Quality, Risk and Patient Safety Reporthealthcareathome.ca/northeast/en/performance/Documents... ·...

Submitted to: Board of Directors December 5, 2014 Analysis and Ideas for Improvement Contributed by Staff of the North East CCAC

Date of Report: November 25, 2014

Quality, Risk and Patient Safety Report Fiscal Year 2014-15, Second Quarter

Quality, Risk and Patient Safety Report, Fiscal Year 2014-15, Second Quarter of 37

TABLE OF CONTENTS

1. INTRODUCTION .......................................................................................................................................................... 3

2. DEFINITIONS ............................................................................................................................................................... 4

3. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE .............................................................................. 5

a. Quality Framework and Enterprise Risk Management Framework ................................................................ 5

b. Quality, Risk and Patient Safety Committee (Operational) ............................................................................ 5

c. Patient Services and Quality Committee of the Board of Directors ............................................................... 5

d. Patient Safety Plan .......................................................................................................................................... 5

e. Quality Improvement Plan (QIP) ..................................................................................................................... 5

f. Insurance ......................................................................................................................................................... 6

g. NE LHIN Risk Registry ...................................................................................................................................... 6

h. Disaster/Emergency Response Planning ......................................................................................................... 6

i. Pandemic Influenza Planning .......................................................................................................................... 6

j. Document Control (Policies, Procedures and Forms) ..................................................................................... 6

k. Risk Events and Feedback ............................................................................................................................... 7

l. Quality and Risk Newsletter ............................................................................................................................ 7

m. Accreditation ................................................................................................................................................... 7

n. Internal Audit/Tracer Strategy ........................................................................................................................ 8

o. Client and Caregiver Experience Evaluation (CCEE) ........................................................................................ 8

4. INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT ........................................................................... 9

5. ACCESSIBLE: Wait time for CCAC services ............................................................................................................... 10

6. ACCESSIBLE: Access to long-term care home .......................................................................................................... 15

7. EFFECTIVE: Keeping people healthy in home care .................................................................................................. 16

8. SAFE: Avoiding harm in home care and the community ......................................................................................... 21

9. PATIENT-CENTRED: Meeting patients’ needs and preferences ............................................................................... 25

10. INTEGRATED: Primary Care Services ........................................................................................................................ 29

11. APPROPRIATELY RESOURCED: Healthy work environment ..................................................................................... 30

12. DATA SOURCES ........................................................................................................................................................ 33

APPENDIX A: Patient Safety Plan Quarterly Report .............................................................................................................. 34


INTRODUCTION

1. INTRODUCTION

Home care is an important foundation for supporting an integrated health care system. Home care has a unique function as a key linkage point between various settings of care, such as acute hospitals, emergency departments, long-term care homes and various clinical services. Home care services are intended to meet patients’ needs in an individualized and comprehensive manner, and go beyond physical and mental health care to engage social supports as well.

1

To ensure that the NE CCAC is monitoring indicators across the quality spectrum, the report has been organized to link indicators to the applicable attribute of quality. The nine attributes of quality that reflect a high performing health system include: accessible, effective, safe, patient-centered, equitable, efficient, appropriately resourced, integrated and focused on population health. The report also incorporates results from the Quality Improvement Plan and the Patient Safety Plan. The report includes data to September 30, 2014, the end of second quarter for fiscal year 2014-15. Status reports and quality improvement strategy updates are current as of the date of the report.

1. Keep me safe

2. Heal me

3. Be nice to me

… in this order

©2006 Healthcare Performance improvement,

LLC. ALL RIGHTS RESERVED.

1 Ontario Local Health Integration Networks M-SAA Performance Technical Specifications Version: December 18, 2008


2. DEFINITIONS

Healthcare Quality Improvement: “A broad range of activities of varying degrees of complexity and methodological and statistical rigour through which healthcare providers develop, implement and assess small-scale interventions, identify those that work well and implement them more broadly in order to improve clinical practice.”

2

MAPLe Score: The MAPLe score was developed to prioritize patients for access to CCAC services. Patients who have been assessed and have MAPLe scores of high and very high represent the CCAC patients most in need of long term care placement. Performance Indicator: A measurement that is linked to a strategic direction. It demonstrates progress towards a stated goal and identifies areas for improvement. Performance Standard: A corridor or range around a performance target. It is established for variance reporting purposes. It takes into account expected variations such as statistical and seasonal fluctuations in performance. The Performance Standard is indicated by dashed red lines on the graphs. Performance Target: Sets a goal to achieve. It is measurable and used to demonstrate progress towards a stated goal. The Performance Target is indicated by a solid red line on the graphs. Quality in Healthcare: The nine attributes of a high-quality health system, as defined by Health Quality Ontario (HQO), are:

ATTRIBUTES OF QUALITY

OUTCOMES

ACCESSIBLE People should be able to get timely and appropriate healthcare services to achieve the best possible health outcomes.

EFFECTIVE People should receive care that works and is based on the best available scientific information.

SAFE People should not be harmed by an accident or mistake when they receive care.

PATIENT-CENTERED Healthcare providers should offer services in a way that is sensitive to an individual’s needs and preferences.

EQUITABLE People should get the same quality of care regardless of who they are and where they live.

EFFICIENT The health system should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information.

APPROPRIATELY RESOURCED

The health system should have enough qualified providers, funding, information, equipment, supplies and facilities to look after people’s health needs.

INTEGRATED All parts of the health system should be organized, connected and work with one another to provide high-quality care.

FOCUSED ON POPULATION HEALTH

The health system should work to prevent sickness and improve the health of the people of Ontario.

Risk: Anything of variable uncertainty and significance that interferes with the achievement of business strategies and objectives. Something goes wrong detracting from the organization’s purpose and the quality of its programs and services. Risk Management: Risk Management is a systematic approach to identify, analyze and respond to risks. Most risks can be managed so that impact to the organization is minimized, mitigated or prevented entirely. Root Cause: The underlying or original cause of an incident or problem.

2 The Ethics of Improving Health Care Quality & Safety: A Hastings Center/AHRQ Project, Mary Ann Baily, PHD, Associate for Ethics & Health Policy, The Hastings Center, Garrison, New York, October 2004.


3. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE

a. Quality Framework and Enterprise Risk Management Framework The Quality Framework outlines the NE CCAC’s commitment to quality improvement in the provision of patient services and a safe, productive workplace. The Framework is aligned with the NE CCAC’s vision, mission, strategic plan and operational plan as well as Accreditation Canada standards. It provides a strategic overview of the key principles and practices necessary for the effective planning, management, delivery and improvement of NE CCAC services.

The NE CCAC Enterprise Risk Management Framework (ERM) supports the identification, assessment, and mitigation of risks through a standardized and documented method. The ERM Framework is currently being reviewed and updated. As of September 2014, the Top Risk Profile Report is compiled for each board meeting.

b. Quality, Risk and Patient Safety Committee (Operational) The Quality, Risk and Patient Safety Committee provides a mechanism to align enterprise-wide quality improvement, risk management and patient safety efforts occurring at an operational level with the organization’s strategic priorities. The Committee includes representation from a broad range of backgrounds and geographic regions to obtain regional views and perspectives, is chaired by the Director, Quality and Risk, and is accountable to the CEO.

The purpose of the Quality, Risk and Patient Safety Committee (operational) is to: • Support a culture of quality, risk management, and patient safety at an operational level. • Identify and remove barriers to patient safety and quality of care. • Analyze organizational performance data and translate this data into meaningful opportunities for improvement. • Support quality improvement initiatives. • Identify strategies to mitigate enterprise-wide risks. The Committee met in September and October to review and provide advice on a number of quality, risk and patient safety areas including follow-up on the Qmentum accreditation survey results, risk assessment, escalation and communication of high risk patient safety events to senior management, updates on the Quality Improvement Plan (QIP) and the Patient Safety Plan for 2014-2015 including education initiatives, and results from the Client Caregiver Experience Evaluation survey.

c. Patient Services and Quality Committee of the Board of Directors This Committee provides governance oversight related to risk management in the areas of patient services, patient safety, human resources, ethics and health system partnerships. The Committee provides input into the development of the annual Quality Improvement Plan.

d. Patient Safety Plan The Patient Safety Plan outlines the North East CCAC’s commitment to Patient Safety and supports the mission and vision through the practice of developing and implementing a culture of safety. The Patient Safety Plan details specific objectives, activities, indicators, responsibilities, and target dates to facilitate meeting the organization’s goals and objectives related to patient safety.

Refer to Appendix A for the 2014-2015 Patient Safety Plan Quarterly Report. The CEO approved the 2014-15 Plan, which

was effective April 1, 2014.

e. Quality Improvement Plan (QIP) The Quality Improvement Plan (QIP) is an annual plan required under the Excellent Care for All Act. This legislation currently applies to hospitals and to the primary health care sector. A Ministry of Health and Long-term Care directive requires that every CCAC shall develop, make publicly available, and submit to Health Quality Ontario their first annual QIP by April 1,


2014 for the fiscal year 2014-2015 using standardized templates and guidance material. As recommended by the CCAC CEOs, the CCAC-specific QIP priority indicators are:

1. Patient Experience – Percentage of “Good”, “Very Good” and “Excellent” Client Experience Survey responses on a 5 point scale (poor to excellent) to the three patient experience KP 1 survey questions:

a. Overall rating of CCAC Services; b. Overall rating of management /handling of care by Care Coordinator; c. Overall rating of service provide by service provider. (Key Performance Indicator 1 – CM Services)

2. 5 Day Wait Times for Nursing Services and PSW Services for Complex Patients 3. Falls – Percentage of adult long-stay home care patients who record a fall on follow-up RAI-HC assessment. 4. Hospital Readmissions – Percentage of home care patients who experienced an unplanned readmission to hospital

within 30 days of discharge from hospital. 5. Unplanned Emergency Department (ED) Visits – Percentage of home care patients with an unplanned, less-urgent

ED visit within the first 30 days of discharge from hospital.

The NE CCAC QIP was approved by the Board of Directors and submitted to Health Quality Ontario in March 2014. The 2014-2015 NE CCAC Quality Improvement Plan status update is incorporated into the quality dimension sections of this report (Accessible, Effective, Safe, Patient-Centered, Integrated, Appropriately Resourced), and is flagged by a highlighted

star – .

f. Insurance

The NE CCAC carries insurance protection through the Healthcare Insurance Reciprocal of Canada (HIROC).

g. NE LHIN Risk Registry

This report alerts the NE LHIN of risks or opportunities that may influence achievement of objectives. The 2

nd quarter Risk

Registry Report was submitted to the NE LHIN on September 18, 2014.

h. Disaster/Emergency Response Planning The NE CCAC Emergency Management Plan provides a systemic response to any emergency. The internal James Bay Contingency plan, outlining a standardized approach to annual James Bay flooding, is in the final stages of development. Contingency plans provide a documented method to consistently respond to identified situations, particularly those that can be predicted with a certain degree of frequency. Staff participated in a webinar meeting hosted by the Ministry of Health and Long-Term Care Emergency Management Branch to review The Health System and First Nations Evacuations. Communication from the Ministry about Ebola Virus Disease has also been reviewed and shared with staff members.

i. Pandemic Influenza Planning The NE CCAC Pandemic Plan provides a systemic response in the case of a pandemic. The NE CCAC participates on a provincial emergency response group that has reviewed the provincial template for CCAC pandemic response plans to ensure it is aligned with the Ministry of Health and Long-Term Care pandemic plan. The template is now finalized and the NE CCAC pandemic response plan will be updated in 2014-15.

j. Document Control (Policies, Procedures and Forms)

The Policy and Procedure Manager software is used to manage policies, procedures and related documents developed to standardize processes within the NE CCAC. Each Senior Director of the Executive Team is accountable for the Table of Contents of their respective portfolio manual and is responsible for delegating, writing and/or editing policies, procedures and related documents to their Managers. Forms are managed and housed on a SharePoint site. Using SharePoint allows for using electronic forms to their fullest capabilities, including fillable Word forms and InfoPath forms. The Forms Management Committee reviews all forms.


As resources permit, documents in the Policy and Procedure Manager system and the Forms site are gradually being reassigned to new document owners based on the new organizational structure.

k. Risk Events and Feedback

The Risk Event and Feedback System (REFS) is a database that captures patient risk events and feedback (compliments and complaints), risk events affecting employees, service providers and other third parties, general feedback, health and safety hazards, non-conformances, as well as enterprise-wide risks. A REFS e-learning intranet site ensures that training materials are available to staff throughout the NE CCAC 24/7. The Business Intelligence team produces Risk Event and Feedback reports and ad hoc data extracts for in-depth analysis and utilization of REFS data for quality improvement initiatives. Risk event and complaint reporting is a challenge for many health care organizations with documented reports reflecting only the tip of the iceberg. Maximizing the overall value of the reporting system as a source of actionable data could be a helpful tool to improve patient safety and patient experience. Software incompatibility issues with Internet Explorer 2010 continue to be addressed. Internal processes are being adapted to ensure that high and very high risk patient safety events, based on the Q&R risk assessment, are communicated and escalated to internal stakeholders. The Quality and Risk Team have worked closely with staff on these events to assist with the investigation process, ensuring that disclosure occurs and that senior leaders are aware of preliminary recommendations for improvement resulting from the investigation.

l. Quality and Risk Newsletter

The Quality and Risk Newsletter is a communication tool to inform all NE CCAC staff about quality and risk issues affecting the organization. The newsletter provides updates on issues related to current systems such as Policy and Procedure Manager, the Risk Event and Feedback System, Patient Safety topics and Accreditation.

The Fall Quality and Risk Newsletter promoted both National Infection Control Week and Canadian Patient Safety Week. The newsletter focused on providing staff with an overview of Infection Prevention and Control resources, education and expected practices.

m. Accreditation The NE CCAC participated in the Accreditation Qmentum Survey from May 4-8, 2014. Although the NE CCAC was Accredited with Commendation, there were two areas highlighted as requiring further improvement: disclosure of adverse events and staff safety. The NE CCAC submitted evidence of disclosure process improvements to Accreditation Canada on October 7, 2014. The evidence included a briefing note detailing the analysis of current and best practices for disclosure, a work plan detailing the NE CCAC’s strategy, and the revised Disclosure Policy and Procedure that is being reviewed by stakeholders. On October 17, 2014 the NE CCAC received the result of the Accreditation Decision Committee’s review of the organization’s follow-up requirement which states: “As a result of the review, we are pleased to advise that the follow-up requirements have been met. Your Quality Performance Roadmap has been updated to reflect compliance with the evaluated criteria. We congratulate you on this achievement that demonstrates your organization’s determination and commitment to ongoing quality improvement. We applaud your leadership, staff and accreditation team members for their efforts and dedication to the provision of safe, quality health services.”


n. Internal Audit/Tracer Strategy “An audit is a systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled.” – ASQ Auditing Handbook

The internal audits were used to evaluate compliance to Accreditation standards and to prepare staff for participation in the Qmentum survey. In 2013, the Quality and Risk Team completed internal audits at all six branch offices, resulting in 38 findings, 36 of which have been corrected and closed.

To sustain the current gains and identify further opportunities for improvement, additional internal audits may be identified by the Executive Team to address specific operational areas. Internal audits are performed by Quality and Risk Specialists who are American Society for Quality (ASQ) Certified Quality Auditors.

NE CCAC Quality & Risk staff collaborated with Central and South East CCAC to complete an analysis of the HIROC Risk Assessment Checklist Program and provided feedback to HIROC. As a result, HIROC had put the program on hold to revise the Risk Assessment Checklists and mitigation strategies so that they are applicable to CCACs. At this time it has been recommended to re-visit this program in a future year to allow HIROC time to make necessary improvements to their program.

o. Client and Caregiver Experience Evaluation (CCEE)

The provincial Client and Caregiver Experience Evaluation (CCEE) Provincial Committee oversees a coordinated approach of ongoing patient surveys to gather comparable information across and within individual CCACs about the satisfaction and experience of their patients, for the purpose of improving service and reporting to funders and the public. The surveys are currently completed by National Research Corporation Canada (NRCC) using a continuous sampling approach spread over four waves during a one year period. The survey tool has been revised and streamlined to reduce the number of questions and amount of time required for patients or caregivers to respond to the telephone survey. The CCEE Annual Report for Year 2 (April 2013 to March 2014) was received from NRCC in September providing an overview of results, as reported in Q1.


4. INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT

The nine attributes that reflect a high performing health system are: 1. Accessible 2. Effective 3. Safe 4. Patient-centered 5. Equitable 6. Efficient 7. Appropriately resourced 8. Integrated 9. Focused on population health

To ensure that the NE CCAC is monitoring indicators across the spectrum of the definition of quality, the following section of the report has been organized to link indicators to the applicable attribute of quality For each attribute, from a NE CCAC perspective, there is a definition of “What we want”, “Consequences if we don’t get it” and “To whom does this matter?”. For each indicator there is a mini-graph to indicate progress or lack of improvement over time. The actual indicator, performance corridor (range) and target are displayed on the graphs as shown in the example below:

As applicable, to the right of each graph there is an arrow indicating which direction is “better” for that particular indicator. As well, there is a brief summary of the current status of the indicator along with a brief analysis and ideas for improvement.

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ACCESSIBLE

5. ACCESSIBLE: Wait time for CCAC services

What we want Consequences if we don’t get it To whom does this matter?

Short wait times and efficient care processes for CCAC services.

Long wait lists represent a barrier to accessibility for patients. In some cases a delay in providing care could result in a crisis and the need for more intensive forms of care.

Patients seeking accessibility to CCAC services in north eastern Ontario.

Indicators and Trends for Wait Time for CCAC Services Analysis and Ideas for Improvement

Q2 Value: 64 days 2014-15 Target: ≤48 days 2014-15 Performance Standard: <60 days Analysis: The metric, at 64 days is still over the target of 48 days but has seen a dramatic improvement over Q4 (94 days) and has remained constant from Q1.

Of the 251 patients who received their first visit in Q1 and were over 48 days from the start of the referral: o 220 had a therapy as the first service

assigned o 26 had personal support as the first

service and were either on a PS waitlist (24) or the service was for respite and the families decided when to use the service (2)

o 1 for nursing (monthly visits that were not required to start for 30 days)

o 90 were for OT (34 of these were for residents of a LTC facility)

o 70 were for PT o Remaining were for the other therapy

services

The number of patients on the OT waitlist has been reduced by 7% (471 patients) and the median days waiting is 2 days shorter (31 days)

PT waitlists (358 patients) and median days waiting (36 days) is remaining constant

OT had 911 patients removed from the waitlist (start their service), and PT had 707

Quality Improvement Strategy:

Close monitoring of the personal support waitlist

Continued focus on reducing patient wait times for therapy services, implementing guidelines, and building capacity

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Data Source: Business Intelligence

Business Intelligence > NE Reports > Indicators > Category: MSAA 2011-14 > MSAA - Metric 90th Percentile Wait Time from Community Setting to Community Home Care

M-SAA Quarterly Progress Report

Q2 result: 102 days As of September 30, 2014, the number of patients waiting for therapy services decreased from 1050 at the end of Q1 to 1003 with over 82% of those remaining waiting for Occupational Therapy and Physiotherapy services. Strategies focused on the rehabilitation service population can have the greatest impact on overall wait time. The “Access to Care Strategy for Therapy Services” aims to provide patients and children with quick access to high quality care. Clinical Services therapy staff members are testing solutions to reduce the wait time for therapy services. Some of the quality improvement ideas include:

Maximizing the use of new OHIP funded PT clinics which are becoming operational across the NE (for patients who have the strength and mobility to access the clinics)

Making more effective use of the Rehab Assistant role and Therapy Team Assistant role

Working with partners in falls prevention to prevent the need for PT/OT referrals

Reducing travel time through: o Geographic assignment of therapy staff o Use of Personal Computer

Videoconferencing enabling clinicians to securely connect from a laptop to their patient in a home or school for reassessments.

Care Coordination education about walker clinics to increase number of appropriate patient referrals

Access to CHRIS and templates to speed up documentation

Inviting hospital therapists to spend a day with community therapists to build

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relationships and support collaboration

Use of technology such as iPads in Speech-Language clinical treatment

Data Source: Business Intelligence

Business Intelligence > NE Reports > Indicators > 90th Percentile Wait Time from Community Setting to Community Home Care

Business Intelligence > NE Reports > Patient Services > Category: Management > Service Waitlist Analysis

2013-14 Q1 Value: 7 days (last available report) 2013-14 Target: ≤ 6 days 2013-14: Performance Standard: ≤ 6.6 days This M-SAA indicator defined by the LHIN measures the number of days from the hospital discharge date to the first non-case management service for patients whose referral source was the hospital. Analysis: This result does not meet the established target and is slightly above the performance standard for Q1, 2013-2014. Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. CCAC is not able to replicate baseline numbers and identifies a large variance in referral to counts. Six month or more delay in data availability impacts reporting abilities. Data Source: Ministry of Health and Long-Term Care, M-SAA Indicators, MSAA 1.1.access_wt1

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ACCESSIBLE


Quality Improvement Plan

Objective: To reduce service wait times Outcome measure/indicator: 5-day wait time for Home Care service measured from Initial Authorization Date by Care Coordinator as start time to First Service Date as the end time. Nursing Service: Q2 Result: 94.82% 2014-15 Target: ≥ 93.0% Personal Support – Complex Patient Only Q2 Result: 85.56% 2014-15 Target: ≥ 81.4% Analysis: The targets have been met for both Nursing and Personal Support – Complex Patients. NE CCAC Clinical Services staff plan to meet with high volume nursing and personal support Service Provider Organizations in late fall to deepen understanding of this indicator and the results, as well as brainstorm interagency strategies which could contribute towards reducing the time patients wait for the first provider visit.

Improvement Initiatives #1: Enhance timely patient access to CCAC services by increasing understanding of how existing processes influence our performance and identifying opportunities for improvement. Methods and Process Measures: Reports readily available for staff to review. Goal: Reports available on a timely basis Q2 Result: Local reports are available on demand at the service level, by branch and by service provider through the Business

Intelligence database.

Improvement Initiatives #2: Care Coordination and Clinical Services managers and staff are informed about this and other QIP indicators and measurements through presentations and other communication strategies such as newsletters. This provides an opportunity to engage with managers and staff to elicit change ideas based on their experience with internal processes.

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5 Day Wait Time - Nursing Visits Percentage of Patients Served Within 5 Days of Service

Authorization

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Authorization

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ACCESSIBLE


Methods and Process Measures:

Number of Care Coordination and Clinical Services Managers who agree that they are informed about the QIP

Number of progress reports to all staff using other communication strategies

Goals: Q2 Result:

80% of managers state that they have received information about the QIP

Result will be available later in fiscal year.

50% of managers state that information about the QIP and progress reports are shared with their staff teams.

Result will be available later in fiscal year.

At least 4 progress reports (quarterly) are provided to all staff through other communication strategies

Q1 Quality, Risk & Patient Safety Report posted

Presentation to the Clinical Services Managers at their September 23, 2014 meeting.

Data Source: Business Intelligence>Indicators>5 Day Wait Times


ACCESSIBLE

6. ACCESSIBLE: Access to long-term care home


Short wait times to get into a long-term care home.

If the person is waiting at home, a heavy burden could be placed on loved ones who are caring for the individual. If the person is waiting in hospital, the hospital bed is used unnecessarily, which can lead to emergency department overcrowding and wasted resources.

Patients in north eastern Ontario who are currently on the wait list for placement into a long-term care home, along with their families and caregivers.

People get their first choice of long-term care home.

Being placed in a second or third choice home may mean being placed further away from loved ones or in a home that does not specialize in meeting one’s ethnic, cultural or medical needs. Residents can move to a higher-ranked choice later, but that can be inconvenient and disruptive to the residents’ continuity of care.

Indicators and Trends for Access to Long-Term Care Home Analysis and Ideas for Improvement

As of September 30, 2014, patients on wait list including transfers: 2106 The number of individuals waiting for initial placement has steadily increased since January 2014 and continues to exceed the number of available beds in Long-Term Care Homes (LTCH). Fluctuations are based on the number of applications pending for placement and the number of available LTCH beds at any point in time. Data Source: Business Intelligence > NE Reports > Patient Services > Category: Placement > Placement Waitlist

October 2013 to September 2014 Average: 1

st Choice: 55.9%

The percentage of patients placed into their 1st choice of LTC home remained consistent and within normal variation in the 12-month period from October 2013 to September 2014. Data Source: Business Intelligence > SSRS Report List > Indicators > Other Misc. Indicators > LT Placements by Ranking

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EFFECTIVE

7. EFFECTIVE: Keeping people healthy in home care

What we want How to get it Consequences if we don’t get it To whom does this matter?

Patients receive effective home care to improve their health, maintain it or prevent deterioration to avoid hospitalization and/or admission to long-term care homes.

Promote activities to maintain health and independence (e.g. preserving bladder function and mobility, controlling pain, preserving communication ability, memory and thinking abilities and avoiding depression and weight loss).

Patients experience loss of independence, reduced quality of life through admissions and/or readmissions to hospital and/or admission to long-term care home.

All CCAC patients

Indicators and Trends for Keeping People Healthy in Home Care Analysis and Ideas for Improvement

Q2 Value (as of September 30, 2014): 58% Target: 60% Performance Standard: 60% The percentage of complex patients who are maintained in their home was slightly below the target and performance standard in September 2014. Through the Integrated Discharge Program coupled with the Home First philosophy, local health service partners are creating a cultural shift in practice to reduce the number of ALC-LTC patients. Data Source: Business Intelligence > Indicators - Other Misc. Indicators > Percentage of Complex Patients remaining in Community for 60 plus days post hospital discharge

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Q2 Value = 83% * M-SAA 2014-15 Target: ≥ 84% M-SAA 2014-15 Performance Standard: ≥ 75% Analysis: The result for this indicator is slightly below the M-SAA target. Most people placed into a LTC home have very heavy needs that require them to be in that type of setting; however, one in four people placed in LTC have relatively lighter needs. Ideas for Improvement: The community crisis escalation process assists with ensuring that the most appropriate patients are placed into LTC. Ongoing monitoring of MAPLe scores continues. *Note: Changes were made to the calculation methodology of this indicator to align with the provincial methodology effective Q1 2013-14. Data Sources:

Business Intelligence > NE Reports > Indicators > MSAA 2014-2017> MSAA - Patients Placed in LTC with MAPLe High or Very High as Portion of Total Patients Placed

Q2 Value: 3515 patients 2014-15 Target: ≥ 3,000 patients 2014-15 Performance Standard: > 2,850 patients The number of patients with high and very high MAPLe scores living at home with CCAC support exceeds the established target. Data Source: M-SAA Quarterly Progress Report to the NE LHIN: (2014-2017)

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50%

60%

70%

80%

90%

100%

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

% o

f P

atie

nts


Patients placed in LTC Home with MAPLe SCORES High or Very High (i.e. appropriately)

2500

2600

2700

2800

2900

3000

3100

3200

3300

3400

3500

3600

3700

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

# o

f P

atie

nts


Patients with MAPLe scores high and very high living in the community supported by CCAC

BETTER

BETTER


EFFECTIVE


Q2 average: 22.1% Target: ≤17% Performance Standard: ≤18.7% Analysis: The Q2 average ALC-Acute rate for the 4 Hub Hospitals has increased and is above the performance standard for 2014-15. Ideas for Improvement:

NE CCAC Directors, Care Coordination, continue to work closely with all four HUB hospitals in the district (North Bay Regional Health Centre (NBRHC), Timmins and District Hospital (TDH), Health Sciences North (HSN) and Sault Area Hospital (SAH)).

Regular meetings of stakeholders (NE LHIN, hospitals and NE CCAC) have supported greater problem-solving at a system level.

Strategies implemented include Weekly ALC Rounds, Executive Escalation Process and unit-specific Discharge Bullet rounds.

E-Referral has been successfully implemented with Health Sciences North, Espanola Health Centre, and Manitoulin Health Center with the support of the OACCAC and the NELHIN. Planning for the next hospital sites is occurring in collaboration with the NELHIN.

Other technological strategies are also being implemented such as HPG (Client Viewer) and ED-Notification

ALC Long Stay/Hard to Serve Committees implemented in Sudbury, North Bay and Sault Ste. Marie. A Case Review Committee in Timmins has a similar mandate to the Hard-to-Serve Committees.

There is engagement with the Retirement Home sector in Timmins surrounding the Home First philosophy.

SAH-NE CCAC-NELHIN-Cedarwood Lodge Committee initiated work towards transition of 50 additional Interim LTC/CCP beds (38 Interim LTC and 12 CCP). A work plan has been developed for transition planning.

Access to Care, Access to Care (ATC), a company that provides high-quality

0%

5%

10%

15%

20%

25%

30%

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Ave

rage

ALC

Acu

te R

ate

Quarter, Year

NE LHIN ALC Acute Rate 4 Hub Hospitals

BETTER


EFFECTIVE


information products and services to help improve performance and ensure accountability within health care organizations, is working with the NE LHIN to review Wait Times Information System (WTIS) consistency in ALC reporting.

Note: For consistency with the M-SAA, quarterly results will be reported rather than monthly results. Data Source: M-SAA Quarterly Progress Report to the NE LHIN (H1) (2014-2017)

Unplanned Emergency Department Visits Data not available


Q2 Result: not available Target: ≤ 12.0%

Analysis: Current performance of 13.1% was noted on the Quality Improvement Plan and was based on data provided by OACCAC for the period Q2 2012-13 to Q1 2013-14 Data Source: Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. Delay in data availability will impact reporting abilities.

Improvement Initiative: To understand the fundamental underlying cause(s) of unplanned ED visits by CCAC patients, and enable development of change ideas to prevent re-occurrence. Methods and Process Measures:

Number and percentage of Home Care patients who have an unplanned, less urgent ED visit within 30 days of hospital discharge as documented in ED Notification Reports

Analysis of reports to discover cause(s) of unplanned ED visits

Goal: eNotification Reports clearly indicate if ED visit could have been averted. Q2 Result: eNotification is in place at Health Sciences North. There are challenges to be addressed to determine which ED visits are planned vs unplanned. Goal: Completed analysis outlining reasons why patients are returning to the ED. Q2 Result: Not available at this time


EFFECTIVE


Hospital Readmissions Data not available


Q2 Result: not available Target: ≤ 14.0%

Analysis: Current performance of 14.9% was noted on the Quality Improvement Plan and was based on data provided by OACCAC for the period Q2 2012-13 to Q1 2013-14 Data Source: Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. Delay in data availability will impact reporting abilities.

Improvement Initiatives #1: Determine baseline number and percentage of NE CCAC patients who have experienced an unplanned readmission within 30 days of hospital discharge. (eNotification process would need to be improved so that unplanned readmissions of NE CCAC patients can be reported.)

Methods and Process Measures: Reports available to assist with root cause analysis

Goal: Measures defined and tracked; root cause analysis complete o Q1 Result: Request for report development submitted to Business Intelligence. RCA will be initiated when data is available.

Improvement Initiatives #2: Improve communications among 24 hospitals and the NE CCAC through implementation of eNotification. (Note: eNotification will replace the term ‘ED Notification’ used in the QIP. eNotification is not restricted only to the Emergency Department but will also be used to notify NE CCAC when patients who have been on care with CCAC are admitted to and/or discharged from inpatient units.)

Methods and Process Measures: Process implemented

Goal: eNotification implemented at 24 hospitals by March 31, 2015 (Note: The target date in the Collaborative Capacity Improvement Plan is May 31, 2015) (Excludes West Parry Sound Health Centre as they do not use Meditech.) o Q2 Result: Health Sciences North & North Bay Regional Health Centre are currently testing the eNotification interface with

plans to go live in January 2015. The User Acceptance Testing schedule is now confirmed with all NEON hospitals and subsequent go live dates are to occur between January 2015 and mid April 2015.

Improvement Initiatives #3: Support seamless patient care by enhancing information sharing among 52 health system partners in the NE CCAC region through Implementation of the Health Partner Gateway (HPG). (Note: The term Community Health Portal (CHP) will be updated to Health Partner Gateway (HPG) in the QIP.)

Methods and Process Measures: Number of health system partners that have implemented HPG o # of hospitals o # of Family Health Teams

Goal: 100% of the 52 identified health system partners implement HPG by March 31, 2015 o Q2 Result: to date, 71% of health system partners (37 of 52) have implemented HPG, including 27 non-hospital health

service providers and 10 hospitals


SAFE

8. SAFE: Avoiding harm in home care and the community

What we want How to get it Consequences if we don’t get it To whom does this matter?

No risk events and complete patient records to identify high risk patients

Implement preventative measures to minimize risk events to the extent possible. Monitor completeness of patient records.

Risk of temporary or permanent disability and death; more emergency department visits and hospitalizations. High risk patients may not get the help they need in an emergency/disaster situation

All patients, caregivers and family members. Those identified as long-stay home care patients are at particular risk.

Indicators and Trends for Avoiding Harm in Home Care and the Community

Analysis and Ideas for Improvement

Q2 Result: 2.24 risk events per 1000 patients

(average)

Analysis: The number of risk events reported per 1000 patients is within expected normal parameters based on past history with minor fluctuations above and below the trend. Ideas for Improvement:

The Quality & Risk Team continues to work with staff members who submit reports as well as those who are responsible for the investigation and resolution. A comprehensive approach has been implemented to ensure that events identified as high risk are thoroughly investigated.

A monthly report of high risk patient safety events has been developed for regular distribution to senior leaders.

Data Source: Risk Event and Feedback System (Report 10-005)

Analysis:

The top 5 patient risk events by specific type remain generally consistent with previous reporting periods. It is noted that there were more events reported about medical equipment and supplies issues in Q2.

A summary of high risk events related to medications, medical supplies and medical equipment was submitted to the respective steering committees.

Data Source: Risk Event and Feedback System

(Report 06-003)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

OCT'13

NOV'13

DEC'13

JAN'14

FEB'14

MAR'14

APR'14

MAY'14

JUN'14

JUL'14

AUG'14

SEP'14

# o

f Ev

en

ts /

# C

lien

ts (

10

00

s)

Month, Year

Total Number of Patient Risk Events per 1000 Clients R12, Oct-13 to Sep-14

52

43

30

26 23

0

10

20

30

40

50

60

ServiceDelivery

-Missed Visit

ServiceDelivery-

Other

Fall Medication/fluid error

MedicalEquipment/

supplies

Nu

mb

er

of

Pat

ien

t R

isk

Eve

nts

Specific Event Type

Number Patient Risk Events by Specific Event Type (Top 5) R12, Oct-13 to Sep-14


SAFE



Severity Level

Definitions

Near Miss An event or deviation that is detected and remedied before an incident occurs, avoiding harm/injury/impact to the patient, CCAC, or to the service provider/organization.

Low Risk The event has actual, or potential for minimal harm/injury/impact to the patient, the CCAC, or to the service provider/organization.

Medium Risk

The event has actual, or potential to result in some harm/injury/impact to the patient, the CCAC, or to the service provider/organization. The occurrence has caused a delay in service or resulted in additional costs or dissatisfaction with CCAC services.

High Risk The event has actual or potential for significant harm/injury/impact to the patient, the CCAC, or to the service provider/organization, has the potential for litigation and/or lack of confidence in CCAC services.

Of the 107 patient risk events reported in Q2, 28 were reported as “high” (26.2%), 36 reported as “medium” (33.6%) and 38 reported as “low” (35.5%). The remaining 5 reports were “near miss” (4.7%). The 28 reported as “high” by the submitter were categorized as follows:

Service Delivery-Missed Visit (5)

Service Delivery-Other (4)

Treatment (3)

Medical Equipment/Supplies (2)

Medication/Fluid Error (2)

Privacy Event/Breach (2)

Alleged Illegal Activity(1)

Communication/Reporting (1)

Damage to Property (1)

Documentation/Consent (1)

Fall (1)

Suicide Attempt/Threat (1)

Unexpected Death (1)

Other (3) Note: Missed visits causing patient harm are documented in the Risk Event and Feedback System (REFS) whereas missed visits where there is no patient harm are captured in CHRIS.

Ideas for Improvement:

Each patient risk event is reviewed for accuracy and appropriate follow-up when submitted.

Unresolved patient safety risk events are reviewed regularly. Follow-up with investigators and managers occurs as needed.


(Report 06-003)

0

10

20

30

40

50

60

OCT'13

NOV'13

DEC'13

JAN'14

FEB'14

MAR'14

APR'14

MAY'14

JUN'14

JUL'14

AUG'14

SEP'14

Nu

mb

er

of

Ris

k Ev

en

ts

Month, Year

Number of Risk Events by Severity Level R12 Oct-13 to Sep-14

High Risk

MediumRisk

Low Risk

Near Miss


SAFE




Objective: The incidence of falls in adult long-stay home care patients will be reduced. Outcome Measure/Indicator: Percentage of long-stay patients who record a fall on follow-up RAI HC assessment. Target: ≤ 29.7% Performance Standard: ≤ 33.0% Q1 Result: 36.77% The current rate of 36.77% does not meet the Balanced Scorecard performance standard though it has improved from 39% in Q1. Results have remained consistently in this range since Fiscal 2012-13. The patient population that is included in this metric has seen a significant increase in the average RAI score. It is not unreasonable that these increasingly complex patients will have a higher rate of falls even with the success of the falls prevention program.

Improvement Initiative #1: Enhance reporting and follow-up of seniors' falls by improving the process for completing the Home Safety Risk Assessment. Goal: Establish baseline % of patients receiving a Home Safety Risk Assessment by December 31, 2014 (YTD end Q3). Note: The baseline data will provide a benchmark to measure results of future improvement initiatives. Q2 Result: Work continues on the reporting mechanism for reporting the actual numbers of Home Safety Assessments completed. We will be continuing to promote use of the Safety Home Assessment as well as follow up with the Care Coordinators, to improve this baseline data. Improvement Initiative #2: Care Coordinators and Clinical staff complete the Falls Prevention e-learning module. Though the e-learning module is mandatory for all Care Coordination and Clinical staff, the priority is for staff working most closely with patients in the home setting. Goal: 60% of Care Coordination and Clinical staff complete the course by March 31, 2015 Q2 Result: 81.5% - 541 employees have completed the Introduction to Falls Prevention e-learning module of the 664 current employees who have been assigned the module Data Source:

Business Intelligence Balanced Scorecard

Talent Development Report

15%

20%

25%

30%

35%

40%

45%

50%

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Pe

rce

nta

ge o

f C

lien

ts

Quarter, Year

Prevalence of Falls for Adult Long-Stay Home Care Clients

BETTER


SAFE



Q2 Result: 3.34% Target: ≤ 2.0% Performance Standard: ≤ 2.2% Objective: Medication Safety for Long Stay Home Care Patients will be improved. Outcome Measure/Indicator: Prevalence of not receiving a medication review by a physician or other appropriate health care professional (e.g., Nurse Practitioner, Pharmacist) for long stay home care patients with a RAI Assessment completed in the last year. The current rate of 3.34% does not meet the performance standard. Further improvements are expected as both the CCAC’s medication reconciliation program and the pharmacy program are utilized by more of our patients. Data Source:

Business Intelligence > Indicators - Other Misc. Indicators > Medication and Falls Safety

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

% n

ot

revi

ew

ed

Quarter, Year

Percentage of Long-Stay clients not Receiving a Medication Review

BETTER


PATIENT CENTRED

9. PATIENT-CENTRED: Meeting patients’ needs and preferences


Patients who are satisfied with the services that they receive from the NE CCAC and our service providers.

Dissatisfied patients. Potential for internal and external appeals, legal proceedings, and loss of reputation.

Patients, caregivers, family members, NE CCAC staff and service providers.

Patient-Centered Indicators and Trends Analysis and Ideas for Improvement

Q2 Result: 1.73 complaints per 1000 patients (average)

Analysis: The overall rate of complaints documented per 1000 patients in Q1 remained within the overall expected volume for the past 12 months.

Ideas for Improvement: Staff members are encouraged to enter all patient complaints in the Risk Event and Feedback System. A process for handling MPP-referred complaints has been implemented.

Data Source: Risk Event and Feedback System (Report 01-001)

Analysis: The top 5 types of complaints in Q2 were consistent with the previous quarter.

Ideas for Improvement: NE CCAC staff follow-up with patients, caregivers and Service Providers as required when investigating patient complaints. Actions are taken to reach a satisfactory resolution of the complaint and to escalate issues that require intervention by a manager or director. Most complaints are resolved by the Care Coordinator in collaboration with internal clinicians and/or external service providers. Data Source: Risk Event and Feedback System (Report 01-002)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

OCT'13

NOV'13

DEC'13

JAN'14

FEB'14

MAR'14

APR'14

MAY'14

JUN'14

JUL'14

AUG'14

SEP'14

# C

om

pla

ints

/ #

Pat

ien

ts (

10

00

s)

Month, Year

Total Number of Complaints per 1000 Patients R12, Oct-13 to Sep-14

90

70

58 56

49

0

10

20

30

40

50

60

70

80

90

100

Communication Competencein Service /Treatment

Attitude /Behaviour

Amount ofService

Coordination

Nu

mb

er

of

Co

mp

lain

ts

Complaint Category

Top 5 - Number of Complaints by Specific Type R12, Oct-13 to Sep-14


PATIENT CENTRED


Classification Definition

Minor Resolution is straight-forward, consisting of an explanation,

clarification or policy/procedure, or simply apology. Involve patient

idiosyncrasies, preferences, or expectations. The issue is easily

resolved.

Intermediate Resolution requires investigation, meeting with patient/family and

other providers, minor changes to policy or procedure; requires

changes to service plan or a review or policy and procedure.

Major Resolution requires extensive investigation, meetings, follow-ups,

major policy revisions or reporting of event to regulatory body or

authorities; may cause litigation to the NE CCAC and/or service

provider.

Analysis: In Q2, there were a total of 83 complaints of which 5 (6.0%) were classified as major by the submitter, 25 (30.1%) as intermediate and 53 (63.9%) as minor in nature.

The 5 major complaints included the following specific types:

Patient Safety (2)

Other (2)

Attitude/Behaviour (1)


(Report 01-001, 10-024)

Q2 Value: 1, Year-to-date: 3 Analysis: The number of complaints about the provision of services in French remains very low with 1 complaint reported in the Risk Event and Feedback System in Q2. The Client Caregiver Experience Evaluation survey provides information about service provision in the patient’s preferred language. There are no new survey results to report this quarter. Data Source:

Business Intelligence>Quality&Risk>French Language Related Complaints

0

5

10

15

20

25

30

35

40

45

OCT'13

NOV'13

DEC'13

JAN'14

FEB'14

MAR'14

APR'14

MAY'14

JUN'14

JUL'14

AUG'14

SEP'14

Nu

mb

er

of

Co

mp

lain

ts

Month, Year

Complaints by Severity R12, Oct-13 to Sep-14

Major

Intermediate

Minor

0

1

2

3

4

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

# o

f C

om

pla

ints

Quarter, Year

French-Language Services Complaints Reported in Risk Event and Feedback System


PATIENT CENTRED


Q2 Value: 1, Year-to-date: 4 2014-15 Target ≤ 3 patient appeals per quarter 2014-15 Performance Standard: ≤ 6 patient appeals per quarter One new internal appeal initiated in the 2

nd

quarter was withdrawn. Data Source: Complaint Log (Action Line, MPP and Appeals) Note: starting with the 2013-2014 Balanced Scorecard, the metric for internal and external appeals was combined, whereas there were separate targets and performance standards in previous reporting periods.

Q2 Value: 1, Year-to-date: 3

14/15 Fiscal Quarter Number

Status

In-Process Resolved

1st 2 0 2

2nd 1 0 1

3rd 0 0 0

4th 0 0 0

Total 3 0 3

Data Source: Complaint Log (Action Line, MPP and Appeals)

Q2 Value: 0, Year-to-date: 1

14/15 Fiscal Quarter Number

Status

In-Process Resolved

1st 1 0 1

2nd 0 0 0

3rd 0 0 0

4th 0 0 0

Total 1 0 1

Data Source: Complaint Log (Action Line, MPP and Appeals)

0

2

4

6

8

10

12

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

# o

f C

lien

t A

pp

eal

s

Quarter, Year

Number of Internal and External Client Appeals

External

Internal

0

1

2

3

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Nu

mb

er

of

Ap

pe

als


Number of Internal Appeals by Type Internal Appeals Committee

Termination

Amount

Exclusion

Eligibility

0

1

2

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Nu

mb

er

of

Ap

pe

als

Init

iate

d


Number of External Appeals by Type Health Services Appeal and Review Board

Termination

Amount

Exclusion

Eligibility

BETTER


PATIENT CENTRED


In the 2

nd quarter, there were 4 complaints from

patients/families referred to the North East CCAC by the Long-Term Care Action Line. One complaint remains in-process. The complaints were about the following concerns:

Amount of service – 3

Coordination/continuity – 1 Data Source: Complaint Log (Action Line, MPP and Appeals)

In Q2, there were 11 complaints or inquiries referred by MPP offices throughout the North East CCAC region and none from the NE LHIN. One issue was referred by both the MPP office and the Long-Term Care Action Line. Analysis: The topics of the complaints referred include:

Amount or type of service (3)

Wait Time for Placement (2)

Wait Time for CCAC services (3)

Coordination/Continuity (1)

Attitude/Behaviour (1) One (1) inquiry concerned planning for care at home. The Senior Director, Strategic Engagement followed up on all complaints/inquiries. Note: tracking of MPP-referred complaints began in April 2013 (Q1 13-14) and NE LHIN-referred complaints in April 2014 (Q1 14-15). Data Source: Complaint Log (Action Line, MPP and Appeals)

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Nu

mb

er

of

Cal

ls


Number of Calls to LTC Action Line

Resolved

In-Process

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

NE LHIN 0 0 0 0 2 0

MPP 7 6 16 32 13 11

0

5

10

15

20

25

30

35

# o

f R

efe

rre

d C

om

pla

ints

/In

qu

irie

s

Quarter, Year

Complaints/Inquiries Referred to NE CCAC by MPP Offices and NE LHIN

MPP NE LHIN


INTEGRATED

10. INTEGRATED: Primary Care Services


No barriers accessing high-quality care because of age, sex, complexity of care, urban or rural residence.

Health can deteriorate when people who are disadvantaged in society do not get the health services they need. This may cause individuals to require higher levels of care or admission to hospital and/or long-term care homes when this could have been prevented through access to needed health services.

All residents in the North East CCAC area.

Integrated Indicators and Trends Analysis and Ideas for Improvement

Q2 result: 77.48% as of September 30, 2014 Target: ≥76.0% Performance Standard: >70% Objective: To increase the number of people connected with a primary care provider through Health Care Connect (HCC) Health Care Connect is a program administered by CCACs that refers Ontarians who don't have a physician to family health care providers. Care Connectors, who are nurses employed by the CCAC, work to match registered program participants with family physicians and nurse practitioners who are accepting new patients. In Q2, the target continues to be met and exceeded. This is calculated based on the total number of referred people from the start of the HCC program in February 2009. Since the calculation uses over 4 years of data, any quarterly improvement will only show a very slight increase in the rate. While the NE CCAC’s rate may not be the highest in the province, we have the highest number of registered patients. Data source: Health Care Connect Monthly Data Report

72%

73%

74%

75%

76%

77%

78%

79%

80%

Oct'13

Nov'13

Dec'13

Jan'14

Feb'14

Mar'14

Apr'14

May'14

Jun'14

Jul'14

Aug'14

Sep'14

% o

f re

gist

ere

d p

eo

ple

re

ferr

ed

Month, Year

Percentage of people registered with Health Care Connect who are referred

BETTER



11. APPROPRIATELY RESOURCED: Healthy work environment


Injury rates for healthcare workers as low as possible – through proper safety training, inspections and organizational commitment to safety.

When workers are off work due to injury, both workload and stress increase for those who cover for injured workers. Workplace Safety and Insurance Board (WSIB) claims increase and premiums may rise. Injuries may result in staff turnover, which disrupts continuity of care and adds to recruitment expenses.

This directly affects all NE CCAC staff. It indirectly impacts all patients of the NE CCAC, due to possible disruption in continuity of care.

Higher job satisfaction for healthcare providers – by reducing stress, keeping workload reasonable and enabling good teamwork and leadership.

Dissatisfied workers may leave their jobs, leading to the problems associated with turnover noted above. Dissatisfied workers may also have more absenteeism and provide lower quality of care or less courteous care if they are feeling stressed or overworked.

Indicators and Trends for Healthy Work Environment Analysis and Ideas for Improvement

The Staff Safety Indicator is calculated as the percentage rate of occupational health and safety incidents reported per full-time equivalent in a given year - annualized and cumulative Q2 Result: 10.39% 2014-15 Target: ≤ 8.0% 2014-15 Performance Standard: ≤ 10.0% Analysis: The Q2 Staff Safety Indicator result (annualized and cumulative) has decreased from Q1 but does not meet the established target or performance standard. The number of employee incidents decreased from 21 in Q1 to 10 in Q2 including the following types:

Harmful Substance/Environment (3)

Overexertion (2)

Fall (1)

Repetition (1)

Other (1)

Slip/Trip (1)

Struck/Caught (1) Prevention notes:

A recent health and safety promotion for staff focused on using our existing tools to scan hazards prior to and during visits at patient homes.

Staff were reminded to refrain from wearing scents and were encouraged to remind visitors of our scent free policy when establishing meetings at the office.

Monthly Health and Safety Agendas are provided to managers for use during their staff meetings. The July edition featured a

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Rat

e o

f O

H&

S In

cid

en

ts (

%)

Quarter, Year

Staff Safety (Frequency of Occupational Health and Safety Incidents)

BETTER




review of the Safety Climate Assessment Report. Regular Monthly Health and Safety Agendas resumed in October with a focus on Influenza Home Visiting and Safety When Visiting a Patient Home.

Data Source: Health and Safety Report

Q2 Value: 1 Claim submitted to WSIB The claim submitted to WSIB was denied. Data Source: Health and Safety Report

0

5

10

15

20

25

12-13,Q3

12-13,Q4

13-14,Q1

13-14,Q2

13-14Q3

13-14Q4

14-15Q1

14-15Q2

Nu

mb

er

of

Inci

de

nts


Total Number of Employee Incidents by Type

Motor VehicleIncident

Slip/Trip

Other

Assault

Harmful Substance/Environment

Fall

Fire/Explosion

Repetition

Overexertion

Struck/Caught

0

5

10

15

20

25

12-13,Q3

12-13,Q4

13-14,Q1

13-14,Q2

13-14Q3

13-14Q4

14-15Q1

14-15Q2

Nu

mb

er

of

Inci

de

nts


Total Number WSIB Claims Compared to the Total Number of Incidents

Total # WSIB Claims Total # Incidents

BETTER

BETTER




Q2 Value: 7.84 days 2014-15 Target: ≤ 9 days 2014-15 Performance Standard: ≤ 11 days Analysis: The Q2 result meets and exceeds the established target. Ideas for Improvement: Continue guiding managers with attendance program. Data Source: Balanced Scorecard, HR Indicators

Q2 Annualized Value: 9.28% 2014-15 Target: ≤ 9.60% 2014-15 Performance Standard: ≤ 12% The Q2 result meets the established target. Note: Employee turnover excludes employees leaving at the end of an assignment period, casual employees and previous retirees. Data Source: Balanced Scorecard, HR Indicators

Analysis: As of September 30, 2014, there were 2 vacant staff positions exceeding 60 days:

2 Care Coordinators – one full-time position in Timmins and one casual position in Parry Sound.

Ideas for Improvement:

The Timmins vacancies are expected to be filled by next quarter.

The Recruiters continue to develop new ideas and tap into employment programs to attract candidates to the NE CCAC.

Effective November 10, 2014, the recruiting function will be distributed among four staff rather two as a result of reorganization within the Human Resources Dept.

Data Source: Staff Vacancy Report

5

6

7

8

9

10

11

12

13

14

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Nu

mb

er

of

Day

s


Absenteeism, Number of Days per Eligible Employee (annualized)

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Q312-13

Q412-13

Q113-14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Turn

ove

r R

ate

(%

)


Turnover Rate (annualized)

0

2

4

6

8

10

12

14

Oct'13

Nov'13

Dec'13

Jan'14

Feb'14

Mar'14

Apr'14

May'14

Jun'14

Jul'14

Aug'14

Sept'14

Tota

l Nu

mb

er

of

Vac

ant

Staf

f P

osi

tio

ns

Month, Year

Staff Vacancies Exceeding 60 Days

BETTER

BETTER

BETTER


DATA SOURCES

12. DATA SOURCES The following data sources were used to compile the Quality, Risk and Patient Safety Report: NE CCAC Business Intelligence

90th

Percentile Wait Time for Patients Referred from Community Settings to Community Home Care

Service Waitlist Analysis Report

5 Day Wait Time

Total Long Stay Wait List, with Transfers (Placement Waitlist)

% of Patients Placed to 1st

Choice of LTC Home (LT Placements by Ranking)

Complex Patients Remaining in the Community for 60 Days or More Post Hospital Discharge

Patients Placed in LTC Home with MAPLe Scores High or Very High (i.e. appropriately)

Patients Placed in LTC with MAPLe High or Very High as Portion of Total Patients Placed

Patients with MAPLe Scores High and Very High Living in the Community Supported by CCAC

Medication and Falls Safety

French-Language Related Complaints

Balanced Scorecard

M-SAA Quarterly Progress Report to the NE LHIN: (2014-2017) Ministry of Health and Long-Term Care,

Wait Time (Days) from Hospital Discharge to Service Initiation (MSAA Indicators, MSAA 1.1.access_wt1)

Health Care Connect Monthly Data Report

Risk Event and Feedback System (REFS)

Total Number of Risk events per 1000 Patients (denominator is based on monthly Caseload Snapshot)

Number of Patient Risk Events by Specific Event Type (Top 5)

Number of Patient Risk Events by Severity Level

Total Number of Complaints per 1000 Patients

Complaints by Severity

Number of Complaints by Specific Type (Top 5) Complaint Log (Action Line, MPP, NE LHIN and Appeals)

Number of Internal and External Appeals

Number of Internal Appeals by Type

Number of External Appeals by Type (Health Services Appeal and Review Board)

Number of Complaints Referred to the CCAC by the LTC Action Line

Complaints/Inquiries Referred to NE CCAC by MPP Offices and NE LHIN Occupational Health and Safety Incident Reports

Total Number of Employee Incidents by Type

Total Number of WSIB Claims Compared to the Total Number of Incidents Human Resources Quarterly Reports

Absenteeism, Number of Days per Eligible Employee (annualized)

Turnover Rate (annualized)

Staff Vacancies Over 60 Days


APPENDIX

APPENDIX A: Patient Safety Plan Quarterly Report

Objective Key Initiatives /

Activities Measure / Indicator

Performance Target

Responsibility

Planned Start /

End Date

Comments and Quarterly Report as of: October 15,

2014

Goal: We will provide accurate information and referral services to staff and patients.

Ensure I&R records are accurate and up-to-date

Record Updates Percentage of North East I&R records that are updated within the past year (both LHIN and non-LHIN funded)

>85% Manager, Care Coordination

(M. Litalien)

April 2014

March

2015

30-Sep-14: Currently at 88%

Educate Care Coordination staff on Key services available

Monthly Staff updates Number of Key Service updates provided to Care Coordination staff

10 Manager, Care Coordination

(M. Litalien)

April 2014

March

2015

1 year to date. May change delivery mechanism and include as part of ‘Hump Day’ newsletter if we can make it fit.

Goal: To improve patient flow from hospital to home.

Facilitate Health System Partners understanding of the Home First Philosophy.

Home First e-learning module produced and shared with Health System Partners

E-Learning module posted on NE CCAC Internet. Health System Partners notified of e-Learning module.

Complete Y/N Director, Care Coordination

(K. Audet)

February 2014

December 2014

Goal: To ensure clear responsibilities and structures are in place to enable staff to provide quality patient care.

Define clear and detailed instructions and required actions that should be followed by Care Coordinators and NE CCAC internal Service Providers in efforts to resolve and prevent Not Seen Not Found visits.

Review and revise NSNF related policies and procedures as necessary to ensure clear and detailed instructions and required actions.

Revised policies and procedures approved.

Revised Policy/Procedure approved.

Care Coordination Director (C. Croteau)

Quality & Risk Specialist (L. Girard)

April 2014

Oct. 2014

Review of existing practices started. FMEA started.

Education related to required actions of NE CCAC staff to resolve and prevent Not Seen Not Found visits.

Number of Care Coordination and Clinical Services staff, who visit patients in their homes, who have received education related to NSNF visits.

70% of staff, who visit patients in their homes, have received education related to NSNF visits.

Care Coordination Director or Manager and Manager, Talent Development

(T. McDonald)

Nov. 2014

March 2015

Previous initiative needs to be completed before this can occur.

Legend:

Green – Completed

Yellow – Work started, not completed

White – Planned, but not started


APPENDIX



Performance Target

Responsibility

Planned Start /

End Date


2014

Goal: We will promote a culture of safety founded upon ethical principles.

Increase the capacity of the organization to apply the Ethics Framework and Tools

Development of an Ethics Portal Site for staff that includes ethics resources and case studies.

Ethics portal site launched.

Complete Y/N Director, Strategic Planning and Integration

(R. Barnett)

Feb. 2014

April 2014

The Ethics Portal Site was launched in April 2014.

Goal: We will reduce the prevalence of falls for long-stay home care patients.

Reduce falls among long-stay home care patients

Improve process for documenting the Home Safety Risk Assessment to allow for greater reporting and follow-up.

Percentage of completed assessments for long-stay home care patients

Establish baseline % of patients receiving a Home Safety Risk Assessment by December 31, 2014

Falls Prevention Team Leads

(S. O’Neill, L. McLachlan)

March 2014

March 2015

Care Coordination and Clinical staff complete the Falls Prevention e-learning module

Percentage of Care Coordinator and Clinical staff who have completed the Falls Prevention e-learning module

60% of Care Coordination and Clinical staff

Falls Prevention Team Leads

(S. O’Neill, L. McLachlan)

April 2015

March 2015

November 3, 2014: 81.5% - 541 employees have completed the Introduction to Falls Prevention e-learning module of the 664 current employees who have been assigned the module.

Goal: To ensure that staff have access to the training and education required to support a culture of quality and patient safety.

Improve staff knowledge in order to positively impact patient safety.

Difficult Conversations Education for staff

Development of education/training strategy to improve Care Coordinator comfort and capability engaging in difficult conversations with patients about changes to their service plan.

Development completed and implementation plan completed

Manager, Talent Development

(T. McDonald)

April 2014

March 2015

A provincial initiative around a product called “Communicate with H.E.A.R.T.” is being explored. The NE CCAC provided information to the OACCAC.

Ensure staff competency related to Accreditation Criteria.

Develop a “Visit Checklist” to be used when Care Coordination or Clinical Services Managers go on home/school visits with their staff, which includes Accreditation criteria, including hand hygiene practices.

“Visit Checklist” developed, implemented and evaluated.

Complete Y/N Quality & Risk Specialist

(L. Girard)

April 2014

December 2014

Home Visit Checklist for Care Coordination is ready for approval. Clinical Services Checklist is in review. Associated Policy and Procedure is currently in review.


APPENDIX



Performance Target

Responsibility

Planned Start /

End Date


2014

Goal: To strengthen and reinforce the process of risk event reporting, investigation, and disclosure within the NE CCAC. To provide learning opportunities for staff and clinicians to learn from risk events.

Ensure that the NE CCAC’s Senior Leaders have an awareness of the risk events and the follow-up to address risk events.

Implement a method to more effectively report patient risk events to the NE CCAC Senior Leaders (Executive Team and Directors)

Regular reports to Senior Leaders of high severity patient risk events and adverse events.

Complete Y/N Director, Quality & Risk

(C. Barnhart)

April 2014

March 2015

Initial report for July, August and September 2014 Patient Safety Events has been reviewed by Senior Leaders. Recommendations have been shared with leads and manager mentors of the improvement teams.

Strengthen and reinforce the process of event reporting, investigation, resolution and disclosure within the NE CCAC to provide safer care to patients.

Develop process to ensure that Sentinel*Events are tracked, investigated, resolved and reported in accordance with Accreditation Canada requirements.

Process implemented to report, track and investigate and resolve sentinel event reports.

Complete Y/N Quality & Risk Specialists

(B. Gartner / L. Girard)

March 2014

March 2015

Quality & Risk has developed a Patient Safety Event Analysis guideline and templates that coincide with the new Disclosure Policy and Procedure. The methodology is currently being trialed for high risk patient safety events.

Provide opportunities for staff and clinicians to learn from risk events.

Develop Patient Safety Case Studies for staff.

Number of Patient Safety Case Studies developed and shared with staff.

Minimum of 1 Case Study per quarter.

Quality & Risk Specialists

(B. Gartner / L. Girard)

April 2014

March 2015

Case Study #1: Restraints

Case Study #2: Cytotoxics

Both Case Studies were launched during Canadian Patient Safety Week.

Goal: The NE CCAC will provide medication reconciliation for patients receiving Nursing Services (Nurse Practitioner or Rapid Response Nursing) and for seniors ages 65 years and older with more than five medications and one or more chronic conditions.

Ensure that medication practices are sustained and improved.

Establish an interdisciplinary team to ensure that medication practices are sustained and improved.

Interdisciplinary team that reviews medication practices has been implemented.

Complete Y/N Director, Clinical Services

(D. Langlois)

Feb. 2014

May 2014

Medication Steering Committee had first meeting in July 2014 and has been meeting monthly.

Improve reporting of medication reconciliation practices.

Trend graphs available to track compliance of medication reconciliation for eligible patients.

Complete Y/N Director, Care Coordination

(C. Croteau)

April 2014

March 2015

Reports on compliance available. Trend graphing request sent through SMA on Oct. 17, 2014.


APPENDIX



Performance Target

Responsibility

Planned Start /

End Date


2014

Goal: The organization’s leaders regularly test the organization’s emergency response plan with drills and exercises to evaluate the state of emergency preparedness.

Perform regular exercises to evaluate the state of the NE CCAC’s emergency preparedness.

Perform 2 table top exercises within the fiscal year.

Number of table top exercises performed.

2 table top exercises performed

Quality & Risk Specialist

(B. Gartner)

April 2014

March 2015

Table top exercise scenario of an infection outbreak has been drafted and is planned for November.

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