterly

600 Conversations with Patients to occurquarterly from across patient care areas

Review Conversations with Patients’ feedback on units and care areas and profile action taken on a bi-monthly basis.

Several strategies will be used to facilitate this: 1. Process to capture data from paper tool to be created 2. Results to be shared with all programs on a monthly basis 3. On a quarterly basis Nursing Council and Interprofessional Practice

will debrief and theme information provided by patients. Nursing Council members will bring feedback and patient engagementlearnings to Quality Conversations on their respective units.

4. Units and Programs will review and act on feedback provided bypatients, with examples of action taken to be profiled organizationally.

5. Stories gathered from Conversations with Patients will be integrated as a part of committee meetings.

% of patient reported information shared with units / programs

# of Nursing Councilengagements in Conversations with Patients,followed by debrief /information theming fordiscussion with teams

# of organizational profiling ofaction taken to respond topatient feedback

100% of feedback shared with units & programmonthly

4 Nursing Councilengagements in having Conversations with Patients, debriefing,theming and sharing results

6 profiles of teams across programs in Sunnynetacting on the feedbackprovided by patients

Develop and pilot a new tool to measure patient experience. The tool would include subjective feedback from patients and objective measures indicating an optimal

1. Develop a patient experience measurement tool ‘prototype’ with input from staff and patients (include QPE committee of the Board)

2. Pilot the tool in three patient care areas over the year, using the results to expand the tool across the hospital in future years.

Prototype developed

Piloted on three patient care areas

Create a patientexperience measurementtool that includes objective and subjective

5% increase per year from Q4 17/18 2017/18 Baseline: 61.0%

1. 2018/19 Target: 64.05.% 2. 2019/20 Target: 67.1% 3. 2020/21 Target: 70.15%

CHANGE


patient experience designed specifically for each patient care area.

indicators of performance that can be measured and affected in ‘real time’.

Quality Improvement Plan 19/20 - Cancer Surgery Wait Times

AIM MEASURE


Timely Reduce cancer surgery wait times

(Wait 2 = time from decision to treat to procedure date)

Percent of Priority 2, 3 & 4 cases completed within target time

Priority 2 target = 14 days Priority 3 target = 28 days Priority 4 target = 84 days

78% of Priority 2,3& 4 cases achieving target wait time

(Q1&Q2 2018/19)

90% of Priority 2, 3 & 4 cases achieving target wait time in Q4 2019/20

Current CCO Target is 90% for priority 3 &4 cases, and 80% for priority 2 cases.

As this indicator is largely influenced by overall hospital occupancy, which has several system-level contributing factors, this is considered a stretch target.

CHANGE


Improve access to urgent / off-hours care for cancer patients (to prevent unnecessary ED visits, reduce admissions from ED, reduce readmissions and alleviate occupancy pressures)

- Create alternatives to ED visits for cancer patients [e.g.use of new C Ground space for urgent assessment ofcancer patients]

- Engage Patient & Family partners from the OdetteCentre Patient & Family Advisory Council in the designand evaluation of the proposed off-hours urgent caremodel.

Number of cancer patients registering in the ED

Number of admissions via ED for cancer patients

Reduce absolute number of cancer patient ED visits by 25%. (Baseline 2017/18 = 4396)

Reduce absolute number of admissions via the ED for cancer patients by 10%. (Baseline 2017/18 = 2181)

Align with corporate OR Cancellation Initiatives, to reduce surgical cancellations that contribute to longer wait times

The OR Cancellation Initiative will explore root causes of surgery cancellations and develop strategies which may include (but not limited to): - Implementation of 3 new High Intensity Short Stay beds- Relocation of MCUE (ICU beds) out of Post-Anaesthetic

Care Unit (PACU) to restore recovery room capacity to16 beds

- Explore ongoing opportunities for reducing surgicallength of stay to free up inpatient capacity

- Examine access to surgical short stay beds on weekends- Determine impacts of an OR smoothing strategy

Ensure cancer program representation at appropriate OR

Rate of OR cancellations Baseline from 2018/19 and target TBD prior to April 2019, to ensure alignment with Senior Leadership Team goals for 2019/20

CHANGE


Cancellation discussions / project meetings to inform initiatives arising from analysis and planning that may further support the overall QIP objectives of reducing cancer surgery wait times.

Quality Improvement Plan 19/20 – Diversity & Inclusion Training Program

AIM MEASURE


Equity Research, Design and Implement a Diversity & Inclusion Program for staff

Develop a course-based Diversity & Inclusion program. Incorporate the Program into Sunnybrook Leadership Institute and Certificate programs for roll out beginning in Q4 2019/20

Program will be new to SHSC (no baseline available).

Program developed for registration on the Sunnybrook MyLearning platform by March 31st, 2020

The comprehensive research, design and implementation of an educational program that includes input from patients and marginalized communities will require the entire fiscal year to develop.

CHANGE


Research core content for Diversity & Inclusion curriculum.

Research will include: - Environmental Scan- Literature Review- Analysis of internal patient demographic

data- Engagement of marginalized populations- Engagement of community groups

Outline of core curriculum (framework)

Framework developed by Q2 2019/20

Understand the staff experience and recommendations for program development

Conduct Focus Groups of staff across all parts of the organization: 1 Leadership (SLT & Directors) 1 PCM /Manager 1 professional practice 2 RN/RPN 2 support services 2 patient focus groups 1 Volunteer group

Number of Focus Groups 10 Focus Groups held between Q1 & Q2, 2019/20 Attendance at focus groups: 80% SLT 60% PCM / Managers 50% Staff 75% Patient & Volunteer

Develop the program The following five workshops (modules) are being proposed for the Diversity and Inclusion Training Program and will be modified based on research and staff engagement results:

Progress toward completed program

Program developed with input from stakeholders as described above by Q3 2019/20

CHANGE


1. Civility & Respect2. Diversity & Inclusion3. Myers Briggs Type Indicator (MBTI):

Communicator Style4. Unconscious Bias5. Cultural Intelligence

Evaluation: % of positive responses of the overall program

Develop a plan for the required organizational supports to embed diversity and inclusion at SHSC

The following are strategies and practices to be integrated into the corporate strategy to build a diverse and inclusive culture:

Demonstrate senior leadership commitmentto Diversity & Inclusion

Communicate the importance of Diversity &Inclusion across the organization

Create and update Diversity & Inclusionpolicies and procedures

Develop and implement a Diversity &Inclusion strategy

Orient new staff on our commitment todiversity and inclusion

Plan developed, including key milestones and performance metrics identified.

Plan articulated (for work to be completed in 2020/21) by Q4 2019/20

Quality Improvement Plan 2019/20: Emergency Department Length of Stay for Non-admitted Patients

AIM MEASURE

Quality

dimension Objective Indicator Current performance Target for 2019/20 Target justification

Timely Reduce length of stay for

non-admitted patients in

the Emergency

Department.

90th percentile Length of

Stay for all Non- Admitted

patients

9.98 hours

YTD FY2018/19 (Oct 20)

≤ 7.7 hours

In Q4 2019/20

The target will remain the same as

2018/19. Although progress was

made in 2018/19, occupancy

pressures and high volumes in the

Emergency Department continue to

challenge this indicator.

CHANGE


Patient Engagement

1. Bring ED QIP initiatives to the ED Community Partner Initiative (CPI)Committee

CPI assists the Emergency Department in enhancing experiences of patients and those accompanying them by promoting awareness and understanding within the community of the services provided by the Emergency Department, and by suggesting ways in which those services may be improved. The Committee consists of Sunnybrook Emergency Department leadership/staff, Sunnybrook Volunteers and community members

ED QIP Representatives will share ED QIP initiative results to the ED CPI Committee and seek ways from the committee members to improve services on a quarterly basis

Report ED QIP initiatives to the ED CPI Committee on quarterly basis and bring feedback from the community members to the monthly ED QIP meeting and/or project working groups

Quarterly feedback and reporting

Physician Initial Assessment (PIA) (PIA is the time interval between the triage date/time and the date/time of the physician initial assessment of the patient in the

emergency department.)

The main challenge to achieve the Physician Initial Assessment target

(PIA) is related to stretcher availability in the Emergency Department

(ED) and overall hospital occupancy. Therefore, three strategies are

presented to reduce the impact occupancy has on the ED to improve

flow so that new patients can be seen by an ED physician sooner after

arrival:

Transitional Zone (TZ) Strategy

The goal of TZ strategy is to flow patients more effectively

within the ED department. A pilot study with select ED staff

physicians was conducted to test proof of concept which

proved to be effective. The focus for FY 2019/20 QIP will be to

spread this initiative to the rest of the ED staff physicians.

Increase awareness and purpose of using the TZ to move

patients out of clinical spaces while they await imminent

discharge or admission to the ward. Current TAHSN Fellowship

will be focusing on this, we will attempt to maintain and build

upon the results of the fellowship which completes in March

2019.

Transfer of Accountability (TOA) Strategy

The goal of TOA strategy is to flow patients more efficiently

from the ED to the inpatient unit. A pilot study on C5 (inpatient

trauma unit) was conducted to test proof of concept. The

focus for FY2019/20 will be to spread the initiative to F2

(inpatient mental health unit), and C2 (inpatient oncology

unit).

Work with C5, F2, and C2 to improve the time it takes to move

a patient out of the ED once a bed is ready on the ward. We

look to finalize this process with these units and expand to

other areas.

Surge Plan Policy Development

Surge may be defined as an unexpected increase in patient

volume and/or patient acuity that exceeds the normal capacity

of space, staff, supplies and systems in the ED.

ED staff to develop surge policy when occupancy related surgeis happening

Strategies currently used are: using the Intake Zone Model with

zone physicians (on days other than Mondays), moving 4-8 ward-

hallway appropriate patients out of the ED zones and into the

‘central hallway’, formalizing criteria to call in additional staff

(RN, PSP, PSW, etc.).

Chief, Emergency Department,

alongside the QIP team members will

oversee the review and

implementation of these initiatives.

Current Performance of time to physician initial assessment:

4.94 hours (FY 2018/19 Oct 20 YTD)

TZ Strategy:

Current performance: current use of TZ spaces 8.40 patients per day (24 hours) (Jun 30-Aug 6 2018)

Process measure: Increase utilization of TZ spaces per day between 1130-2330 by 40%

Outcome measure: create 24 hours of TZ care spaces between 1130 and 2330 each day, by utilizing the TZ strategy which will increase patient throughput and ED capacity by 1 care spaces per day.

TOA Strategy:

Current Performance: 2.26 hours (C5, F2, C2 combined) (FY 2018/19 Q2)

Process measure: Decrease 90

th Percentile Ward ready to

ED Discharge time 1.2 hours

Outcome measure: By achieving the target we will increase bed utilization by 0.5 care spaces per day.

Surge Plan:

Increase throughput over an 8 hour shift from waiting room to dept. by 12 patients per shift.

Central hallway will create 4-8 additional monitored care spaces.

Target: 3.7 hours to physician initial assessment

Consult Interval

Following the development of individual service performance measurement in 2018/19, the team will report new consultation time measures (from consultation request date/time to patient’s ED discharge date/time) for the eight most frequent consulting services to the monthly ED QIP meeting.

Actively engage General Internal Medicine consulting services as pilot to look for opportunities to improve consult interval times and launch a quality improvement plan. This pilot will build upon previous learnings with Psychiatry as a pilot service (completed in 2018/19).

(An ED consultation is when an emergency medicine physician contacts/requests from another physician (specialist or otherwise) for advice or intervention regarding patient care)

Change led by Head of General Internal Medicine

General Internal Medicine Representative(s) will participate and collaborate with the quality improvement plan regarding their department consult interval times

Progress to be shared at Emergency Department Quality Improvement Plan meetings.

Convene meeting of relevant stakeholders to further discuss the suggestions made for improving GIM consult interval times and implement change

Current performance (GIM: 9.2 hours FY 2018/19 Dec 16 YTD. 90

th percentile

Present GIM consult

interval findings,

recommendations for

improvements and

progress updates to the

ED QIP committee.

Target (all consulting services): 5 hrs. 90

th

percentile

Medical Imaging

Expand current on-site ultrasound (US) technologist coverage (Monday

- Friday 8:00 a.m. up to 12:00 a.m.) to Monday – Sunday 24 hours a

day.

Expanded imaging services were determined based on analyses

completed on the 2018/19 QIP plan.

Change led by Head of the

Emergency & Trauma Radiology

Division and Director, Medical

Imaging.

Progress to be shared at Emergency

Department Quality Improvement Plan

meetings.

US Turnaround Time; order

to first report. 90th

percentile

Note: First report is assumed

to be simultaneously with

exam completion

Current performance: The

Order First Report TAT for

ED US cases from Jan to Sep

2018; 4.6 hours. (excludes

patients discharged and

returning for ultrasound)

Eliminate discharge of

patients for next day

ultrasound

Target: Reduce US

Turnaround Time to 3.3

hours by Sep 2019

Based on analyses completed on the 2018/19 QIP, a Business Case was developed and will be presented for approval from Senior Leadership Team to increase CT (computerized tomography) technologist staffing to two staff per after-hour shift.

This change idea is part of the initiative to improve turn-around time of Endovascular Treatment (EVT) in stroke management. Internal reporting will include 50

th, 75

th and 90

th percentile performance measures.

Change led by Director, Medical Imaging.

Progress to be shared at Emergency Department Quality Improvement Plan meetings.

CT Turnaround Time in afterhours; order first report. 90

th percentile

Current performance: The Order-First Report TAT for ED CT cases between 10pm – 8am from Jan to Sep 2018; 4:35:28 hours

Target: Reduce CT turnaround times to 3.3 hours in after-hours by 6 months after approval of business case

Implement the Senior Leadership Team approved construction project of

building a point-of-care radiology reading room in Emergency

Department to improve radiologist support in an acute clinical setting.

Change led by Director, Medical Imaging



meetings. Corporate Planning and

Development will assign a Project

Manager to start this project.

Radiologists of various

applicable sub-specialties,

including Emergency &

Trauma Radiology Division,

interpreting and consulting

in this shared reporting

room.

By Fall 2019,

construction project

will be complete.

In collaboration with the Sustainability Program Office (SPO),

Environmental Support Services and the Emergency Department,

continue to improve flow of patient transportations from the

Emergency Department to Medical Imaging for tests and treatment

procedures from 2018/19 QIP.

Actively engage Environmental Support Services to provide regular

data monitoring reports to the Emergency Department regarding

transportation of patients from the Emergency Department to the

Medical Imaging Department, and ultimately to set improvement

targets and look for opportunities to improve flow of patient

transportations.

Change led by Director of Medical Imaging,

Director of Environmental Support

Services in collaboration with SPO and the

Emergency Department team.



meetings

Together with SPO,

Environmental Support

Services and the

Emergency Department,

monitor, audit and

provide continuous

feedback on the data

analysis related to

transporting patients

from the Emergency

Department to Medical

Imaging on a timely basis.

Increase alignment of Patient

transportation arrival times

with appointment times.

SPO to establish project,

scope, objective(s) and

the high level project

plan in January 2019

Together with SPO,

Environmental Services and

the Emergency Department,

co-set targets by end of

March 2019.

Ambulance offload time

Continue to improve the time from ambulance arrival to ambulance offload. The focus will be on sustainability for FY 2019/20 and build upon the learnings and successes from the previous year.

Transfer of Care Time (EMS Offload time)

Evaluate effectiveness and impact of EMS Intake nurse starting at 10:30am (funded June 2018-June 2019) and seeking permanent/extended funding if pilot is successful.

Kiosk for Ambulance paramedics self-check-in.

On arrival, the paramedics will check-in using the kiosk and

their unique Trip Number. This will alert the triage nurses that

the ambulance has arrived and allowed them to call the crew

for triaging. Triage is the first step for the patients to be

identified by the Emergency Department system and allows

them to be placed in appropriate areas based on their severity.

Timeframe: Ambulance: 1) Kiosk Live Date: Q3 2018/2019 2)

Kiosk Trial Period: 3 months between Q3/Q4.

Time points measured: 1) Time from Ambulance Arrival to

Kiosk Check-in 2)Time from Kiosk Check-in to Patient Triage

This will add the ambulance patients to the triage nurses’

worklist, rather than having a separate queening system for

EMS and walk-in patients.



meetings.

Ambulance Check-in Kiosk is developed

by the Emergency Department

Information System Administrator. The

WebER system, which is an open source

web based application platform created,

managed, and maintained by the System

Administrator for the ED specifically, is

currently in use in the ED and will be set

up and running by end of FY 2018/19 to

receive EMS server data as a link to the

Kiosk.

Leaders for Change Idea steps are:

1. Toronto Paramedic ServicesStakeholder

2. Emergency Department ClinicalEducator/APN

3. Quality and Patient SafetyRepresentative

4. Information System Administrator

Compare data from Patient

Distribution System managed by the

Toronto Paramedic Services and the

Check-in Kiosk.

Transfer of Care Time (EMS

Offload time)

Current Performance: 54 min (Jan-Oct 2018) 90

th

percentile

Use EMS Kiosk to

identify to triage

nurse that EMS has

arrived.

Current performance: Time from Ambulance Arrival to Patient Triage 24 min (Jan-October 2018)

Target: Reduce Time from Ambulance Arrival to Patient Triage to 10 min. 90

th percentile

Target: EMS Offload

time < 45 min. 90th

percentile

Hand Hygiene Quality Improvement Plan 19/20

AIM MEASURE

Quality dimension Objective Indicator

Current performance

Target for 2019/20

Target justification

Comments

Safe To improve hand hygiene compliance across medical and surgical inpatient units at Sunnybrook Health Sciences Centre using electronic monitoring (E-monitoring), a key intervention in preventing the spread of hospital acquired infection.

Percentage of hand hygiene compliance measured using electronic monitoring across the 10 specified medical and surgical units for three consecutive months during 2019/20.

Numerator: the number of times that healthcare providers (nurses, residents, physicians, allied health, environmental service partners, patient service partners) clean their hands

Denominator: the expected number of hand hygiene opportunities

1) Currentperformance oforiginal pilot units (B4,D2, D3, C5, D5) is 59.8% over the past 6-months (1,306,323hand hygiene eventsdivided by 2,185,643hand hygiene opportunities)

2) Currentperformance of newunits (C2, C4, D4, C6,D6) is estimated at44.8% (baseline compliance in pilotstudy units)

Average performance of all units in Q4 2019/20 > 62.5%

During 2018, the five original pilot units improved their Hand Hygiene compliance from 44.8% to 59.8% as of November 2018. A similar improvement is expected across the new medical/surgical units while the original pilot units need to set a new goal, which has been raised by an additional 5%.

This annual increase is considered a stretch target based on the strict compliance standards that are required for hand hygiene. The standards measure adherence to what is referred to as the ‘four moments’ of hand hygiene (entering a patient’s room, interaction with a patient, post-interaction with a patient, and leaving the area). No system for measuring hand hygiene is perfectly accurate in capturing each moment, and this target takes this into account while working toward continuous improvement.

Hand hygiene compliance is a patient safety indicator of Health Quality Ontario. The traditional method of measuring hand hygiene is based on direct observation during spot audits which overestimates performance and is inaccurate for benchmarking performance. E-monitoring, introduced first at Sunnybrook in 2017, measures hand hygiene compliance continuously on the unit using a built-in motion-activated censor in the dispenser. The system has been calibrated based on the expected number of hand hygiene opportunities across these medical/surgical inpatient units (Nayyar et al, Infection Control Hospital Epidemiol 2018).

CHANGE

Change Ideas Methods

(Accountability and Responsibility) Process Measures Goal for Change Ideas

Implement provision of weekly E-monitoring Feedback Reports that provide hand hygiene compliance for the prior week to front-line staff. These reports will be sent electronically to leaders and champions of each inpatient unit. Hand hygiene performance will also be posted on large poster in the entrance of each unit.

Infection Prevention and Control will set up a system so that Feedback Reports will be automatically generated and pushed to all hand hygiene champions, Team Leaders, Advanced Practice Nurses and Patient Care Managers for the unit to share with all staff.

% of unit leadership and front-line staff receiving E-monitoring Feedback Reports on a weekly basis

100% of unitleadership

>50% of the front-linestaff on the pilot studyunits.

Ensure that hand hygiene performance based on E-monitoring Feedback is discussed at a minimum of one weekly Quality Conversation for 5 minutes that empowers unit staff to identify opportunities for iterative changes* that promote better hand hygiene compliance.

*Examples of iterative changes arising from huddles mayinclude walk-arounds to identify specific physical locationswhere hand sanitizer location may be optimized to improveworkflow, reviewing hand hygiene data at specific times ofday to correlate with patient care activities, changes inplacement of gloves to promote appropriate use of gloves,etc.

Quality Conversations are organized by unit managers with the support of Infection Prevention and Control. These conversations are attended by most clinical staff on the unit.

Weekly meetings will be organized among unit managers and hand hygiene champions to allow them to share their change ideas, successes and challenges with other units at Sunnybrook and other hospitals across the HH-IMPACT network.

Frequency and content of weekly Quality Conversations will be recorded by unit leadership and Infection Prevention & Control

At least 1-2 new ideasor lessons aregenerated on each unitevery month. Thesewill be monitored byIPAC and shared withother units asapplicable to driveimprovement.

Each unit will set a 1-month and 3-month goal for hand hygiene compliance.

Goals will be set by the unit during Quality Conversations on the unit and

posted on Quality boards

included in Feedback Reports

shared with the Unit and Hospitalleadership

1-month and 3-month goalswill be tracked on monthlycorporate E-monitoring reports

To set a monthly E-monitoring goal at least 10% above baseline at the start of each month.

To set a 3-month E-monitoring goal at least 10% above baseline every quarter.

CHANGE

Change Ideas Methods

(Accountability and Responsibility) Process Measures Goal for Change Ideas

Empower patients and families to make hand hygiene an expectation of care by:

1) Providing point of care hand hygiene bottles toimprove accessibility for healthcare providers.

2) Formalizing empowerment of patients and familiesto assist with audit and feedback of healthcareprovider hand hygiene

E-monitored point of care bottles will beinstalled at the bedside by the Patient CareManagers and Infection Prevention andControl Coordinator will monitor productuse.

Infection Prevention & Control will work with the Patient Engagement Team, and patient/family representatives to design a process that formalizes patient/family involvement in providing audit and feedback to healthcare providers about their hand hygiene.

Absolute number of hand hygiene events using point of care bottles will be monitored and reported using the e-monitoring system.

To increase the number of hand hygiene events using point of care bottles on the intervention units.

(Target to be set with Sunnybrook’s patient engagement team.)

Quality Improvement Plan 19/20 - Palliative Patients Dying with the ‘Right’ Care

AIM MEASURE

Quality Dimension Objective Indicator

Current performance

Target for 2019/20


Effective Increase the number of acute care

patients who has an Advanced Care plan

(ACP) / Goals of Care documented notes.

For those acute patients at their final

stage of illness, ensuring that their

palliative needs are identified, assessed

and documented as early as possible will

ensure that patients are dying with the

‘right’ care in the ‘right’ place based on

their goals and values.

Percentage of patients with Advanced Care

Planning (ACP)/Goals of Care documented notes

from total discharged patients. **

Exclusions: excluding all elective discharges, Newborn / Obstetrics and deaths within less than 8 hours of admission.

12.1%

April – Dec 2018 (projected average based on 9 months)

Numerator: 1,816 Denominator: 14,961

13.3% of patients with ACP/Goals of Care notes documented at discharge, in Q4 2019/20

This is the second year that SHSC is implementing ACP/Goals of Care notes in SunnyCare. Results to date are very positive. Aiming for a 13.3% target will require greater collaboration between different clinical groups, additional investment in education and awareness programming.

13.3% (2,000 ACP Notes) is a 10% increase from 18/19 baseline of 1,816 acute discharges with ACP notes.

CHANGE


1. System PartnershipEstablish a North Toronto Sub-Regional Palliative Care collaborative comprised of provincial, LHIN, community and hospital provider stakeholders to develop a three-yearPalliative Care Action Plan. Three interventions will be identified, based on provincial, regional and local priorities and directions.

Year 1: Co-chairs of the Palliative Care Journey Committee will lead the development of the three-year implementation and measurement plan, reporting to the Interprofessional Quality Committee.

Development and implementation of Sub Regional Palliative Care Action and Measurement Plan

Action and measurement plan in place with work on 3 interventions begun by March 2020.

Palliative Care Committee bi-monthly meetings (Target: 5 meetings held in 2019/20)

2. Build Capacity in Health Care Teams for Advance CarePlanning (ACP), Goals of Care, and End of Life Conversations *

Develop a formalized education program to build capacity for “Essential Approaches to Care” in collaboration with Organizational Development and Leadership and the Simulation Centre for staff and system partners focusing on:

Person Centred Approaches to Care

Advance Care Planning and Goals of Care Conversations

Patient Oriented Discharge (PODS) and Transitions

Warm Handovers

End of Life Conversation

Director of Interprofessional Practice will report to Palliative Care Journey Committee quarterly on the number of learners who complete the training.

Develop template for documentation of goals of care and palliative needs.

Improved knowledge of health care providers on ACP, identification/assessment of palliative needs, End of Life Conversations will be measured by pre/post scores on a knowledge test.

Total number of staff and system partners trained

50 staff and system partners trained by March 2020.

30% improvement in self-reported knowledge scores post education

CHANGE


3. Implement Technology Based Solutions to Support and Measure Integration of Palliative Care

a. Centralize consult request, response and outcome process.

b. Use BetterCare platform as a mechanism to share ACP information to support improved continuity in care

Palliative Care Journey Executive Committee will provide oversight and recommendation to Decision Support and SunnyCare for design of the Palliative Care Dashboards, monitoring of metrics and integration with clinical documentation.

Modifications to Palliative Care Dashboard to align with interventions and associated measures Number of discharge summaries that include goals of care documentation (family physicians will not be accessing Better Care) Access to documented ACP information / notes (from SunnyCare) through BetterCare

Refreshed Palliative Care Dashboard aligned with new Palliative Care Action Plan by Q3 2019/20 Discharge Summaries in Sunnycare will include Goals of Care documentation ACP clinical notes available in Better Care platform by Q2 2019/20

4. Timely Access to Palliative Care Support within Sunnybrook: a. Enable emergency departments/hospital ward to

discharge palliative care patients back home (if desired) with symptom relief kits and care resources matched to need (i.e. First 48 hours Program)

b. Ensure level of care offered is matched to palliative patient needs e.g. patients with low Palliative Performance Scale (PPS) scores to be redirected to appropriate settings (hospice, home), Palliative Care Unit admission for patients with high PPS scores or other care complexities.

In alignment with priorities identified within Change Idea #1 (above), the Palliative Care Journey Executive Committee will provide oversight for interventions related to timely access to palliative care support, and will report progress to the Palliative Care Journey Committee and Interprofessional Quality Committee. Structural Indicator: Palliative Care Consult Team (MD/RN) as part of a QI team (ED MD/RN, SW, H&CC) in the emergency department or ward to develop and pilot admission avoidance strategies

Number of palliative care consults in the outpatient or ED setting (non-malignant, malignant) Number of avoided admissions in the ED through connections to other PC settings including home Number of teams/clinics caring for patients with life-limiting illness who have a designated Palliative Care Consult provider (for advice/support/consults and team capacity building) Number of ALC palliative patients who die in acute care setting (including the ED) Number of patients admitted to the Palliative Care Unit with high PPS scores

10% increase in the number of palliative care consults in the outpatient setting (including ED) Data includes the following notes: Team Meeting, Telephone Advice, Consult note and Progress note. Baseline: Jan- Dec 2018 – 1,123 notes Target: 19/20 – 1,253 Measurement to be developed with ED team 10% increase in teams caring for patients with life limiting illnesses that are able to provide palliative care. Target TBD based on baseline 20% reduction in palliative ALC deaths in acute care (including ED) Baseline: 18/19, projected based on 9 months – 51 ALC palliative deaths Target: 19/20 – 41 ALC palliative deaths Zero palliative patients admitted to the PCU with high PPS score (PPS score of > 40%)

CHANGE


5. Establishing Palliative Urgent Care Models The newly established Odette Palliative Care Advisory Council will establish what urgent care models and interventions are required to address acute palliative needs earlier in the palliative patient journey.

Conduct needs assessment and

identify possible improvements to

decrease number of avoidable

admissions, LOS and ED visits by

patients approaching end-of-life

through improved care planning

earlier in their palliative journey and

addressing urgent care needs

efficiently in the outpatient or

community setting, and achieving

improved patient/family

satisfaction.

# of alternative care urgent models developed and accessible (# pts, # days per week) Increase the # of Patients Admitted to ‘Home Palliative Care’ with Home & Community Care Services, or Temmy Latner or Primary Care Physician as the Most Responsible Physician (MRP). Increase the # of direct Admit to PCU from home (pts of Odette Cancer Centre) bypassing the ED and Acute Care.

2 models developed and implemented # of Patients Admitted to Home Palliative with H&CC Services and Temmy Latner/Primary Care physician as MRP Baseline: 17/18 = 398; 18/19 YTD (projected) = 311 19/20 Target = 400 (same as 17/18) # of direct Admit from Odette Cancer Centre bypassing ED/Acute Care Baseline: 17/18 = 90; 18/19 YTD (projected) = 68 19/20 Target = 90 (same as 17/18)

(*)

ACP conversations enable patients to reflect on and discuss their values, beliefs and wishes as they relate to future health care needs and to make their wishes known to their Substitute Decision Makers ACP conversations can occur at any stage of a person's life, whether they are healthy or have a serious illness. Advanced Care Planning conversations can be used to inform goals of care discussions when treatment or care decisions need to be made in the future. (**)

ACP logic – From the first time ACP note is created during an admission, that admission/discharge and any subsequence admissions/discharges would be counted as ACP. For admissions and

discharges prior to the first ACP note creation date, those would not be counted as ACP discharges.

Quality Improvement Plan 19/20 – Patient Safety Culture

AIM MEASURE


Safe Strengthen our Patient Safety Culture (as measured by staff perceptions of incident follow up)

Percent positive response to Patient Safety Culture Survey Question: “Staff are usually given feedback about changes put into place based on incident reports”

2016 Safety Culture Survey: 58% positive score (agree + strongly agree) on the select survey question

63% positive score (agree + strongly agree) on the select survey question. Survey to be repeated in late Q3 2019/20 (results reported in Q4).

Safety Culture is a very subjective and difficult measure to influence, as is unique to each individual unit. The historical range for this question is 49% - 58% (since 2009). It is felt that a 5% improvement overall is a stretch target given historical performance.

CHANGE


Modify Safety Reporting System Explore modifications to the online iSpeak Up Safety Report system to allow frontline staff to review details of the follow up activities in response to safety reports they submit. Engage frontline staff in discussions, via focus groups, to provide input into possible modifications.

Modifications, as defined and approved by staff, are live in the iSpeak Up Safety Report System (see also outcome measure re: staff feedback)

All modifications are live by March 31

st, 2020

Safety Culture Pilot Project in CICU: Design and Implement a series of technical and adaptive exercises on the unit (CICU) to boost culture of safety

Design and implement a pilot project with leadership from the CICU, aimed at engaging staff in reviewing safety reports and discussing follow up, as part of Quality Conversations.

1) Conduct a safety culture survey to establish baseline 2) Train staff on science of safety using local training

sessions and the Patient Safety Specialist 3) Discussing safety reports at the Quality Conversation

monthly (focusing on lessons learned and the positive impact of speaking up)

4) Providing loop closure to staff involved in the safety event, as well as the event reporter

1) Measure the culture of safety before and after the pilot by analyzing the survey (measure: staff safety culture knowledge, culture of speaking up, staff perception of safety incident reporting benefit)

2) Measuring the number of safety reports submitted (before and after)

3) Measuring and analyzing the severity of safety reports based on lessons learned from discussions.

Targets: 1) Increase the pilot units’

culture of safety by 10% (50% increase in staff safety culture, 20% increase in culture of speaking up, 70% increase in staff perception on the benefits of safety reporting)

2) 5% increase in safety report submission (overall)

3) Reduce severe harm events to less than 1% of all events (baseline = 4%)

Revise Patient Safety Specialist role profile Pilot enhancements to the Patient Safety Specialist role, with greater involvement in the follow up of select, individual safety reports to strengthen the Safety Report Life Cycle and support safety culture at the unit level.

Implementation of role modifications Role changes designed, piloted, evaluated by March 31

st, 2020

CHANGE


Revise Patient Safety trend oversight model Establish regular reporting of patient safety data trends and culture data at the Interprofessional Quality Committee (IQC). Further define the committee support structure (working group) to address items arising from the regular review of this data (possibly including the Quality Practice Advisory Council and/or the Medication Safety Subcommittee of P&T)

Reports provided to IQC % of general safety event categories (types) with a designated review committee

100% compliance with reporting to IQC at frequency set out by the committee. 80% have a designated review committee receiving regular reports

Integrate safety questions for patients/families into Mock Tracer Program

Integrate questions about patient/family comfort level with speaking up or reporting safety concerns into the Mock Tracer process. Questions will be asked of patients by mock surveyors, which include other patients (patient partners). The data collected through quarterly mock tracers will be shared with inpatient area leads, the Patient Engagement Steering Committee and reported to Accreditation Steering Committee, and the Interprofessional Quality Committee for appropriate follow up.

# patients asked per year during mock trackers Number of Respondents who were asked the question - “Do you feel comfortable (safe) reporting mistakes or concerns if you witness or experience them?”

Target = 12 (4 per quarter) Target 60% positive response

Collaborative Change Idea: Toronto Serious Safety Event Collaborative

Establish a collaborative with the University Health Network (UHN), Unity Health Toronto, the Sinai Health System, Women’s College Hospital, North York General Hospital and Michael Garron Hospital to develop a common classification system for serious safety events, to compare data and recommendations from the review of high harm events for the purpose of broadening our learning culture and further reduce the risk of preventable patient safety events.

Serious safety event rate Complete staff education workshop on Serious Safety Event taxonomy / classification system. Coordinate collaborative meetings

Rate target TBD (classification to be created and baseline determined first) 4 Sunnybrook staff trained in the SSE methodology. Target 4 collaborative meetings per year

Quality Improvement Plan 2019/20 – Patient Oriented Discharge Summary (PODS)

AIM MEASURE

Quality Dimension

Objective Indicator Current

performance Target for 2019/20


Effective Provide patients with

the information they

need to prepare for

transition home

Percentage of respondents who responded positively to the following question: “Did you receive enough information from hospital staff about what to do if you were worried about your condition or treatment after you left the hospital?” (The Canadian Patient Experience Survey (CPES) question #37)

49.6% (Average from Nov 2017 – Oct 2018) for 5 patient care units (D2, B4, C4, C6, D3)

58.1% average in Q4 2019/20 for CHF, COPD & CAP* patients from target inpatient units (Responses captured during a post discharge telephone call

The target is set at the NRC Canada national average and is considered a stretch target as these questions are difficult to influence.

* CHF = congestive heart failure; COPD = Chronic obstructive pulmonary disease; CAP = community-acquired pneumonia

CHANGE

Planned improvement initiatives Methods Process Measures Goal for change ideas

IMPLEMENTING PATIENT ORIENTED DISCHARGE SUMMARIES Develop, implement and evaluate PODS (Patient Oriented Discharge Summary)

1 with three Quality Based Procedure populations (congestive

heart failure, chronic obstructive pulmonary disease and pneumonia). Implementation of PODS will include simulation based education for staff on the core competencies of Health Literacy

2 and Teach Back

3.

1 Summary provided to patients typically with five key pieces of

information they need to know in order to effectively manage their health after a hospital discharge:

Signs and symptoms to watch out for

Medication instructions

Appointments

Routine and lifestyle changes

Telephone numbers and information to have available 2 Health Literacy is the degree to which patients have the capacity to

obtain, process, and understand health information needed to make appropriate health decisions. 3 The teach-back method, also called the "show-me" method, is a

PODS Working Group will lead the implementation of PODS and evaluate effectiveness and feasibility. The Working Group will report progress to the Discharge and Transition Planning Committee monthly.

On the following units (D2, B4, C4, C6 and D3):

Compliance of using PODS with eligible patients who are discharged

80% of eligible patients will have a PODS provided to them at discharge across 5 units by Q4 2019/20

CHANGE

Planned improvement initiatives Methods Process Measures Goal for change ideas

communication confirmation method used by healthcare providers to confirm whether a patient (and/or their care takers) understands what is being explained to them. If a patient understands, they are able to "teach-back" the information accurately.

Staff education programming and evaluation will be completed in collaboration with Michael Garron Hospital to further advance system partnership and collaboration.

Sunnybrook has co-developed staff training in collaboration with Michael Garron Hospital and Sunnybrook’s Canadian Simulation Centre. Staff education will be completed in partnership with Patient and Family Education and progress will be reported to both the Discharge and Transition Planning Committee and the Sunnybrook Education Advisory Committee (SEAC).

Completion of bothHealth Literacy andTeach Back education

Healthcare providersatisfaction – FocusGroup

80% of staff on 5involved unitscompleted education byQ4, 2019/20

80% staff feel the PODSprocess is better overallthan the prior dischargeprocess

Post discharge calls to patients and families will be used to evaluate the effectiveness of PODS.

Post Discharge Calls will be completed by a Nurse Navigator Program.

The purpose of the calls will be to: provide additional information based on need and to evaluate the impact of the PODS tool.

Patient and familysatisfaction – PostDischarge TelephoneCalls

75% of patientsdischarged from the 5units report satisfactionwith dischargeinformation &instruction by Q4,2019/20

3/21/2019

Quality Improvement Plan 19/20 – Suicide Prevention

AIM MEASURE


Safe Establish process to screen patients for suicide

Percentage of patients screened for suicide risk in:

1. General Internal Medicine2. Emergency Department –

(focus: patients withsubstance abuse, overdose,withdrawal or mental healthconcerns)

3. Veterans Program4. Psychiatry – F2

Baseline equally weighted average: 55% (excludes GIM, as formal screening process not yet begun)

1. General Internal MedicineQ1-Q3 2018/19 baseline =0% as a new process wasimplemented in Q32018/19

2. Emergency Department –baseline data from June2018 82% screeningcompliance for patientspresenting in triagerequiring mental healthassessments (to beexpanded to patients withsubstance abuse,overdose, andwithdrawal)

3. Veterans Program – Q12018/19 screeningcompliance 64%

4. Psychiatry – screeningpractices in place for F2staff and Psychiatrist.Implemented Sunnycareform for suicidescreening, Baselinescreening documentationfor form use is 57% Q1-Q22018/19

Equally weighted average of 70% or greater across the target areas in Q4 2019/20.

The target of an equally weighted average of 70% compliance across all 4 patient populations is felt to be feasible based on wide variation at baseline and lessons learned from year 1 of implementation of suicide screening across these core areas.

Further, compliance will remain less than 100% as nonverbal and aphasic patients will be unable to respond to screening questions.

The use of an equally weighted average is to account for large differences in the sample sizes for each respective population, and to reflect the importance of ensuring adoption and performance in all 4 of these areas of focus.

3/21/2019

CHANGE


General Internal Medicine (GIM)

Engaging teams to co-design screening and documentation tools to enhance suicide screening practices. Interventions such as the coping card will be implemented.

Teams within GIM have utilized Quality Conversations (weekly staff huddle) to discuss strategies and ideas on how to implement screening processes. A documentation tool was developed in 2018/19 Q3 and will be piloted on C4 for suicide screening.

In 19/20, teams will continue to assess the use of the screening tool and refine processes as needed. Plans will be developed to spread screening process to other GIM units and implement interventions such as the Coping Card.

Percent of patients with screening documentation complete

80% of patients in each General Internal Medicine unit to have completed screening tool by April 1, 2020

Emergency Department

Expand current screening processes for mental health patients to ensure patients presenting to the Emergency Department with substance abuse, overdose, withdrawal and/or mental health conditions are screened for suicide.

Screening practices have been implemented in 2017/18 for patients presenting in triage with Mental Health concerns. Audits in 2018/19 indicate that screening practices have been sustained, and improvement work has focused on determining process for documenting the suicide screening during secondary assessment.

For 2019/20, collaboration with Emergency Department leadership to determine roles and responsibility in screening patients presenting in the Emergency Department with substance abuse, overdose, withdrawal and/or mental health conditions.

Percent of suicide screening completed for patients assessed with substance abuse/overdose/ withdrawal and/or mental health conditions

80% of patients with substance abuse/overdose/ withdrawal and/or mental health conditions, with documentation of suicide screening by April 1, 2020

Veterans Program

Monitor algorithm use to ensure suicide screening is completed for residents in the Veterans Centre. Palliative Care Consult Team to include suicide screening during consults.

An algorithm was developed in 2018/19 to guide staff in suicide screening process and frequency.

For 2019/20 Veterans Centre Leadership

Percent of positive screens with intervention(s)

80% of residents in Veterans Centre with positive screen have intervention in place by April 1, 2020

3/21/2019

CHANGE


to monitor completion of suicide screening and include screening into Palliative Care Consult team practices. Work will continue to ensure algorithm is utilized and interventions are implemented for those who are screened positive.

Psychiatry Monitor interventions such as coping card for those who screen positive for suicide. Collaboration with Mood Disorders Association of Ontario to implement Caring Contacts for patients presenting in the Emergency Department and assessed by Psychiatry. Caring Contacts is a program that is used as an adjunct to treatment; an automatic message is sent to patients after they are discharged to remind them of available support and safety strategies. Method of communication to be determined and trialed as part of implementation.

Columbia Suicide Severity Rating Scale implemented in Sunnycare as a form, evaluation of use of this form to be done in 2019/20. Department of Psychiatry Leadership and Mood Disorders Association of Ontario to implement Caring Contacts at Sunnybrook in 2019/20.

Percent of completed Columbia Suicide Severity Rating Scale, completed by Psychiatry via Sunnycare Number of caring contacts sent within 2 weeks of ED visit/ # eligible patients

80% of Psychiatry consults with electronic Columbia Suicide Severity Rating Scale complete in Sunnycare by April 1, 2020 80% of caring contacts sent to eligible patients within 2 weeks of ED visit

Increase internal capacity for delivery of suicide prevention strategies and treatments. Increase access to interventions for those who have screened positive for suicide:

Coping Card and Hope Kit

Access to online and community-based psychotherapy resources

Access to Problem-based app

Changes led by Brain Sciences and Department of Psychiatry and monitored by the Psychiatry Working Group.

Coping Card and Hope Kit training through Learning Management System module completion to be monitored. Module was implemented in August 2018, at time of submission, 60 staff have completed the module

Collaborate with Big White Wall and Bounce Back (community mental health agencies) to increase awareness to their Psychotherapy resources through education events at Sunnybrook

Problem Based App to be launched for men presenting to the Emergency Department with suicidal thoughts,

Number of staff who have completed the Coping Card Learning Module Percent of positive screens with intervention(s) – see Program Process Measure and Goal.

60% increase in LMS module completion

3/21/2019

CHANGE


this work will be completed as part of a study led by Dr. Sinyor and Dr. Schaffer

Collaborative Change Idea with Community Partners to improve access to suicide prevention strategies Host two half day education event(s) on suicide screening and prevention strategies for Community Agencies, Primary Care Physicians, and North Toronto Region Advisory Council. Workshop(s) will enhance coordination with Sunnybrook services; provide resources to the community to support suicide screening, North Toronto Hope Campaign, and interventions such as the coping card.

First workshop to be hosted at Sunnybrook Health Sciences Centre Spring 2019.

A second workshop will be organized in Winter/Spring 2020 to share best practices across community organizations.

Lunch and Learn sessions to be held at various community sites to raise awareness of available resources

Department of Psychiatry has engaged with Primary Care Physicians and Community Agencies within the North Toronto Region via Grand Rounds and events to provide resources such as Coping Card and Hope Kit to the community (Completed in 2018/19). An education event will be hosted by Sunnybrook in collaboration with the North Toronto Region Advisory Council to enhance coordination to support suicide screening. Implementation of the North Toronto Hope Campaign to be completed in partnership with the Department of Psychiatry Patient & Family Advisory Committee, North Toronto Region Advisory Council, and Department of Psychiatry on North Toronto Hope Campaign

Number of community agencies and primary care physicians attending workshop

>30 representatives from Community Agencies >20 Primary Care Physicians attend forum

of 2

Quality Improvement Plan 19/20 – Wait Time for Inpatient Bed

AIM MEASURE

Quality dimension Objective Indicator

Current performance

Target for 2019/20


Timely Transition patients to inpatient unit or operative room as quickly & efficiently as possible.

Maximum length of time that 90% of patients admitted from the emergency department wait for an inpatient bed or an operating room from the decision to admit.

39 hours Q3 2018/19

(2018/19 YTD =

34 hours)

35 hours in Q4 2019/20

10% reduction from baseline

This indicator is driven by multiple processes that include services and stakeholders from across the organization. Therefore, a modest target is warranted.

CHANGE

Change Ideas Methods Process Measures Goal for Change

Ideas Maximize referrals to transitional care beds and programs (e.g. at Pine Villa, Humber, Holland).

Implement processes to support assessment and referral

of patients who meet eligibility criteria.

Leads: Professional Leader for Social Work, Operations

Directors and Patient Care Mangers will ensure staff are

aware of and maximizing the number of appropriate

referrals to transitional care beds and programs.

Report progress regularly into Alternate Level of Care Task Force

# patients referred per month to transitional care beds and programs

Baseline: 5/ month (Nov 2017 – Oct 2018) Target: ≥ 10/ month

Performance monitoring

Monitor and report the following data on ongoing basis to Occupancy Executive Committee(OEC):

Inpatient bed turnover rate

Total length of time admitted patients spend in ED

Percentage of alternate level of care (ALC) patients

Patient flow metrics reported at OEC huddles

Monthly reporting begins Q1 2019/20

of 2

CHANGE

Change Ideas Methods Process Measures Goal for Change

Ideas Reduce the time from patient discharge to their bed becoming available.

Work with Environmental Services to minimize the time required to complete the bed cleaning request Teams: Environmental Services, in-patient units

Average time to complete the cleaning request

Reduce time to complete cleaning by 10%.

Engage with the emergency department and inpatient wards to reduce the time taken to conduct transfer of accountability, as well as to complete transfer requests.

Work with the emergency department to find ways to facilitate the process of transfer of accountability. Work with Patient Transport to optimize the deployment of porters to minimize the time required to complete the transport requests

Average time from the reserved bed available to the time a transport request is placed Average time required to complete transport request from the emergency department to inpatient units/operating rooms

Reduce time to complete transport request by 10%

Prioritize operating room cases in the emergency department

Work with OR and related services to develop a prioritization matrix for operating room patients in the ED to reduce length of stay.

Average length of stay for emergency department patients awaiting surgery

Reduce emergency department length of stay by 10%

Explore the patient perspective to understand and identify further opportunities for improvement in the processes and experience of transfer from the Emergency Department to inpatient wards

Conduct a focus group or survey of a sample of patients admitted through the Emergency Department who experienced long wait times for an inpatient bed to determine opportunities for improvement. Review verbatim comments from the patient experience surveys to identify any further opportunities for improvement related to the transfer at admission processes.

Identification and implementation of patient-focused improvements

At least 1 change idea is identified by patients and implemented by March 31st, 2020.


Total Margin

AIM MEASURE


Efficient Improve

organizational

financial health

Total Margin (consolidated): Percent,

by which total corporate

(consolidated) revenues exceed or fall

short of total corporate

(consolidated) expenses, excluding

the impact of facility amortization, in

a given year.

2.11%

Q2 2018/19

≥ 0%

Maintaining a balanced budget

(expenses do not exceed revenues) is

a greater and different challenge

each year and continues to be a top

priority for the hospital.

CHANGE


Improve the patient experience, and increase revenue from patients accessing Hearing Services at Sunnybrook by:

Improving the Hearing Services clinic accessibility

Improving the rate of hearing aid sales to patients

Increase the new patient volumes accessing products and services

The Executive lead will receive progress reports developed by the Sustainability Program Office. Once implemented, monthly financial review will include the variance analysis against the revised budget

Increase rate of hearing aid sales to industry average

Expand the sale of hearing aid and cochlear implant accessories

Increase of 10% in F19/20 gross revenue from F18/19 actual

Optimize implementation of bundle care model to ensure financial sustainability

Develop working groups and integrated clinical pathways to ensure that new bundle care model such as the Hip & Knee Bundle can be implemented with no financial risk to the organization.

Minimize the financial risks to the organization

No deteriorating financial outcome for the bundle care (base line = F18/19)

Explore options to improve non-Ministry revenue

Continue to expand retail and other opportunities by scaling existing services, delivering new services, and re-assessing offered prices and costs to increase net revenue to the organization.

Increase in net margin (net revenue over expenses)

Increase net margin over F18/19 actual

Reduce wastage of commonly used point-of-care supplies (for example gloves and wipes) by introducing new policies and procedures for stocking supplies in patient rooms

The Executive lead will receive progress reports developed by the Sustainability Program Office. Once implemented, monthly financial review will include the variance analysis against the revised budget

Implementation of new policies and procedures related to waste management

Implementation of new procedures or best practices for reducing supplies waste.

Reduction of waste with phased approach in the top identified categories found through waste audits conducted in 18/19

1

Updated January 24-19


Workplace Violence Prevention

AIM MEASURE


Safe Reduce harm to staff

Number of workplace violence incidents (overall) reported by hospital workers within a 12-month period.

Note: workplace violence incidents are reported via the incident reporting system.

Note: Definitions for the terms “worker” and “workplace violence” will be those in the Occupational Health and Safety Act (OHSA, 2016).

(January – Dec 2018) 1212

The inclusion of the following information is requested by HQO (to support QIP analysis and interpretation):

As of November 14, 2018, Sunnybrook has 6058.54 full-time equivalent (FTE) employees, 586 active acute care beds and 530 long-term and complex continue care beds.

Fiscal year 2019/20 we have set a target of 1,500

With continued efforts to identify and address workplace violence, it is projected that the number of overall workplace violence incidents will continue to rise in 2019-20.

Education and emphasis on patient safety care plans are enhancing awareness across the organization. Additionally high occupancy can negatively impact patients with conditions that can lead to behaviours that put others at risk (e.g. trauma and dementia). Note that our incident data includes volunteers.

Sunnybrook’s main focus continues to be on reducing events that result in harm, with the goal to decrease lost time incidents per quarter by 10% (from .58% to .52%). This metric will be a part of our ongoing reporting.

2


CHANGE


In our effort to address staff safety and ensuring appropriate clinical care post violent incident, we will continue to monitor that the Framework for Responding to Reported Violent Incidents is being followed. Standard violence interventions are initiated by the unit at the time of a first incident. This year's focus will be on ensuring the implementation of the patient safety care plan after all repetitive incidents and/or actual/potential serious harm incidents as per the hospital's Safety Report - Reporting & Learning from Safety Events policy. Until electronic patient health record documentation is launched we will be focused on an alternative electronic strategy to have the patient safety care plan on-line in a printable format and formally secured in the patient's health record.

Completed patient safety care plans will be included by the PCM/ delegate/Risk management in the electronic incident report and the patient’s health record (for repetitive and/or actual /potential serious harm incidents).

% of patient safety care plans completed after repetitive incidents and/or actual/potential serious harm incidents

Target: 100% of required Patient safety care plans are completed.

Continued focus on Non-violent Crisis Intervention education to high risk areas and teams

Recertification is a biennial requirement; therefore, results will be reported on that basis with an interim report.

Review data to update the high risk areas

Re-evaluate the education format to enhance uptake of staff participation.

Continue to monitor staff attendance via the Learning Management System and share results with leaders.

2 High Risk Areas are the Emergency Department, Veterans

The Emergency Preparedness Team will report progress quarterly to the Emergency Preparedness Steering Committee and the Operations Directors to ensure accountability in reaching targets.

Percentage of Active Staff assigned on a regular basis in high risk areas that attend a non-violent crisis intervention education session. Denominator: Count of Active Staff as of April 1, 2019.

Target: 90%

3


CHANGE


Centre units (Dorothy Macham, LGSE, LGSW, LSSE, and LSSW) and acute care units C5, D5, and F2 (Mental Health). 2018-19 Q1 – Observers have been added to the high risk group based on reported incidents.

Continue to support practice change to enhance violence prevention with staff. Admitted patients in the Emergency Department will continue to have an Observed Behavioural Assessment completed in the patient's health record. To increase compliance this tool has been included in the permanent patient care record in year 2019 and will continue to identify:

Patients who have a history of, or have demonstrated behaviour that puts others at risk and

De-escalation care strategies that can be used to address the behaviour

On 2 units (1 pilot unit engaged in violence prevention work in 2018/19 and an additional unit) implement a unit-based care planning process for the identified behaviour and more intense care interventions for prevention / mitigation.

Senior friendly lead will report progress to the High Risk Behaviour and Observers Advisory Committee for discussion and recommendations and the Joint Occupational Health and Safety Committee for the purpose of engagement and feedback

% of admitted patients in the Emergency department who have a completed Behavioural Assessment and Care Intervention tool % of admitted patients from the Emergency department who have a history of or have demonstrated behaviour that puts others at risk, who have a completed care plan on the two inpatient units

Target: ≥75% of required Behavioural Assessment and Care Intervention tools are completed Target: ≥60 % of required care plans are completed

Develop a flagging protocol to identify patients at high risk for violent behaviour. It is recognized that this is a sensitive ethical issue that will require significant consultation, inter-professional collaboration and leadership to establish the rigour for success.

Occupational Health & Safety, Risk Management and Senior Friendly and will continue to participate in this work.

The oversight committee and leadership have been established. A Terms of Reference

Completed by March 31, 2020

4


CHANGE


Occupational Health and Safety and Risk Management will co-lead the development of a committee including Ethics and Mental Health; develop a terms of reference and outline the scope of work to develop a patient-centred flagging protocol. This will be done in consultation and collaboration with community and family partners.

prepared. Outline of the process to flag patients developed.

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