Read the Mississauga Halton CCAC 2015/2016 Quality
Transcription
Read the Mississauga Halton CCAC 2015/2016 Quality
2015/16 Quality Improvement Plan for Mississauga Halton CCAC - Workplan "Improvement Targets and Initiatives" AIM Quality dimension Safety Effectiveness Measure Objective To reduce falls among long-stay home care clients To reduce the number of unplanned ED visits among home care clients Measure/ Unit/ PopulaIndicator tion Percentage of % / Adult long adult long-stay stay home home care clients care clients that have a fall on their follow-up RAIHC Assessment Percentage of % / Home home care clients Care Clients with an unplanned, lessurgent ED visit within the first 30 days of discharge from hospital Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan Change Source / Current Period Performance Target HCD, RAI-HC 37.2 35.4 via LSAS / Oct 1, 2013 - Sept 30, 2014 HCD, DAD, NACRS / Jul 1, 2013 - Jun 30, 2014 4.4 5.1 Target Justification Recent performance approaches this target and being able to sustain these gains is the desired outcome. NOTE: This indicator is NOT adjusted for risk factors. Consistently outperforming the provincial CCAC average. MH CCAC is committed to sustaining its performance and views the target as an upper limit rather than increasing target threshold based on past performance, and an uncertainty of hospital impact. Planned improvement initiatives (Change Ideas) 1) Program for Chronic/Complex Patient Populations - Spread Medication Management within the organization for complex, chronic and specialty program patients. Methods [1] Formalize and document working group structure. [2] Ensure education of medication management program. [3] Complete gap analysis. [4] Develop action plan that ensures we met all tests of compliance for Accreditation site survey visit in 2017. [5] Monitor establishment and progress of the working group. Process measures Process measures at present would include milestone monitoring until the project charter and other measures have been determined. Goal for change ideas 100% of new complex, chronic and speciality program patients to have medication reconciliation by Q2 2015/16, with further plan for organization roll out to be approved. 2) Evaluate Rehabilitation Programming - specifically Physiotherapy model of care (3 streams and Rapid Recovery) to validate patient's positive improvement of functional status, and a lower risk of falls. [1] Develop and implement evaluation process. [2] Collect data via patient experience surveying; outcome achievement via service provider scales and outputs; and monitoring of costs and service utilization. [3] Review results [4] Integrate learnings into further improvement opportunities. Process measures at present would include milestone monitoring until the project charter and other measures have been determined Evaluate rehabilitation programming - specifically Physiotherapy model of care (3 streams and Rapid Recovery) by Q2 2015/16. 1) Adopt and implement evidence based pathways for Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure (CHF) programming as an approach to reduce the number of unplanned ED visits and improve the quality of life and functional status of patients. [1] Formalize and document working group structure for COPD, and CHF. [2] Ensure distribution and education on pathways. [3] Complete gap analysis. [4] Develop action plan. [5] Monitor establishment and progress of the respective working groups. Process measures at present would Implement the COPD Pathway include milestone monitoring until by Q3 of 2015/16, and the CHF the project charter and other Pathway by Q3 of 2015/16. measures have been determined. Page 1 of 4 AIM Quality dimension Effectiveness (cont'd) Measure Objective To reduce the number of unplanned ED visits among home care clients (cont'd) To reduce avoidable hospital admissions among home care clients Measure/ Indicator Percentage of home care clients with an unplanned, lessurgent ED visit within the first 30 days of discharge from hospital (cont'd) Change Unit/ Population % / Home Care Clients Percentage of % / Home home care clients Care Clients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan Source / Current Period Performance Target HCD, DAD, 4.4 5.1 NACRS / Jul 1, 2013 - Jun 30, 2014 HCD, DAD, NACRS / Jul 1, 2013 - Jun 30, 2014 15.7 14.9 Target Justification Consistently outperforming the provincial CCAC average. MH CCAC is committed to sustaining its performance and views the target as an upper limit rather than increasing target threshold based on past performance, and an uncertainty of hospital impact. Current performance continues to show MH CCAC as a high performer in the sector and our aim is to maintain this performance and to sustain recent gains. Planned improvement initiatives (Change Ideas) 2) Lead the development and implementation of the South West Mississauga Health Link (1/7 health links being planned for Mississauga Halton area and coordinated by the Health Link Secretariat) and to demonstrate a positive impact of integrated care coordination on this population, emergency department and inpatient utilization. Methods [1] Develop business plan. [2] Develop/approve project charter and associated project management process requirements. [3] Current state analysis and process mapping for future state. [4] Determine data and metrics to be collected and reported on. [5] Time studies and analysis of patient flow. [6] Ensure staffing plan alignment. Process measures Process measures at present would include milestone monitoring until the project charter and other measures have been determined. Goal for change ideas South West Mississauga Health Link to be implemented by Q4 2015/16. 3) Redesign care coordination programming for chronic/complex populations to enable meaningful primary care connections and reliable care coordination practices which have demonstrated to reduce the need for unplanned ED visits or inpatient emergency experiences. [1] Identify priorities for improvements in coordinated care planning and care delivery models; [2] Complete analysis to confirm deployment plans for key improvements; [3] Formalize project structures for design and implementation; [4] Monitor implementation, measure results of coordinated care planning improvements. Process measures at present would include: a) rate of care coordinator primary care connection; b) project implementation milestones (to be confirmed); c) Consistency in understanding roles and responsibilities across an integrated community care team; Coordinator care plan completed for 90% of complex patients within guidelines; care conferencing rate is 75% for complex population by Q4 FY 2015/16. 1) Partnership with Trillium Health Partners to design a new innovative approach to transitioning patients from hospital to home - Seamless Transitions. To design a process were care is wrapped around the patient from admission through to discharge and recovery at home. Test with patients admitted on two physician caseloads in the Medicine program at THP-CVH. Quality improvement cycles ("Plan-Do-StudyAct") will be utilized to assess and refine the process during the test phases. Ongoing monitoring of data - lead and lag measures - to determine whether change idea is having the intended impact. Key outcome measures: readmission rate, return to Emergency Department visit rate, length-of-stay and patient experience. A replicable, scalable, patientcentered approach for hospital to home transitions by Q4 2015/2016. Page 2 of 4 AIM Quality dimension Access Client-centred Measure Source / Current Period Performance Target Ministry of 91.3 91.1 Health Portal / Oct 1, 2013Sept 30, 2014 Planned improvement Target Justification initiatives (Change Ideas) Methods Process measures Goal for change ideas Maintain current high Mississauga Halton CCAC will continue our current work processes and efforts to sustain our results in these areas and will continue to monitor performance. performance and initiate actions if we fall below current performance target. 5 Day Wait Time - % / Home Nursing Visits: % Care Clients of patients who received their first nursing visit within 5 days of the service authorization date. Ministry of Health Portal / Oct 1, 2013Sept 30, 2014 96.2 95 Maintain current high Mississauga Halton CCAC will continue our current work processes and efforts to sustain our results in these areas and will continue to monitor performance. performance and initiate actions if we fall below current performance target. To improve Percent of home % / Home client experience care clients who Care Clients responded "Good", "Very Good", or "Excellent" on a five-point scale to any of the client experience survey questions: i) Overall rating of CCAC services ii) Overall rating of management/han dling of care by Care Coordinator iii) Overall rating of service provided by service provider OACCAC / Apr 1, 2013 - Mar 31, 2014 90.9 93 Continue to strive to 1) Share Care Council to meet the target set in develop a Patient Caregiver Bill 2014/15 QIP. of Rights internally and with service providers as a consistent commitment to a positive patient experience. Objective To reduce service wait times Measure/ Indicator 5 Day Wait Time Personal Support for Complex Patients: % of complex patients who received their first personal support service within 5 days of the service authorization date. Change Unit/ Population % / Home Care Clients Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan [1] Develop engagement opportunities. [2] Collect qualitative and quantitative data. [3] Review results. [4] Integrate insights and noted opportunities into care integration programming. Process measures at present would include: a) Milestone monitoring until measures have been determined; b) Quality of Content to patient/caregivers. 1) Approve the Patient Caregiver Bill of Rights May 31st, 2015. 2) Produce new patient information package reflecting the bill of rights language by Q4 2015/16. 3) Incorporate strategically patient and care giver insights into the design of Seamless Transition work and to inform "how it is going to work" by Q1 2015/16. Page 3 of 4 AIM Quality dimension Client-centred (cont'd) Measure Objective To improve client experience (cont'd) Measure/ Indicator Percent of home care clients who responded "Good", "Very Good", or "Excellent" on a five-point scale to any of the client experience survey questions: i) Overall rating of CCAC services ii) Overall rating of management/han dling of care by Care Coordinator iii) Overall rating of service provided by service provider Change Unit/ Population % / Home Care Clients Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan Source / Current Period Performance Target OACCAC / Apr 90.9 93 1, 2013 - Mar 31, 2014 Target Justification Continue to strive to meet the target set in 2014/15 QIP. Planned improvement initiatives (Change Ideas) 2) Design a "neighbourhood cluster model" of care service delivery model as a means to increase flexibility with scheduling 3) Partnership with Trillium Health Partners to design a new innovative approach to transitioning patients from hospital to home - Seamless Transitions. Methods Provide patients and families with increased choice over personal support scheduling; increase consistency of care team; joint assessments with personal support supervisor and care coordinator Process measures Implement target numbers for chronic/complex patients end of Q1 FY 2015/16; Evaluate results across following domains: patient experience, cost effectiveness, hospital avoidance. [1] Develop and implement an evaluation Number of patients surveyed (to be process. [2] Collect data from patient determined). experience by: a) phone call asking questions about their transition of care experience; and b) by surveying at discharge (on the floor) asking questions about their transition of care experience. [3] Review results. [4] Evaluate the effectiveness of the new survey sampling approach. Goal for change ideas Pilot a "neighborhood cluster model" for patients to provide an increase in choice in scheduling personal support care by Q3 2015/16. 1) To develop a survey sampling approach based on results of phone and discharge evaluation by Q1 2015/16. 2) Based on the final sampling plan strategy, to collect and incorporate patient experience data into potential opportunities for improvement by Q3 2015/16. Page 4 of 4