Quality Improvement Plan 20/21 Workplace ViolenceQuality Improvement Plan 20/21 Workplace Violence...

Quality Improvement Plan 20/21 Workplace Violence

AIM MEASURE Quality

dimension Objective Indicator Current performance Target for 2020/21 Target justification

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 2019) approximately 1251 The inclusion of the following information is requested by HQO (to support QIP analysis and interpretation): As of December 19, 2019, Sunnybrook has 6671 full-time equivalent (FTE) employees, 586 active acute care beds and 530 long-term and complex continue care beds.

Going forward, this QIP will be reported by fiscal year. For fiscal 2020/21 the target will be reduced from 1500 to 1,250

We believe that the capture of workplace violence incidents has now been standardized and is a regular part of expected incident reporting. As a result we are not expecting to see increased volumes as a result of reporting compliance. Therefore, the target for number of incidents has been reduced from the last fiscal year. 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 Incident Frequency Rate be less than or equal to the previous quarter.

CHANGE

Change Ideas Methods Process Measures Goal for Change Ideas

A core pillar of this QIP continues to be on providing Non-violent Crisis Intervention education to high risk areas and teams. The high risk areas are recalculated annually Code White incident Rate (Number of Code Whites per 100 workers) and based on those units/departments that have 20 or more workers/100 involved in a Code White to ensure that high risk areas receive the support and training they require to manage safety. This education includes: • Recertification is a biennial requirement; therefore, results

will be reported on that basis with an interim report. • Continue to monitor staff attendance via the Learning

Management System and share results with leaders. 2 2020-21: High Risk Areas are the Emergency Department, Dorothy Macham (LDMH), and acute care units, C5, D5, F2/PICU (Mental Health) and Security.

NVCI Training Q3 2019/20 Data

Department

Code White Incident Rate

Total # Completed

Total # of Active Staff

Percent

Emergency Dept 51% 57 132 43.2 Dorothy Macham (LDMH)

27% 15 20 75

C5 64% 38 56 67.8 D5 28% 34 58 58.6 F2/PICU (Mental Health) 113% 46 59 78 Security N/A 19 28 67.9

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 or security training every other year. *Staff included in the denominator are active staff as of March 31, 2021

Target: >80% of staff assigned in high risk areas calculated on March 31, 2021.

CHANGE


The Workplace Violence Committee has struck a sub-committee (including physicians and a patient) which will develop a patient-centred flagging protocol. IT will be engaged in terms of how to leverage current computer system to support the flagging. This will be done in consultation and collaboration with community and family partners.

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

Flagging protocol has been developed.

Completed by March 31, 2021

Partner with Quality and Patient Safety to undertake a systematic review of aggressive and abusive patient incident reports to identify actionable themes. These will help inform NVCI training.

Quality and Patient Safety to provide semi-annual report to the Workplace Violence Committee and Emergency Preparedness.

Process for reporting is in place and 1-2 themes identified and incorporated into NVCI training.

Completed by March 31, 2021

Quality Improvement Plan 20/21 Hand Hygiene

AIM MEASURE Quality


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

Hand hygiene compliance, reported as a percentage, measured using E-monitoring across the 16 specified medical, surgical and critical care units throughout the 2020/21 fiscal year. Numerator: the number of times that healthcare providers (nurses, residents, physicians, allied health, Environmental Service Partners, and Patient Service Partners) clean their hands. Denominator: the expected number of hand hygiene opportunities per day.

1) Current performance of medical and surgical units (B4, C2, C4, C5, C6, D2, D3, D4, D5, and D6) is 60.1% for Q1/Q2 19/20. 2) Current performance of critical care units (B5ICU, CICU, CRCU, CVICU, D4ICU and RTBC) for November and December 2019 is 40.1%.

Average performance of all units in Q4 2020/21 > 65%

During 2019, the ten medical and surgical units maintained an overall hand hygiene compliance of approximately 60%. Improving this to 70% for 2020/21 is their target. Previously, units new to E-monitoring have improved their performance 15-20%; a similar improvement is expected across the new critical care units. We selected > 65% as the overall indicator target which combines the sub-targets for the two groups of units: 1) > 70% overall performance

across our 10 units with prior experience with interventions

2) > 55% overall performance

across our six new critical care units.

CHANGE


Implement/continued provision of weekly E-monitoring feedback reports that provide hand hygiene compliance for the prior week to front-line staff in critical care units, and continue to provide these reports to medical and surgical units. These reports will be sent electronically to leaders and champions of each participating unit. The hand hygiene performance will also be posted on a large

Infection Prevention and Control has a system in place so that feedback reports are automatically generated and pushed to all hand hygiene champions, Team Leaders, Advanced Practice Nurses and Patient Care Managers for the unit to

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

• 100% of unit leadership

• >50% of the front-line staff on E-monitored units

CHANGE


poster at the entrance to each unit. share with all staff.

Ensure that hand hygiene performance, based on E-monitoring feedback, is discussed on existing and new units at a minimum of one Quality Conversation per month per unit for at least 5 minutes, in order to empower unit staff to identify opportunities for iterative changes* that promote better hand hygiene compliance (for units performing below target), or ways to maintain high compliance rates (for units performing at or above target). *Examples of iterative changes arising from huddles may include walk-arounds to identify specific physical locations where hand sanitizer location may be optimized to improve workflow, reviewing hand hygiene data at specific times of day to correlate with patient care activities, changes in placement of gloves to promote appropriate use of gloves, etc.

Quality Conversations are organized by unit managers and supported by Infection Prevention and Control (IP&C). These conversations are attended by most clinical staff on the unit. In addition, weekly meetings will be hosted by IP&C for unit managers and hand hygiene champions to allow them to share their change ideas, successes and challenges with each other within Sunnybrook and with other hospitals across the HH-IMPACT network.

Frequency and content of weekly Quality Conversations will be recorded by unit leadership and IP&C.

New critical care units: At least 1-2 new ideas or lessons are generated on each unit every month. These will be monitored by IP&C and shared with other units through the weekly HH-IMPACT network meetings to drive improvement. Existing medical and surgical units: To foster an environment where change ideas are welcome and quality conversations remain a platform for engagement

Units who have maintained a high rate of hand hygiene compliance (e.g., > 80% for 3 months or longer) will be supported to create an action plan^ to be initiated if hand hygiene rates fall below a pre-determined target (e.g., 80%). ^Examples of items to be included in action plans may include increasing frequency of unit conversations about hand hygiene, analyses of root causes of decreased compliance, e-mail reminders to staff, etc.

High performing units will be supported by IP&C to create a written individualized action plan to be initiated if hand hygiene rates fall below a pre-determined target.

% of high performing units who have created a written individualized action plan for managing decreases in hand hygiene compliance.

Implementation of action plan results in an increase in hand hygiene compliance rates on affected unit to previous high compliance rate.

CHANGE


Each critical care unit will set a 1-month and 3-month goal for hand hygiene compliance. Goals for medical and surgical units are in place and the need to increase goals will be monitored.

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

• posted on Quality boards • included in Feedback Reports • shared with the unit and hospital

leadership

Unit goals will be tracked on monthly corporate E-monitoring reports.

To set a monthly E-monitoring goal at least 10% above baseline at the start of each month for critical care units. To set a 3-month E-monitoring goal at least 10% above baseline every quarter for critical care units. To increase medical and surgical unit goals once they have consistently met their current goal for a period of three months.

Create a formal role for patient engagement in hand hygiene improvement activities by identifying, and engaging a patient who has been affected by a hospital-acquired infection and providing them with hand hygiene education so that they can attend and participate in unit quality conversations and HH-IMPACT network teleconferences on a quarterly basis. The patient may share their story of hospital-acquired infection informally or via formal presentation.

IP&C will seek out an appropriate and willing patient partner and provide them with hand hygiene education in order to support them to:

• Attend and participate in unit quality conversations (with IP&C support)

• Attend and participate in HH-IMPACT network teleconferences

Number of quality conversations and HH-IMPACT network teleconferences attended by a patient partner per quarter.

To bring the patient perspective directly to front line staff to emphasize the importance of performing hand hygiene and the potential consequences of low compliance.

Quality Improvement Plan 20/21 Hospital Acquired Pressure Injury

AIM MEASURE Quality


Safe Reduce the incidence of Hospital Acquired Pressure Injuries (HAPI)

% of patients with a newly acquired pressure injury stage 2 and above while in hospital. Denominator Total number of patients in acute care and critical care Numerator Number of patients with a new hospital acquired pressure injury in acute care and critical care Exclusions • Patients with a pressure injury on admission to

Sunnybrook. • Patients not admitted to acute care or critical

care at the Bayview Campus, Reactivation Care Centre or Holland Centre

Annual prevalence data measured from February 2019 across Acute Care and Critical Care at the Bayview Campus and the Holland Centre. February 2019 Sunnybrook prevalence study rate – 7.9%

Reduce the incidence of HAPI, excluding stage 1 to < 5.6% in Q4 2020/21

5.6% is a stretch target. The current Canadian benchmark for HAPI excluding stage 1 is 5.6% Sunnybrook currently participates in a yearly prevalence assessment to measure HAPI, each February via Hill-Rom’s International Pressure ulcer Prevalence Study. In addition to this data collection method, quarterly spot check prevalence via the same methodology will be conducted to track progress.

CHANGE


Enhance the capacity of the interprofessional care teams and unit leadership through education to complete high quality assessments, implement evidence based and patient focused prevention strategies, treatments and engage in monitoring for improvement.

The Complex Wound Consultation Service team in partnership with the Wound, Ostomy and Continence Steering Committee (WOC SC) will provide leadership and support the following : 1) HAPI –Leadership for Harm Reduction

Series for unit based Advanced Practice Nurses (APNs) and Clinical

1. Percentage of unit based APNs, and CEs that participate in the HAPI – Harm Reduction Series

2. Percentage of interprofessional Wound Care champions,

70% of unit based APNs, and CEs, will participate in the Leadership for Harm Reduction Series- Hospital Acquired Pressure Injury 70% of Interprofessional Wound Care champions will complete advanced

CHANGE


Educators (CE), which support leaders to embed harm reduction principles, strategies and evidence into their leadership strategies

2) Targeted, local pressure injury assessment, prevention and treatment education with the IP team facilitated by APNs and CEs and local volunteers. a. WOC SC will create competency

recommendations to integrate into ongoing orientation for health professionals to support sustainability.

3) Unit Champions education to support

colleagues with HAPI prevention strategies and management

4) Corporate communication strategy to disseminate broad HAPI evidence based prevention and assessment recommendations implemented in collaboration with Communications (Laura Bristow)

5) Create and sponsor a targeted HAPI TAHSN Clinical Fellowship for 2020 to conduct specialized practice-based projects to reduce HAPI rates.

participate in advanced education to support colleagues with HAPI Prevention and Management Strategies.

3. Monthly education tips will be disseminated to the interprofessional team

4. Number of user hits to the tip of the month shared on Sunnybrook Intranet

education 12 monthly education tips will be released. 100 monthly user hits

Patient and families receive education about pressure injuries, including their personalized risks; an overview of PI; the importance of strategies to reduce risk (e.g. mobilization); and who to contact on the Sunnybrook team in the event of a concerning change (per Health Quality Ontario Guidelines).

The WOC SC will create a communication plan in collaboration with the Communications team, and volunteer patient and family partners to disseminate the Patient Education Pamphlet focused on prevention of PI, and individualized care plan strategies. An online location will be identified and developed to enable easy access to the brochure and additional patient and

The Patient Education Pamphlet will be accessible in print and online. Patient Education Pamphlet provided to patient identified as high risk for pressure injury development as per Braden Screening and their family in critical care and acute care – Bayview campus.

The Patient Education Pamphlet will be accessible in print and online 70% of patients identified at risk of developing a pressure injury will receive the pamphlet with their personalized care plan in critical care and acute care – Bayview Campus.

CHANGE


team, education resources

Evaluate the number of HAPI that originate within the admitted Emergency Department (ED) patient population and develop recommendations to support at risk patients.

A collaborative working group with representation from the ED clinicians and APN/CE or PCM and the WOC SC will develop an evaluation strategy to identify the incidence of HAPI that occur in the ED and recommendations to address evaluation results.

Evaluation strategy will be developed and implemented with quantification of need, including HAPI rates for admitted patients.

Evaluation strategy implemented with baseline HAPI rates for admitted ED patients.

Patients who are identified at risk of pressure injury are placed on the appropriate pressure relieving surface, both bed and chair, to reduce risk.

1) Develop an integrated surface management strategy with SPEC and Capital Service Delivery to ensure appropriate surfaces are available and maintained.

2) The Complex Wound Consultation Service team, in partnership with the Wound, Ostomy and Continence Steering Committee (WOC SC), will develop and disseminate decision support aids for the interprofessional team to assist with identifying appropriate surfaces for patients based on risk status

Surface management system implemented across all inpatient campuses. The surface decision support aids will be created and accessible in print and online.

All inpatient campuses will implement the surface management strategy for beds, stretcher and wheel chairs. Decision support aid online by March 2021

Quality Improvement Plan 20/21 Advance Care Planning and Goals of Care

AIM MEASURE Quality

Dimension Objective Indicator Current performance

Target for 2020/21 Target justification

Effective Increase the number of COPD, CHF, CAP, Oncology, Nephrology, and select Trauma* patient inpatient encounters with a new or updated Advance Care Plan (ACP) or Goals of Care (GOC) note documented in SunnyCare. For those acute patients, with life limiting 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.

*Trauma patients will be screened for eligibility for ACP/GOC.

Percentage (%) of COPD, CHF, CAP, Oncology, Nephrology, and select Trauma patient inpatient encounters with either of the following:

• A new or updated Advance Care Planning (ACP)/Goals of Care (GOC) note documented in SunnyCare during the inpatient encounter in the reporting period

• An existing Advance Care Planning (ACP)/Goals of Care (GOC) note documented in SunnyCare within the last year of the inpatient encounter.

Numerator: Number of COPD, CHF, CAP, Oncology, Nephrology, and select Trauma patient inpatient encounters with either of the following:

• A new or updated Advance Care Planning (ACP)/Goals of Care (GOC) note documented in SunnyCare during the inpatient encounter in the reporting period

• An existing Advance Care Planning (ACP)/Goals of Care (GOC) note documented in SunnyCare within the last year of the inpatient encounter.

Denominator: Total number of COPD, CHF, CAP, Oncology, Nephrology, and select Trauma patient inpatient encounters during the reporting period.

Baseline: 15.95% 19/20 (Q1, Q2 and Q3 combined) Note: baseline does not include Trauma patients.

20.73% of inpatient encounters with new, updated or existing ACP/GOC note documented in SunnyCare in Q4 2020/21.

Aiming for a 20.73% target will require greater collaboration between different clinical groups, additional investment in education and awareness programming. Target is a 30% increase from 19/20 baseline of 15.95% (19/20 - Q1, Q2 and Q3 combined)

CHANGE


1. System Partnership Continued leadership of the North Toronto Sub-Region (NTSR) Palliative Care Journey Committee comprised of provincial, LHIN, community and hospital provider stakeholders to implement a three-year Palliative Care Action Plan. Through cooperation with committee partners, implement the 4 change ideas identified through stakeholder engagement and quality improvement methodology in FY 18/19:

1) Sharing ACP/GOC information with partners across the system

2) Create a system pathway to identify palliative needs

3) Create a North & East Toronto “Code Palliative” for urgent palliative care needs

4) Educate the public about palliative care

Year 2: Co-chairs of the Palliative Care Journey Committee will lead the implementation of the three-year plan, reporting to the Interprofessional Quality Committee.

Process measures and data collection plans for will be identified as project plans for change ideas are refined in Q4 19/20.

Implement 4 system partnership change ideas by March 2021. NTSR Palliative Care Journey Committee bi-monthly meetings (Target: 5 meetings held in 2020/21)

2. Build Capacity in Health Care Teams for Advance Care Planning (ACP), Goals of Care, and End of Life Conversations In collaboration with Organizational Development and Leadership, Division of Palliative Care, and Veteran’s Centre, increase enrollment of staff and system partners in formalized capacity building education offerings focused on: • Person Centred Approaches to Care • Advance Care Planning and Goals of Care

Conversations • End of Life Conversations

Director of Interprofessional Practice will report to Palliative Care Journey Committee quarterly on the number of learners who complete the training. Facilitate electronic access and enrollment through Learning Management System (LMS), identification of key staff groups for training, and refined education offerings focused on key topics across the spectrum of palliative care.

Total number of staff and system partners trained Improved knowledge and preparedness of health care providers to facilitate/engage in ACP, identification/assessment of palliative needs, End of Life Conversations will be measured by pre/post scores on a knowledge test. Integrate the regionally approved template for documentation of Advance Care Planning and Goals of Care into staff training.

200 staff and system partners trained by March 2021. 30% improvement in self-reported knowledge scores post education

CHANGE


3. Ensure timely care is matched to palliative needs Ensure level of care offered is matched to palliative patient needs, and care is accessed in a timely manner. Focus on timely transitions from Emergency Department for two populations not requiring acute care admission: • Patients requiring admission to Palliative Care Unit • Patients requiring outpatient, community, and OHT

services

Facilitate timely transitions from the Emergency Department (ED) to the Sunnybrook Palliative Care Unit (PCU) for PCU-ready patients. Reduce acute care admissions for patients requiring support for access to outpatient, community, or OHT services.

Reduce acute care admissions for PCU-ready patients (patients with PCU application) From Palliative Care Consult Team (PCCT) data: Decrease the proportion of patients arriving in ED requiring transitions to outpatient, community, and OHT services who are admitted to acute care from 36% to 30%. (Denominator: patients known to clinic, have PCU application for palliative community services, or received PCCT consult)

From PCCT data: Baseline: n=22, or 6% of patients seen by PCCT From PCCT data: Baseline: 36% Goal: 30%

4. Establishing Standardized Processes and Pathways for Palliative Oncology Patients The newly established Odette Palliative Care Advisory Council will help guide priorities for standardization of processes and pathway for palliative oncology patients. These priorities include, but are not limited to:

- Increasing standardized documentation of ACP and GOC conversation in both inpatient and outpatient settings

- Establishing patient and family preferences for ACP and GOC conversations to help guide these processes

- Establishing trends of oncology patients dying in acute care to address gaps in precedent care, both in the community and ambulatory settings. Theses gaps will help inform new models of care, including potential urgent palliative care models

a) Chart review of oncology patients dying in Sunnybrook acute care settings in 2017. Establish trends and gaps.

b) Patient and family survey for establish preferences for GOC and ACP conversations

c) QI project lead by oncology

medical residents to improve standardized GOC/ACP conversation documentation using the SunnyCare ACP/GOC tab/template

a) Chart review will help establish gaps and goals for change. Due for final analysis in Jan-Feb 2020.

b) Goal to align current ACP/GOC conversations in ambulatory oncology settings based on patient and family preferences identified through patient and family survey conducted in FY 19/20.

c) ACP/GOC documentation project first

PDSA planned for Feb 2020 – potential interventions include dictated ACP/GOC note type to mirror typed ACP/GOC tab with clinician KT, reminders, and audits. Process measure will be % of lung and GI stage 4 patients admitted that had ACP/GOC

b) Goals TBD based on analysis of

patient and family survey (to be presented January 2020)

c) ACP/GOC documentation:

Initial chart review of 150 patients found 40% had ACP/GOC documented using template within 3 months of final admission. Goal to increase to 65%.

CHANGE


- Improving access to community palliative care supports for cancer patients while bypassing acute care/ED

note dictated or typed in previous 12 weeks. May expand to patients starting 3rd line therapies.

5. Increasing ACP/GOC conversations for positively screened admitted Trauma patients

Leverage learnings from the Practice-Based Research Fellowship pilot of a screening tool to identify appropriate Trauma patients for ACP/GOC conversations, and prompt an ACP/GOC conversation for positively identified patients. In FY 2020/21, implement the screening tool for all Trauma patients admitted to CRCU, B5ICU, C5, and D5.

Support CRCU, B5ICU, C5, and D5 with implementation of screening tool

Promote documentation of ACP/GOC in the ACP/GOC tab in SunnyCare

Process measure: Compliance with screening tool for all Trauma patients admitted to CRCU, B5ICU, C5, and D5. (Based on Trauma registry data) Outcome measure: Proportion of Trauma patients positively identified through the screening tool that receive an ACP/GOC conversation within 1 week of screen. (Based on Trauma registry data) Baseline: 28.4%* (July-August 19/20) *based on proxy criteria to approximate appropriate population, as screening tool has not yet been implemented.

Screening tool will be administered to 60% of Trauma patients admitted to CRCU, B5ICU, C5, and D5 70% of positively screened Trauma patients have an ACP/GOC conversation within 1 week of screen

6. Sustaining improvements in ACP/GOC documentation Support teams that care for COPD, CHF, CAP, Oncology, Nephrology, and Trauma patients to sustain improvements in ACP/GOC documentation gained through change ideas implemented in FY 19/20.

Utilize audit and feedback to keep teams informed of their team results of ACP/GOC documentation. Share data at Quality Conversations for discussion with the interprofessional team, where applicable.

Distribution of team-specific ACP/GOC documentation data for COPD, CHF, CAP, Oncology, Nephrology, and Trauma patients.

Data will be distributed to key teams on a quarterly basis.

CHANGE


(*) 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 having an ACP. For admissions and discharges prior to the first ACP note creation date, those would not be counted as discharges with an ACP.

Quality Improvement Plan 20/21 Wait Time for Inpatient Bed

AIM MEASURE Quality


Timely Transition patients to inpatient units or operating room as quickly 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.

Fiscal Year 2018/2019: 33.6 Hours Q1 2019: 37.4 Hours Q2 2019: 36.5 Hours Q1,Q2 Average: 36.8 Hours

33.1 hours in Q4 2020/21 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


Conduct analysis to identify why Sunnybrook Health Sciences Centre Time to Inpatient Bed performance is significantly higher when compared to Toronto Central LHIN peers.

Manger of Patient Flow will work with Decision support to conduct data analysis. Contact peer hospitals to gain insights into operational efficiencies and processes that could be leveraged at Sunnybrook.

Translate findings into a report highlighting actionable recommendations.

Share findings with the Director of Patient Flow and the Integration and Implementation Committee.

Prioritize and select one new improvement strategy based on findings of the peer analysis.

Report created and presented New improvement strategy identified and implemented by March 31st, 2021

Patient Flow office will encourage and prompt the movement of patients with ED Length of Stay greater than 30 hours.

Patient Flow office will initiate review of patients with ED Length of Stay greater than 30 hours on a daily basis. This will be integrated into patient flow daily rounds

Number of eligible patients reviewed daily

100% of eligible patients reviewed daily

CHANGE


Expedite movement of patients with an available inpatient bed Manager of Patient Flow will lead the design and development of notification system to enhance visibility on inpatient wards regarding patients with an available and assigned bed, to help develop a “pull” culture. This will be developed as part of the ED/PACU to inpatient ward Working Group.

90th percentile time from “bed ready to patient transfer complete” for admitted patients in ED.

1 hour (this is a stretch target) Current performance is 2.5 hours

Enhance visibility of factors impacting time to inpatient bed for patients in ED.

Manager of Patient Flow will work with Decision Support to develop a dashboard with indicators impacting time to inpatient bed for patients in ED.

Performance monitoring dashboard report will be reviewed by members of the Integration and Implementation Committee:

• 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 2020/21

Listen and act on patient reported feedback

Partner with the Office of the Patient Experience to identify complaints related to ED admission wait times and use that data to identify opportunities.

Number of patient complaints related to ED admission wait times Prioritize and select at least 1 new improvement strategy based on review

At least 1 change idea is identified by patients and implemented by March 31st, 2021.

Enhance the flow of Alternate Level of Care (ALC) patients from the Bayview site by enabling systems real time tracking

Develop a bi-directional interface from Sunnycare to Resource Matching and Referral. This is expected to impact documentation efforts and reduce time and efforts required to document i.e.

Number of ALC patient discharges from the Bayview site. (Exclude discharges to St. John,

Increase number of ALC patient discharges to 46 weekly. Current performance is 44

CHANGE


double documentation will no longer be required. Develop a bi-directional interface from Resource Matching and Referral to Information Management. This will positively impact business processes as it will allow ALC referral status updates to be “pushed” to the end user.

Holland and RCC)

ALC patient discharges weekly.

Quality Improvement Plan 20/21 Cancer Surgery Wait Time

AIM MEASURE Quality


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

86% of Priority 2,3& 4 cases achieving target wait time (Q3 2019/20)

90% of Priority 2, 3 & 4 cases achieving target wait time in Q4 2020/21

Current Cancer Care Ontario target is 90% for priority 2, 3 and 4 cases.

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 of cancer patients]

- Evaluate results of the 2019/20 pilot space in C606 Monday to Friday 8 hrs per day, staffed by a Physician Assistant, to project the potential impact of the C Ground space.

- Incorporate feedback from 2019/20 engagement of Patient & Family partners from the Odette Centre Patient & Family Advisory Council into the design and evaluation of the permanent C Ground off-hours urgent care model.

Number of cancer patients registering in the ED Number of admissions via ED for cancer patients

Assess and determine with data collection the types (reason for admission) and how many admissions are avoided (Mon to Friday) and how many others could have been avoided with dedicated space 24/7. C Ground to open 2021 Determine the # of admissions and where the patients come from i.e. home, emergency department, clinic and other locations.

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

(projected for March 2020 due to funding) - Relocation of MCUE (ICU beds) out of Post-Anaesthetic

Care Unit (PACU) to restore recovery room capacity to 16 beds

Number of OR cancellations due to No Bed

44 OR cancellations due to No Bed

CHANGE


- Explore ongoing opportunities for reducing surgical length 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 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 20/21 Conversations with Patients (CWP)

AIM MEASURE Quality


Patient-Centred

Increase the number of “Conversations with Patients*” that are held across the organization. *Conversations with Patients (CWP) is an opportunity for Sunnybrook staff, physicians, students and volunteers to talk with patients in real time about their experiences, hear their stories, learn what is important to them, and then act as teams to enhance care based on the shared information.

Number of Conversations with Patients (CWP) held with patients and families across all Sunnybrook campuses, including both inpatient and ambulatory care settings.

Currently staff are engaging 252 patients/families per month in CWP. This represents Sunnybrook’s focus and intention to learn more the experiences of patients and their families. Through face to face dialogue team members hear how we consistently engage patients and families through relationships, act on what is most important to them, using a compassionate approach. In the upcoming year, with the addition of a new team question, we will additionally learn about the patient and family experience of how well their team worked together. 756 quarterly average (April 1 – Nov 30 2019)

3,175 between April 1, 2020 and March 31, 2021 (5% increase based on current quarterly performance)

The target has been established at a 5% annual increase and will require intensified collaboration with Programs and clinical settings, both inpatient and ambulatory to engage more patients and families in conversations each month. In this annual cycle learners and students will additionally be engaged to participate in conversations.

CHANGE


Increase the number and frequency of Conversations with Patients interviews

Interprofessional Practice will collaborate with program leadership to sustain the implementation plan for Conversations with Patients, which includes program specific targets for completion of Conversations with Patients. The plan includes:

• Sharing of tools and resources including paper template, web form, script, thank you cards for patients and families

• Development and sharing of tools and resources (e.g. demonstration video, thank you cards) to ensure there is consistency in engaging patients and families in Conversations with Patients

• Define number of conversations will be completed in various care settings, including both inpatient and ambulatory care

• The number of Conversations with Patients occurring quarterly

• 793 Conversations with Patients to occur quarterly from across patient care areas

Collaboration with Interprofessional Education to integrate identified Team Assessment Questions into Conversations with Patients interview guide. Interview Guide will be integrated into all new Team Assessments to ensure that patient/family feedback can inform Team Assessment process.

Revise Conversations with Patients support materials to include Team Assessment questions. Pilot test and obtain baseline data to confirm improvement targets for 20/21. Train existing Conversations with Patients participants to the new version

• Team Assessment questions will be integrated into interview guide, interview guide will be pilot tested and baseline data will be collected.

• Baseline data and improvement target will be identified.

Collaborate with Interprofessional Education to invite student learners to participate in Conversations with Patients.

Students will be provided with tools and resources to engage in CWP, as part of their onsite learning experience. Students will be supported by Preceptors and Professional and Educational Leaders to review and debrief conversations, contributing to ideas for quality improvement and advancing their own personal development through reflective practice.

• Number of students/learners who engage in CWP

• 25 students will participate in CWP

Review Conversations with Patients’ feedback on units and care areas and profile improvement actions taken every two months.

Several strategies will be used to facilitate this: 1. Process to capture data from paper tool to be

created

• # of stories of

improvement/changes in

• 100% of feedback

shared with units & program monthly

CHANGE


2. Results to be shared with all programs on a monthly basis through the Business Intelligence platform.

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 engagement learnings to Quality Conversations on their respective units.

4. Units and programs will review and act on feedback provided by patients, 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

response to patient feedback

• Organizational profiling of action taken to respond to patient feedback

• Four Nursing Council engagements in having Conversations with Patients, debriefing, theming and sharing results

• Six profiles of teams across programs in Sunnynet acting on the feedback provided by patients

Develop and pilot a new tool to measure patient experience. The tool will include subjective feedback from patients and objective measures indicating an optimal patient experience designed specifically for each patient care area.

1. Develop a patient experience measurement tool ‘prototype’ with input from staff and patients and the Quality and Performance Committee of the Board

2. Pilot the tool in three patient care areas over the year.

3. Analyze (evaluate) the use of the tool, with the intent to adapt and spread the use of the prototype

• Prototype developed • Piloted on three patient

care areas • Develop evaluation

strategies

• Create a patient experience measurement tool that includes objective and subjective indicators of performance that can be measured and improved in ‘real time.’

Share stories of Person-Centred Care throughout the organization to reinforce behaviours and situations that positively impact patients' experiences

1. Collect and curate stories from all parts of the organization

2. Incorporate story-sharing time into agendas during corporate and unit level meetings

3. Debrief story sharing moments to allow members to link story outcomes to purpose, strategic priorities and organizational values

4. Use Most Significant Change methodology to identify stories that showcase Person-Centred Care principles

• Number of stories collected per quarter

• Number of corporate

committees where stories are shared

• Qualitative feedback and report on the value of story-sharing activities

• Identify three stories (using Most Significant Change methodology) that

• Using storytelling to promote (patient experience focused) culture and awareness at all levels of the organization

• Double the number of corporate committees where stories are shared

• Incorporate storytelling as a skill that values patient feedback, builds team listening,

CHANGE


best illustrate Person-Centred Care

understanding and communication, and supports change

Quality Improvement Plan 20/21 Connected Care and Navigation

AIM MEASURE Quality

Dimension Objective Indicator Current performance

Target for 2020/21 Target justification

Efficient Increase the total number of patients, who are seen by and/or have their care coordinated by the Sunnybrook Connects Team* enabling access to care coordination, communication and safe and supported transitions to the community.

*Sunnybrook Connects is an innovative model that was designed in collaboration with patients, families and system partners to improve the coordination, continuity and integration of care both within the hospital and community setting, through two streams of care including the Emergency Department (ED) One Team and My Healthcare Navigators. By enabling access to this connected model, the experience for patients with high complexity care needs and their families will be improved. ED One Team is an interprofessional team of health professionals, community and homecare partners embedded in the ED to facilitate safe and supportive transitions to the community for patients presenting to the Emergency Department. MyHealthcare Navigators work with patients with high complexity needs and their health care teams to ensure

The total number of number of patients seen by and/or have their care coordinated by the Sunnybrook Connects Team. Patients who may be referred include those with:

• Multiple visits to the Emergency Department or admissions to hospital

• Risk of re-admission to hospital • Ambulatory Care Sensitive conditions

(e.g. Congestive Heart Failure, Chronic Obstructive Pulmonary Disease)

• Opportunities to improve connections with Primary Care or community/social supports

• Impacted by Social Determinants of Health (e.g. social supports, coping skills, physical environments, access to health services)

194 patients/month (December 2019 data)

The ED One Team saw 174 patients (December, 2019)

My HealthCare Navigator roles carry a caseload of approximately 15 patients each for up to 90 days, equating to 60 patients a year. With currently 4 Navigators that is 240 patients per year or on average 20 patients per month

2,400 patients by end of FY 2020/21

The target is composed of patients cared for by both ED One Team and My HealthCare Navigators. It is a projection based on what the initial pilot of these programs has demonstrated. In March 2020, the total number of Navigators will increase to 8, with a total annual caseload of 480 patients. However, given the potential for staffing changes within the ED One Team with pilot funding the target is conservative.

the patient's care plan advances their health care goals. They assist with care planning and coordination during a patient's hospital stay, and will continue to support patients and their caregivers for up to 90 days after they leave the hospital.

Sunnybrook Connects ensures patients with complex needs return home seamlessly with the right community supports, thereby reducing preventable ED visits and admissions.

CHANGE


1. Creating efficient and collaborative pathways Evaluating and developing collaborative pathways between team members to identify, assess and create plans for patients. Improving the communication and flow of information.

Process map and apply LEAN tools to evaluate the process for team members to identify, assess and create plans for patients. Use quality improvement methods such as Plan, Do, Study, Act (PDSA) to develop new models of flow with rapid evaluation.

Process map developed for both ED One Team and Navigators Number of new models of flow trialed and evaluated

Map the process for both ED One Team and Navigators Trial and evaluate 2 new models of flow

2. Improve System Partnership

Sunnybrook Connects Team is composed of interprofessional team members from both within the hospital and community setting who work together to assess the needs of patients and their families, determine level of care coordination and care planning based on patient specific goals and alignment of care team resources based on need. Sunnybrook Connects will define and strengthen care processes building a network that enhance system partner collaboration (e.g. connection to Primary Care) to positively impact the patient experience of care.

Both the ED One Team and the Navigators will work in collaboration with system partners to co-create care processes that enable integrated care along the continuum such as hospital-community huddles, warm handovers and standardized communication and documentation tools. This will include establishing a workflow to connect with Primary and/or Community care.

Integrated care planning processes will be identified and implemented (e.g. huddles, warm handover, standardized communication and documentation processes) in collaboration with system partners. Establish a workflow for enhanced to connect with Primary and/or Community care

Identify and create 2 or more integrated care planning processes with partners.

3. Improve use of electronic tools for patient identification and notification of team members Utilizing appropriate electronic tools to identify patients that would be appropriate for the Sunnybrook Connects Team, rapidly alerting the team members of patients in the hospital.

Develop workflow and leverage BetterCare to: 1. Alert the ED One Team of

patients in the ED who meet criteria

2. Alert the Navigators when a patient on their caseload presents to ED

Use of electronic tools for flagging and notification for the Sunnybrook Connects Team

Implement 1 or more electronic tools

4. Build Capacity in Sunnybrook Connects Team and collaborators through the implementation of best practices for communicating and connecting with patient and families. Create and implement a competency based education program for the Sunnybrook Connects Team that supports the advancement of person centred communication skills focusing on: • Essential Professional Conversation Approaches • Health Literacy and Teach Back • Advance Care Planning and Goals of Care

Conversations

Sunnybrook Connects team members will participate in education and simulation based training to advance communication and navigation competencies.

Number of Sunnybrook Connects Team and System Partner collaborators who complete the training.

20 staff and system partners trained by March 2021.

5. Implement Evaluation of Caregiver Strain Caregivers play an essential role to enable their loved ones to continue to be cared for in their own home and community. Changes in their own roles can result in feelings of strain, influencing their ability and resilience to continue their caregiving role. This change idea will seek to pilot test the Caregiver Impact Tool as a method to explore and discuss the impacts experienced by the caregiver, and to support implementation of interventions to support both the patient and caregiver. Patients who are cared for by Sunnybrook Connects will have the opportunity to participate in an evaluation of Caregiver Impact.

Pilot test the Caregiver Impact tool to evaluate its feasibility for supporting caregivers in their roles.

Caregiver Impact Tool will be evaluated for the feasibility and efficacy to support evaluation of caregiver needs.

Evaluation will be complete and will inform future implementation of caregiver support interventions.

6. Initiate and Document Advance Care Planning Conversations Advance Care Planning (ACP) and Goals of Care Conversations are essential conversations that enable the identification and clarification of values that support preferences for care. Personalized goal setting should be built on values and preferences for care. ACP

Navigators will engage patients and their substitute decision makers in Advance Care Planning Conversations, document in the patient’s health record and build Coordinated Care Plans based

Percentage of patients, receiving care for 30 days or more, who have an Advance Care Planning Conversation documented in the patients’ health record.

75% of patients, receiving care for 30 days or more with the Sunnybrook Connects team members, will have a documented Advance Care Planning Conversation.

conversations will be initiated for all patients who require intensive navigation, greater than 30 days of care. These conversations will support a positive patient experience through the development of meaningful, person centred care plans.

on the discussed values and preferences.

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