Quality Improvement Planning2014/15

March 17, 2014

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Quality Improvement Plans• QIPs are mandatory.• 11 indicators are all recommended by Health

Quality Ontario / MOHLTC. • No additional indicators at this time.• QI work should build on and help inform

existing initiatives.• Data sources include client surveys, MSAA

reports, ICES profiles, etc.

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DOMAIN: ACCESSObjective Access to Primary Care when needed.Indicator % of clients able to see a MD/NP on the same day or

next day, when needed.Target 43.5% 50%Initiatives 1. Track # of unused appts increase supply

2. Track # late cancellations & no-shows: Admin follow up & Client education

3. Med Sec training on triage & U/C booking4. Client education re type of appointments5. Add questions to client survey• Same day/next day consultation via phone• Offered but rejected same day/next day appt.

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DOMAIN: ACCESSObjective Reduce ED use by increasing access to

primary careIndicator % of clients who visited the ED for

conditions best managed elsewhere (BME).Target 7.6 per year 7 per yearInitiatives 1. Client education

2. Medical Secretary training re triage and scheduling urgent care appts.

3. Monitor and assess electronic data from SJHC when available.

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DOMAIN: INTEGRATEDObjective Timely access to primary care appointments post-

discharge through coordination with hospital(s).Indicator % of clients who saw their primary care provider

within 7 days after discharge from hospital for selected conditions.

Target Maintain at < 5 people per year Initiatives 1. Client education

2. Medical Secretary training 3. Monitor and assess electronic data from SJHC

when available.

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DOMAIN: INTEGRATEDObjective Reduce unnecessary hospital readmissionsIndicator % of clients who are readmitted to hospital after

they have been discharged with a specific condition.Target -Initiatives Less than 5 clients were discharged from hospital

during the ICES study time. Until hospital discharge data becomes available, this indicator will not be measured and no quality improvement initiatives will be implemented.

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DOMAIN: PATIENT-CENTREDObjective Receiving and utilizing feedback regarding client

experience with the organization.Indicator % of clients who stated that when they see the

MD/NP, 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.

Target 87.5% > 91%

Initiatives 1. Update survey question.2. Review survey results with Clinical Team and

discuss opportunities for improvement.

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DOMAIN: PATIENT-CENTREDObjective Receiving and utilizing feedback regarding client

experience with the organization.Indicator % of clients who stated that when they see the

MD/NP, they or someone else in the office (always/often) give them an opportunity to ask questions about recommended treatment?.

Target Maintain current performance of 97.5% Initiatives 1. Update survey question.

2. Increase survey frequency and collect baseline for monthly survey response rate.

3. Review survey results with Clinical Team and discuss opportunities for improvement.

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DOMAIN: PATIENT-CENTREDObjective Receiving and utilizing feedback regarding

client experience with the organization.Indicator % of clients who stated that when they see

the MD/NP, they or someone else in the office (always/often) spend enough time with them?

Target Maintain current performance of 91.1%Initiatives 1. Update survey question.

2. Review survey results with Clinical Team and discuss opportunities for improvement.

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DOMAIN: POPULATION HEALTHObjective Reduce influenza rates in older adults by increasing

access to the influenza vaccine.Indicator % of client population over age 65 that received

influenza immunizations.Note: we are expanding this initiative to capture all high-risk clients, including those over the age of 65.

Target 36% > 40%Initiatives 1. Clinical Team to review 13/14 MSAA data.

2. Clinicians to implement automated recall feature in new EMR.

3. Outreach to identified clients.

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DOMAIN: POPULATION HEALTHObjective Reduce the incidence of cancer through

regular screening.Indicator % of eligible clients who are up-to-date in

screening for breast cancer.Target 62% > 65%Initiatives 1. Clinical Team to review 13/14 MSAA

data.2. Clinicians to implement automated

recall feature in new EMR.3. Outreach to identified clients.

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DOMAIN: POPULATION HEALTHObjective Reduce the incidence of cancer through

regular screening.Indicator % of eligible clients who are up-to-date in

screening for colorectal cancer.Target 55% > 58%Initiatives 1. Clinical Team to review 13/14 MSAA data.

2. Clinicians to implement automated recall feature in new EMR.

3. Outreach to identified clients, and health promotion / education initiative (eg workshop).

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DOMAIN: POPULATION HEALTHObjective Reduce the incidence of cancer through

regular screening.Indicator % of eligible clients who are up-to-date in

screening for cervical cancer.Target 79% > 90%Initiatives 1. Clinical Team to review 13/14 MSAA

data.2. Clinicians to implement automated

recall feature in new EMR.3. Outreach to identified clients.

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