Quality Improvement Plan (QIP) Narrative for Health Care … · 2019. 4. 18. · Insert...
Transcript of Quality Improvement Plan (QIP) Narrative for Health Care … · 2019. 4. 18. · Insert...
-
Insert Organization Name 1 Insert Organization Address
Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario
3/29/2018
This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.
-
Insert Organization Name 2 Insert Organization Address
Overview The centre de santé communautaire Chigamik Community Health Centre is a non-profit, community-
governed, primary health care organization located in Midland, Ontario. This unique centre serves the
Indigenous and Francophone communities of the entire North Simcoe and Muskoka LHIN and the
Anglophone community of Midland, Penetanguishene, Tay, and Tiny. Chigamik provides a combination
of primary care, allied health services, health promotion programs, traditional Indigenous medicine and
culturally relevant community development initiatives which are holistic, and offered in French and
English.
This document provides an overview of the CHIGAMIK Quality Improvement Plan (QIP) for the 2018-
19 fiscal year and describes quality improvement achievements from the past year and plans for
improvement in the next. CHIGAMIK's 2018-19 plan focuses on safe, effective, efficient, equitable
client centred care. Within the last year changes have been implemented to drive a new and robust QIP
that includes collaboration with community partners, clients and the interdisciplinary team to provide an
excellent patient experience at Chigamik.
Our upcoming QIP includes new indicators which match our strategic plan goals, those dictated in our
MSAA and priorities identified by Health Quality Ontario. The QIP priorities include:
Developing seamless communication and transitions between partnering agencies including Health Link and local hospitals.
Developing thorough interdisciplinary assessments and care plans for clients with living with diabetes
Increasing health equity in our community by collecting more robust data from community members attending programming to further inform service and program development
Addressing the opioid crisis through practice analysis and change
Ongoing measurement of client satisfaction and engagement
The details of the change ideas to be implemented can be found in our concurrently submitted work
plan.
The upcoming QIP has maintained a clinical focus and includes new indicators for our other services
and programs. Community Health Centres (CHCs) work within a model that allows wrap around care
for clients. We have a strong focus on the mitigation of the influences of social determinants of health
on clients’ lives. This work is achieved by providing services and programs which address health
inequities both in the local community, and systemically.
Describe your organization's greatest QI achievements from the past year During this fiscal year, Chigamik’s most influencing change initiative toward quality improvement was
the rejuvenation of the QI committee. The committee previously had a very narrow focus on the
attainment of Advanced Access. With the addition of new members, including a client advocate and a
new quality improvement chair, the committee was able to broaden the scope of quality improvement
within Chigamik. This included a plan for a quality dashboard and report card to keep QI initiatives
closely in line with our MSAA and strategic plan objectives. These plans are currently being initiated
and will help to guide the QI work of the upcoming year.
-
Insert Organization Name 3 Insert Organization Address
Over the last four years, the Chigamik team have embarked upon the journey toward Advanced Access.
This scheduling process creates available appointments for clients on the same or next day. The concept
of Advanced Access remains foreign to many clients who have expectations of extensive wait times to
see their primary care provider- as this is typical of the physician starved rural areas of Ontario.
Chigamik has achieved Advanced Access and is now offering same day appointments with primary care
providers. This change has been received positively by Chigamik’s clients. During the implementation
of this change we were cognisant that some appointments require future booking and have therefore
carved out four appointments per day that allow us to meet the specific needs in special circumstances.
During the upcoming year, the client satisfaction survey will be used as a tool to measure satisfaction
among our clients ensuring that this booking strategy meets the needs of all Chigamik clients.
In our past two QIPs, we addressed transition to the community from our local hospitals and Chigamik
collaborated with the data management team at Georgian Bay General Hospital (GBGH), the local acute
care hospital to facilitate the transfer of relevant discharge data. The two data teams worked together to
develop a system which is meant to provide the Chigamik team with timely discharge information,
including reason for admission. Unfortunately, this system has not been effective and without electronic
communication, timely access to discharge information is not possible. As such, we have opted not to
place these indicators in our QIP 2018-19 since the data we receive from community hospital is not
complete. Our focus this year will be to continue our conversations and advocacy efforts to improve data
sharing and hope to set a target for improvement next year.
Resident, Patient, Client Engagement In the past year, client satisfaction surveys were completed by over 10% of Chigamik clients. This
significant increase in the completion of the survey is a result of the inclusion of a biannual phone blitz
to facilitate the completion of the survey by a random sampling of clients. The results of the survey have
been analyzed and findings have contributed to this QIP and informed the indicator whose action item
ensures clients are included in decision making related to their care. Current initiatives include:
interdisciplinary case management of complex clients which incorporate clients’ health care goals and
ensure a full understanding of the rationale associated with their care plans.
A significant effort to engage our clients and the community at large through a membership campaign
has resulted in the addition of over 150 members this year. Membership brings with it special privileges
including eligibility to vote at the annual general meeting. The next steps in engaging our members will
include the establishment of client advocacy groups including: substance users, those who are
precariously housed, or homeless, people who identify within the LGBTQ2 communities, francophone
and indigenous clients. These advocacy groups will then further allow Chigamik to meet the needs of
those most vulnerable in the North Simcoe region. Additionally, members who are passionate about the
work done at Chigamik can transition into board roles as informed participants.
Collaboration and Integration Interagency partnership and collaboration is a cornerstone of the work at Chigamik. The North Simcoe
Health Link has had a home within Chigamik since its inception. Health Link is a system navigation
service available for the highest users of the medical system within Chigamik’s catchment area. This
-
Insert Organization Name 4 Insert Organization Address
service has been established to provide close one-to-one guidance for those who have a number of
chronic conditions that need multiple services. Health Link has successfully diverted clients from
unnecessary hospital visits by guiding them through the medical system. It is through feedback from
Chigamik’s primary care providers that a gap in the services was identified- a lack of communication
between Health Link navigators and the referring provider. Our close partnership has positioned
Chigamik to include Health Link in our QIP and jointly develop a communication tool from which all
referring providers will benefit. It is anticipated that providing a robust update on the progress of clients
to the referring providers will build further confidence in the service and increase uptake by standalone
physicians.
Engagement of Clinicians, Leadership & Staff The engagement of all CHC staff is paramount to quality improvement at Chigamik. Internal staff
committees are working to facilitate this engagement and address systemic issues at the front line level.
Our committees are created to align with the board of director’s strategic plan. They include:
Indigenous, Francophone, Harm Reduction, health and safety and interdisciplinary workgroups. The
work of these groups is communicated fluidly from front line staff to leadership and through to the
board. This global sharing of information offers staff, and board members the opportunity to engage in
meaningful dialogue about the shared quality improvement goals and commitments developed for the
centre. These groups also provide opportunity for front line staff to use practice to inform new and
ongoing quality improvement initiatives.
Population Health and Equity Considerations
Chigamik’s mission statement is: To provide culturally relevant holistic programs and services to equip
our communities to achieve optimal health and well-being through awareness, health promotion and
illness prevention
Our mission to meet the needs of the specific cultural groups within our community has lead Chigamik
to create culturally specific committees which include staff, clients and community members. These
new, culturally specific committees address the health disparities experienced by the francophones and
Indigenous community members of the North Simcoe Muskoka region. Intentionally reducing barriers
to health and well-being for marginalized groups facilitates the creation of an environment of cultural
safety and relevant care. As part of our mission, this is an ongoing priority which is incorporated into all
decisions made at an organizational and operational level.
Access to the Right Level of Care - Addressing ALC
Chigamik’s primary care services are often an entry point for clients into the medical system. Our
collaborative interdisciplinary management of complicated clients is a key factor in reducing admission
to hospital by teaching self-management and increasing people’s engagement in activities which
promote health and well-being. Our upcoming QIP implements two change ideas specifically related to
the interdisciplinary care of clients living with diabetes. This care and education will more deeply
establish therapeutic relationships between client and care providers empowering clients with self-care
practices that mitigate admissions to hospital with diabetes related health consequences.
-
Insert Organization Name 5 Insert Organization Address
Opioid Prescribing for the Treatment of Pain and Opioid Use Disorder
Community Health Centres across the province have been advocates of harm reduction practices for
many years. Our experience with clients who use substances and how misuse effects their lives
significantly informs our practice and is one of the corner stones of our practice. Our commitment to
these clients has been addressed this year with the establishment of a harm reduction committee.
Decisions are made on this interprofessional committee through evidence based research and a harm
reduction lens to support clients with substance use and misuse issues. The current priority of the
province on opioid use and overdose prevention has been addressed in our practice by implementing the
following changes:
A change initiative to be implemented with the upcoming QIP; full medication reviews of those clients who have been prescribed opioids and other controlled substances for longer than 6
months. The reviews will evaluate effectiveness, dosing of current medications and the addition
of allied services to support pain management. The interdisciplinary initiatives supporting pain
management and opioid use are:
dance therapy for chronic pain access to acupuncture as an alternative therapy facilitation of the self-management program Living Life with Chronic Pain an
evidence based program developed by Stanford University
Partnership with the local shelter in the development of a drop-in support group for people with substance use issues.
All staff have been trained in the distribution of nasal naloxone kits and are able to distribute to anyone requesting a kit. Primary care providers are also encouraging clients on long standing
opioid prescriptions to have a kit at home in case of accidental overdose by themselves or a
family member.
Ongoing distribution of harm reduction supplies to facilitate relationships with substance users in our community by creating a safe, judgement free space to ask for help.
In this upcoming fiscal year we will be taking part in the establishment of a Rapid Access Addiction Medical clinic in partnership with local acute care centre, Royal Victoria Health
Centre providing timely response for those seeking treatment for their substance use issues.
The upcoming QIP focuses on our internal measurable change initiatives. The data initiative focuses on
developing a tool to extract appropriate data on our clients who have been prescribed opioids for longer
than 6 months. During this upcoming fiscal year we will be transitioning to a new EMR, PS Suites, and
we intend to use it to better manage our data then our current EMR Nightingale on Demand (NOD).
Workplace Violence Prevention At CHIGAMIK we ensure staff feel safe in their work environment and are free from workplace
violence in a number of ways:
- All new staff must complete a thorough Workplace Health and Safety orientation upon hire that
includes the following: WHIMIS, emergency exit procedures, accessibility standards, rights and
responsibilities, hazards in the workplace, privacy and confidentiality, use of personal protective
equipment and reporting accidents and injuries. Furthermore new employees are provided with a tour of
the space to observe the locations of exits, first aid supplies, the defibrillator, alarms, health and safety
board with all required information as per the OHSA, and fire extinguishers.
-
Insert Organization Name 6 Insert Organization Address
- We conduct annual staff training on workplace violence and harassment with corresponding quiz and
policy review
- All staff are fitted for masks every (3) years to be worn in the event of an outbreak
- Most staff are trained in First Aid/CPR
- We have a Business Continuity Plan in place in the event of an external disaster
- Every 2 years we conduct a confidential staff survey regarding workplace violence and harassment
evaluating perceived staff safety
- Every 2 years all staff take part in Crisis Intervention Training with a focus on crisis intervention,
communication and self defense.
- Staff are offered ergonomic assessments of their work space by our physiotherapist to ensure a safe
and comfortable work environment
- Every office where clients are seen include a panic button in case of emergency. When the panic
button is activated a silent alarm will notify reception and police of the office location.
- We have a policy and procedure to cover employees who conduct home visits to ensure their safety
and security. This policy covers our in/out board at reception, work cell phones, and a buddy system.
- Incident reports are reviewed on a bimonthly basis by the Health and Safety Committee where
appropriate changes to processes and policies are initiated to mitigate the impact of future incidents.
Contact Information Quality Improvement Cttee Chair
Name: Gabrielle Maurice
Email: [email protected]
Executive Director
Name: David Jeffery
Phone: (705)527-4154 ext. 201
Email: [email protected]
Board of Directors Chair
Name: Sean Bisschop
Phone: (705)549-3181 ext. 2863
Email: [email protected]
Other
CHIGAMIK CHC currently utilizes Nightingale on Demand (NOD) as its information management
system. NOD is the primary method for collecting data related to our client populations. For the 2017-18
fiscal year NOD continues to be the main resource for the collection of data associated with quality
improvement. For example, information related to the CHC’s supply and demand, provider activity, and
client demographics, is collected solely through NOD.
During the 2016-17 year, NOD was purchased by TELUS. TELUS software platform called PS SUITES
is currently being validated by the AOHC to ensure that it meets our needs. Once this validation is
complete they will begin to transfer CHC's onto the new Electronic Medical Records system, PS
SUITES. This is expected to occur during the 2018/19 fiscal year. At that time PS SUITES will then be
the main resource for the collection of data associated with quality improvement.
-
Insert Organization Name 7 Insert Organization Address
Sign-off
It is recommended that the following individuals review and sign-off on your organization’s Quality
Improvement Plan (where applicable):
I have reviewed and approved our organization’s Quality Improvement Plan
Board Chair _ ______________ (signature)
Quality Committee Chair or delegate __ _____________ (signature)
Executive Director / Administrative Lead ____ ___________ (signature)
Other leadership as appropriate _______________ (signature)
-
ID
INDICATOR
(UNIT; POPULATION;
PERIOD; DATA SOURCE)
ORG
ID
PERFORMANCE
STATED IN
PREVIOUS QIP
PERFORMANCE
TARGET AS
STATED IN
PREVIOUS QIP
CURRENT
PERFORMANCE COMMENTS RESULTS ACTIONS
1
Percent of patients who stated that when
they see the doctor or nurse practitioner,
they or someone else in the office
(always/often) involve them as much as
they want to be in decisions about their
care and treatment?
( %; PC organization population
(surveyed sample); April 2016 - March
2017; In-house survey)
91566 82.81 85.00 79.71
The survey
remained
available online in
both French and
English. The
question on the
current survey
asks the clients
perception
regarding being
involved in their
care. Using the
client advocacy
groups to better
inform inquiries
made via the
client survey may
be an effective
way to augment
client
involvement in
care decision
making.
2
Percent of patients/clients who see their
primary care provider within 7 days after
discharge from hospital for selected
conditions.
( %; Discharged patients with selected
HIG conditions; April 2015 - March
2016; CIHI DAD)
91566 CB 80.00
Collecting this
data for the first
year it is evident
that an 80% target
was very
ambitious. We
appreciate the
need for focused
efforts on
effective
transitions
however, we have
opted not to place
javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl00','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl07','')
-
ID
INDICATOR
(UNIT; POPULATION;
PERIOD; DATA SOURCE)
ORG
ID
PERFORMANCE
STATED IN
PREVIOUS QIP
PERFORMANCE
TARGET AS
STATED IN
PREVIOUS QIP
CURRENT
PERFORMANCE COMMENTS RESULTS ACTIONS
these indicators in
our QIP 2018-19
since the data we
receive from
community
hospitals is not
complete. Our
focus this year
will be to mitigate
hospital visits for
clients living with
chronic
conditions.
Clients will be
educated on the
importance of
transition back to
the care of their
family
practitioner.
3
Percentage of patients and clients able to
see a doctor or nurse practitioner on the
same day or next day, when needed.
( %; PC organization population
(surveyed sample); April 2016 - March
2017; In-house survey)
91566 28.57 50.00 27.42
The survey
remained
available online in
both French and
English. This year
the survey was
distributed twice.
It is noted that the
question directly
related to this
indicator is based
on client
perception. In the
upcoming year,
the wording of
this question will
javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl00','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl07','')
-
ID
INDICATOR
(UNIT; POPULATION;
PERIOD; DATA SOURCE)
ORG
ID
PERFORMANCE
STATED IN
PREVIOUS QIP
PERFORMANCE
TARGET AS
STATED IN
PREVIOUS QIP
CURRENT
PERFORMANCE COMMENTS RESULTS ACTIONS
be changed to ask
the client to focus
on the last time
they called for an
appointment if
same day
accessibility was
offered.
4
Percentage of patients who were
discharged in a given period for a
condition within selected HBAM
Inpatient Grouper (HIGs) and had a non-
elective hospital readmission within 30
days of discharge, by primary care
practice model.
( %; Discharged patients with selected
HIG conditions; April 2015 - March
2016; DAD, CAPE, CPDB)
91566 8.40 6.20 8.40
Chigamik is
currently working
with GBGH to
improve our
method of
communication
regarding our
clients being
discharged from
their facility.
Once a reliable
system is
established for
obtaining this
information we
expect to see a
profound increase
within this
indicator.
5
Percentage of patients with diabetes,
aged 40 or over, with two or more
glycated hemoglobin (HbA1C) tests
within the past 12 months
( %; patients with diabetes, aged 40 or
over; Annually; ODD, OHIP-
CHDB,RPDB)
91566 69.00 80.00 57.70
Chigamik's clinic
team has engaged
with clients to
complete biannual
HbA1C exams.
The clinical team
will continue to
seek out
javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl00','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl07','')
-
ID
INDICATOR
(UNIT; POPULATION;
PERIOD; DATA SOURCE)
ORG
ID
PERFORMANCE
STATED IN
PREVIOUS QIP
PERFORMANCE
TARGET AS
STATED IN
PREVIOUS QIP
CURRENT
PERFORMANCE COMMENTS RESULTS ACTIONS
monitoring
measures that
provide reliable
data and meet
client needs.
6
Percentage of screen eligible patients
aged 50 to 74 years who had a FOBT
within the past two years, other
investigations (i.e., flexible
sigmoidoscopy) within the past 10 years
or a colonoscopy within the past 10
years.
( %; PC organization population eligible
for screening; Annually; See Tech
Specs)
91566 61.90 65.00 67.00
Chigamik has
exceeded the
commitment to
the LHIN on this
indicator and will
continue to strive
to improve
methods to
engage clients in
cancer screening.
7
Percentage of those hospital discharges
(any condition) where timely (within 48
hours) notification was received, for
which follow-up was done (by any
mode, any clinician) within 7 days of
discharge.
( %; Discharged patients ; Last
consecutive 12 month period.;
EMR/Chart Review)
91566 32.60 60.00 52.50
Chigamik is
currently working
with GBGH to
improve our
method of
communication
regarding our
clients being
discharged from
their facility.
Once a reliable
system is
established for
obtaining this
information we
expect to see a
profound increase
within this
indicator. Clients
who are seen in
javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl00','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl07','')
-
ID
INDICATOR
(UNIT; POPULATION;
PERIOD; DATA SOURCE)
ORG
ID
PERFORMANCE
STATED IN
PREVIOUS QIP
PERFORMANCE
TARGET AS
STATED IN
PREVIOUS QIP
CURRENT
PERFORMANCE COMMENTS RESULTS ACTIONS
other hospitals
where the
information is
obtained
electronically are
contacted within
seven days.
8
Percentage of women aged 21 to 69 who
had a Papanicolaou (Pap) smear within
the past three years
( %; PC organization population eligible
for screening; Annually; See Tech
Specs)
91566 74.60 85.00 77.00
Chigamik's clinic
team has recently
implemented PAP
are working
towards reaching
our target and
continue to strive
to ensure our
cancer screening
is completed.
© Queen's Printer for Ontario 2018
javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl00','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl02','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl03','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl04','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl05','')javascript:__doPostBack('ctl00$ctl00$MainContent$MainContent$RadGrid1$ctl00$ctl02$ctl00$ctl07','')
-
Aim Measure Change
Quality
dimensionIssue Measure/Indicator Type
Unit /
PopulationSource / Period
Organiza-
tion Id
Current
performanceTarget Target justification
Priority
level
Planned improvement
initiatives (Change Ideas)Methods Process measures
Target
for process measureComments
created
communication
tool
New indicator:
Collecting baseline data
to compare and set
target in the following
fiscal year.
Joint effort with Health Links
to develop a communication
tool between Health Links and
referring care providers.
All Health Link clients will have completed care plans
shared with their primary care provider at Chigamik.
This correspondence will be added to the clients charts
as response to referrals.
done/not done 100% of Chigamik clients
using Health Link
navigators will receive
current care plans and
client status reports.
New indicator:
Collecting baseline data
to compare and set
target in the following
fiscal year.
Clients with diabetes, who are
identified at risk of developing
foot ulcers, are assessed by a
trained foot care nurse using
the monofilament test.
Clients will be identified by their providers or the foot
care nurse and the test will be administered.
done/not done 20% of all clients with
diabetes over the age of
18 will be assessed for
risk of foot ulcers.
Percentage of clients with
diabetes, aged 40 or over, with
two or more glycated
hemoglobin (HbA1C) tests
within the past 12 months.
A % / clients with
diabetes, aged 40
or over
EMR 91566* 57.70 80.00 By the end of fiscal year
2017/18 we aim to be
having 80% of our
clients with diabetes
(aged 40 or over) have
a minimum of 2 HbA1C
high 1) Nurse to review all eligible
medical records to ensure
clients are coming in twice a
year for HbA1C testing.
A quarterly report of eligible clients will be shared with a
delegated staff member to complete a medical record
review. All clients with missed tests will be contacted to
schedule a HbA1c test, as required.
done/not done Quarterly report.
100% of eligible clients
contacted to schedule
testing.
Equity New indicator:
Collecting baseline data
to compare and set
target in the following
fiscal year.
1) Improve socio-demographic
data collection methods with
non-rostered clients
(community members),
specifically equity-based
indicators.
Upon program registration, community members will be
asked to answer questions about OHIP, social
determinants of health, self-identification, Core 8
variables, Loneliness scale, sexual orientation, and
gender. We hope to use this data to inform program
planning as of 2019-20.
Number of non-rostered clients who receive and are
asked to complete a community intake form.
By end of 2018-19, 70%
of non-rostered clients
will have been asked to
complete a community
intake form.
1) Ensure the Client Experience
Survey is implemented
appropriately.
In 2017-18, a plan was developed to ensure good data
collection and sampling throughout the year. This year,
we will aim to Implement the plan accordingly and have
a biannual connection with clients by telephone to
prompt survey completion..
Number of clients who complete the survey. 250 responses per
annum.
2) Review client and
community member
compliments and complaints.
In 2017-18, the client relations process was reviewed
and enhanced. This year, we will conduct bi-annual
audits to watch for emerging trends and key issues.
done/not done 2 audits per year.
1) Develop and implement
process for easy report-
retrieval of clients with 6+
months of controlled
substance use.
Develop an easy report template to be retrieved on a
quarterly basis and shared with providers to encourage
controlled substance use medication review.
done/not done Quarterly report as of Q3
2018-19.
2) Providers to conduct
medication review of clients
charts with 6+ months of
controlled substanced use.
Physicians and Nurse Practitioners will identify
qualifying clients as prescription requests are received.
Clients will be called to come for appointments to
review medications and where appropriate begin the
tapering process.
Percentage of clients with 6+ months of controlled
substance use with completed medication review.
By end of 2018-19, 30%
of clients with 6+ months
of controlled substance
use will have completed
a medication review.
1) Pilot a same-day
appointment model.
As part of a quality improvement initiative, we are
piloting an appointment model whereby most
appointments are made same-day, with the exception of
4 appointment slots per day for advanced booking (such
as required follow-ups or based on other individual
needs).
Number of appointments booked same-day vs.
appointments booked beforehand.
By end of 2018-19, we
hope to change our
appointment model
permanently so that 70%
of all appointments
made will be same-day.
This is a change idea
that will begin its
PDSA cycle in Q1
2018-19.
2) Efficient booking of follow-
up appointments quality
improvement initiative.
As part of a quality improvement initiative, clients
requiring a follow-up appointment (after an initial visit)
are given a paper slip from the healthcare provider to
bring to the reception. Slips are tallied at the end of each
month to identify trends in reasons for follow-up visits
and to identify which providers request the most follow-
up visits.
Monthly report tracking paper slips and reasons for
follow-up appointments.
Reduction in the amount of unnecessary follow-up
appointments (and promotion of making same-day
appointments).
Monthly report.
Increase access to same-
day afternoon
appointments by 20%.
No data has been
compiled to date on
these indicators. The
data will be collected
over 2018-2019.
Greater focus this
year on proper data
collection; next year,
improvement
initiatives will more
directly impact
results.
Safe Medication
safety
Percentage of clients with 6+
months of opioid and
benzodiazapine use who
participate in a medication case
review.
highModerate target allows
time for data collection
process to be
developed and
implemented, then
some action.
30.00CB91566*A % / clients with
6+ months of
controlled
substance use
(see specific
substances)
EMR/Chart
Review
79.71
medium
medium
Timely 27.42 35 Target is set based on
the North Simcoe
Muskoka LHIN "primary
care" indicator average
of 30.9% (March 2018).
In addition, our Centre
aims to pilot a same-
day appointment
model.
2018/19 Quality Improvement Plan"Improvement Targets and Initiatives"
Centre de sante communautaire CHIGAMIK Community Health Centre Inc. 10-845 King Street, Midland, ON L4R 0B7
88.00Person
experience
Percentage of clients who stated
that when they see the doctor
or nurse practitioner, they or
someone else in the office
(always/often) involve them as
much as they want to be in
decisions about their care and
treatment; client perception.
P % / surveyed
sample of clients
In-house survey /
April 2017 -
March 2018
91566*
Equitable
ODD, OHIP-
CHDB, RPDB
highTimely access
to care/
services
Percentage of clients who stated
that they were able to see a
doctor or nurse practitioner on
the "same day" or "next day",
when needed; client perception.
P % / surveyed
sample of clients
In-house survey /
April 2017 -
March 2018
91566*
91566*
Patient-
centred
This is an ambitious
target, set based on the
North Simcoe Muskoka
LHIN "primary care"
indicator average of
87.6% (March 2018).
CB CB
A % / clients
meeting Health
Link criteria
Population
health
Percentage of non-rostered
clients (community members)
who provide self-reported socio-
demographic and equity-related
data.
C % / non-rostered
clients
(community
members)
participating in
programs.
Effective
91566* CB CB mediumPercentage of clients with
diabetes, age 18 or over, who
are identified at risk of foot
ulcers are assessed for pedal
neuropathy.
91566* CB CB mediumCoordinating
care
A % / clients with
diabetes, aged 18
or older
EMR/Chart
Review
Wound Care
Percentage of clients identified
as meeting Health Link criteria
who are offered access to
Health Links approach.