2015/16 - Almonte General Hospital · 2015/16 Fairview Manor 75 Spring St., Almonte, ON., ... (QIP) is driven by the ... Staff recognize the importance of offering ice in a way that

Fairview Manor 75 Springs St., Almonte, ON. KOA 1A0 April 2015

2015/16 Quality Improvement Plan for Ontario Hospitals

Fairview Manor 75 Spring St., Almonte, ON., K0A 1A0

Overview of Our Organization’s Quality Improvement Plan 1. Overview of our quality improvement plan for 2015-2016 Fairview Manor is a 112 bed long-term care home located on the campus of Almonte General Hospital. Almonte General Hospital (the Hospital) is a small, rural hospital located in Almonte, Ontario, 40 kilometers west of downtown Ottawa. It serves a catchment population of over 30,000 people. The Hospital offers a wide range of acute and continuing care services including an Emergency Department. There are 21 Medical/Surgical beds, five level-one Obstetrical beds, 26 Complex Continuing Care beds and two Operating Rooms. In addition to Fairview Manor, the Hospital operates the Lanark County Paramedic Service. The Hospital campus also includes the Ottawa Valley Family Health Team; the Leeds, Grenville & Lanark District Health Unit and Lanark County Mental Health. Together, these facilities provide our hospital patients and long term care home residents with integrated, coordinated healthcare to support their seamless movement from one care setting to another.

Fairview Manor’s Quality Improvement Plan (QIP) is driven by the corporate mission to provide a continuum of integrated acute care, complex continuing care and long term care to our communities, focusing on quality care and personal attention, accountability and fiscal responsibility. The QIP is a tool to affirm and map the commitment of the Board of Directors and all staff in the continuous pursuit of positive clinical outcomes, positive resident experiences and positive staff work life.

The QIP was developed with consideration to the requirements of the Excellent Care for All Act, 2010. Data from resident, family and staff surveys, critical incident reviews and the patient relations process were reviewed and assisted with prioritizing initiatives in the plan. The plan has been aligned with other in-hospital planning processes and Accreditation Canada initiatives. Fairview Manor prides itself on its history of working collaboratively across the range of continuum of care providers in order to support residents as effectively as possible. The QIP explicitly includes some common indicators that reflect the integration between Fairview Manor, the Hospital and the Ottawa Valley Family Health Team. Overall, the plan is aligned with the priorities of the Champlain LHIN and the Ministry of Health and Long-Term Care including Ontario’s Action Plan for Health Care, 2012.

Fairview Manor plans to strengthen services by focusing on four of the dimensions that define quality within the Excellent Care for All Act, 2010: Safe, Effective, Resident-Centred, and Integrated.

Priority Objectives Providing the Foundation for our 2015-2016 Quality Improvement Plan:


The following information describes the objectives and the planned initiatives that will ensure we are able to successfully reach our QIP targets.

a. Falls: More than one third of individuals 65 years or older will experience a fall. Between April 2012 and March 2013, about one in seven long-term care residents across Ontario experienced a fall. Although some falls are unavoidable, the Long-Term Care Homes Act, 2007, requires all long-term care homes in Ontario to have a falls prevention and management program to reduce the incidence of falls and the risk of injury.

Falls result in pain and suffering for individuals and their families. Falls in older adults often result in moderate to severe injuries (e.g. hip fractures and head injuries with residual deficits). Falls increase the risk for early death and can make it difficult for individuals to live independently.

In order to prevent falls, all residents at Fairview Manor will have Universal Fall Precautions in place. The Universal Fall Precautions initiative is founded on the principle that all residents are at risk for falls and a core set of fall prevention principles is applied by all staff to all residents. The acronym S.A.F.E. (Safe environment; Assist with mobility; Fall-risk reduction; and Engage resident and family) is utilized to describe the key strategies for universal fall precautions. This is a shared quality improvement initiative between the Hospital’s Complex Continuing Care unit and Fairview Manor. The fall-related change initiatives included in each of the quality improvement plans (AGH and FVM) will be developed and implemented in collaboration.

Fairview Manor’s current fall rate for residents is 8.65%. The Provincial Average is 13.8%. The improvement target has been set at 8.5%.

b. Pressure Ulcers Pressure ulcers are a common and painful health condition, particularly among people who are elderly or physically impaired. Residents who develop pressure ulcers are at risk of serious health complications, such as infections and severe pain. The Long-Term Care Homes Act, 2007, requires all long-term homes in Ontario to have a wound program to promote skin integrity, prevent the development of wounds and pressure ulcers, and provide effective wound care interventions.

Nurses will review pressure ulcer risk scores and identify resident-specific interventions for inclusion in care plans. In addition, staff will be provided with education and training on best practices related to pressure ulcer identification.

Fairview Manor’s current pressure ulcer rate is 1.69%. The Provincial average is 3.3%. The improvement target has been set at 1.5%.


c. Restraints Some long-term care homes use restraints as a way of managing potentially harmful resident behaviours, such as wandering or aggression. Residents who display these behaviours often have dementia or other cognitive impairments and can sometimes pose a risk to themselves or others.

However, restraints are known to cause injury and even accidental death, and they are also associated with social isolation and reduced quality of life. Fairview Manor uses a least restraint philosophy, which acknowledges a resident’s quality of life and strives to maintain a resident’s dignity.

Fairview Manor’s current physical restraint usage rate is 12.98%. The improvement target has been set at 12%; representing a 5% decrease from the baseline rate of 12.98%. d. Medication Reconciliation Medication reconciliation (MedRec) is a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully assessed and documented. Health care providers follow a formal process to work together with residents, families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care.

Fairview Manor nurses will be provided with education on how to conduct a Best Possible Medication History (BPMH). The BPMH is an important part of the initial MedRec process that captures the patient’s actual medication use, which may be different from what is contained in their records. Increasing the quality of the BPMH supports strengthened accuracy when medications are reconciled at all future transition points.

This is a shared quality improvement initiative between the Hospital’s Medical/Surgical unit and Fairview Manor. The MedRec-related change initiatives included in each of the quality improvement plans (AGH and FVM) will be developed and implemented in collaboration. This quality improvement initiative positions the organization well in advance for meeting Accreditation Canada’s 2018 expectation to implement MedRec at care transitions across all services. In addition, it provides the organization with opportunity to monitor compliance with the MedRec process and make improvements as required.

The theoretical best compliance rate for MedRec Quality Score is 100%. The National Benchmark MedRec Quality Score is 73%. Fairview Manor will determine its baseline MedRec Quality Score and then set an improvement target for 2015-16.

e. Total Margin (consolidated): Improving the Hospital’s (including Fairview Manor’s) financial health poses a significant challenge given that there is no expected increase in provincial funding for 2015-16. This coupled with


collective agreement increases in salaries and other inflationary pressures limits the organization’s ability to improve fiscal stability. As such, the organization will continue to review the efficiency of operations as well as identify opportunities for revenue generation. The organization will achieve a consolidated operating income position of balanced or better.

f. Worsening Bladder Control (Bladder incontinence): Incontinence can have a negative impact on the health, dignity and overall quality of life for residents. It can lead to loss of independence and is associated with a higher risk of other conditions, such as pressure ulcers.

Nurses will focus on developing resident-specific continence care interventions for inclusion in care plans. This will include ensuring toileting routines are included in care plans to prevent/reduce incidence of bladder incontinence.

Fairview Manor’s current bladder incontinence rate is 10.38%. The Provincial average is 19.2%. The improvement target has been set at 9.86%; representing a 5% decrease from the baseline rate of 10.38%.

g. Resident Satisfaction: Staff recognize the importance of offering care and service in a way that is sensitive to an individual's needs and preferences. The organization is committed to ensuring that every resident enjoys safe, effective, and responsive care in order to achieve the highest quality of life.

84.5% of Fairview Manor’s residents who participated in the satisfaction survey responded “yes definitely” to the question: “Would you recommend this nursing home to others?” (15.2% responded “yes probably”). The improvement target has been set at 85%.

h. Avoidable Emergency Department Visits: Emergency department visits among seniors can be hard for the individuals affected and their families and exact a high cost on Ontario’s health system, as they can mean the beginning of a loss of independence and a serious deterioration in quality of life.

Registered Nurses, Registered Practical Nurses and Personal Support Workers will be provided with ongoing education and mentoring to strengthen their ability to monitor residents for signs of deterioration in order to identify problems earlier. In addition, alternate ways to provide early treatment of conditions, supported by best practice, will be identified and disseminated to staff.

Fairview Manor’s current rate of avoidable emergency department visits is 5.9%. The Provincial Score is 23.82% (Oct. 1, 2013-Sept. 30, 2014). The improvement target is set at 5.31%; representing a 10% decrease from the baseline rate of 5.9%.


2. Integration and Continuity of Care The residents of Fairview Manor benefit from being located on a campus that is shared by an acute care hospital (Almonte General Hospital) and a primary care family health team (The Ottawa Valley Family Health Team). This facilitates ease in access to the appropriate level of care as well as continuity of care whereby the resident’s most responsible physician is able to provide care for the resident in the long-term care home as well as in the hospital in the event of a hospital admission.

Fairview Manor (FVM) staff work in collaboration with Almonte General Hospital (AGH) staff to strengthen the provision of senior friendly care. As example, nurses from FVM and AGH were invited to attend a joint education session on signs and symptoms of delirium, provided by the Regional Geriatric Psychiatry Outreach Team.

3. Challenges, Risks and Mitigation Strategies The improvement priorities identified in our QIP are recognized as necessary initiatives to ensure that care and services are effective, integrated, patient-centred, and safe. Risk Management at Fairview Manor is founded on the philosophy that leadership sets the tone and directs efforts across the organization to foster a culture that values learning, continuous improvement, innovation, and commitment to high quality, patient-centred care. Staff are instrumental in improving quality of care and services despite fiscal and human resource challenges. Limited availability of human resources to assist with testing for compliance is a relevant risk for all initiatives. In response, checklists will be developed to increase the efficiency of compliance testing and testing will be conducted quarterly rather than monthly. Given that there remains no increase in provincial funding for 2015-16, coupled with collective agreement increases in salaries and other inflationary pressures is a risk to the organization’s ability to provide resources to support implementation of the Quality Improvement Plan.

4. Information Management Systems Fairview Manor uses Mede-Care as the electronic medical record (EMR) software solution. This software is regularly used to better understand the needs of residents as well as to drive and inform ongoing quality improvement. Here are some examples of how the software is used each month during Care Team meetings in each of the 4Home Areas:

Pressure Ulcer Risk Scores: The Care Team identifies residents with high pressure ulcer risk scores, reviews current care and treatment interventions and makes changes to each resident’s plan of care as required.

Use of Physical Restraints: The Care Team reviews data related to use of physical restraints during each Home Area meeting to ensure the philosophy of least restraint is upheld and alternate interventions in place of restraint use are considered and used as appropriate. In addition, the Team reviews each restraint use to ensure protocol for safe application is followed (e.g. hourly observation, position changes and documentation).

Falls (in the last 30 or 180 days): data including falls that result in fracture/critical incident are reviewed by the Care Team during each Home Area meeting. Falls prevention strategies are reviewed and interventions are updated on care plans as required. The Falls Prevention Team meets monthly to review falls, help strengthen processes and provide education to staff as necessary.

Responsive Behaviours: The Care Team reviews data related to responsive behaviours in order to


strengthen the Team’s understanding and use of resident-specific interventions required to support reduced responsive behaviours.

The Pharmacy and Therapeutics Committee reviews data related to use of antipsychotics in the absence of a diagnosis of psychosis as well as the use of 9 or more medications and makes recommendations to physicians for them to consider in preparation for each resident’s 3 month medication review. 5. Engagement of Clinical Staff & Broader Leadership Fairview Manor engages clinical staff and broader leadership in establishing shared quality improvement goals and commitments for the organization in the following way: Broad representation on internal committees including (but not limited to): the Quality

Improvement & Risk Management (QIRM) committee, Infection Prevention & Control Committee, Joint Occupational Health & Safety Committee, Ethics Committee, Privacy Committee, Obstetrics Committee, Pharmacy & Therapeutics Committee, Perioperative Committee, and Leadership Team.

Late Career Nursing Initiative funded quality improvement projects Ongoing quality improvement efforts to remain compliant with Accreditation Canada standards Policy development and review in response to legislative, regulatory and professional practice

requirements

6. Patient/Resident/Client Engagement

Fairview Manor has a well-established and engaged Resident Council. The Council meets monthly to discuss any issues that the residents bring forward as well as to share information from the organization. The Council focuses on issues that directly impact the quality of life and safety of residents e.g. suggestions for changes or additions to meal menus and suggestions for recreation activities and outings. 7. Accountability Management In accordance with legislative requirements, the following positions (Senior Team) are subject to performance-based compensation:

President and Chief Executive Officer Chief of Staff Vice President, Patient and Resident Services and Chief Nursing Executive Vice President and Chief Financial Officer Vice President, Corporate Support Services

All of the members of the Senior Team (“the Team”) are responsible for the operations of Almonte General Hospital and Fairview Manor. In addition, all members except the Chief of Staff support the operations of the Lanark County Paramedic Service. Selection of the goals for compensation was based on this principle and the three that were chosen are those to which every member of the Team makes a contribution.


8. Performance Based Compensation (As part of Accountability Management) The performance-based compensation plan (“the Plan”) reflects our corporate values of Accountability for fulfilling our obligations, Respect for the contribution that each member makes to the organization and the Teamwork that is necessary for the organization to succeed. As such, a Plan has been created that contains congruent, not conflicting, goals for each member of the Team, and which rewards the Team for working together towards achievement of the goals. The culture of the organization would not support a Plan which contained incentives for contrary behavior by different members of the team who were each striving to achieve their own objectives.

The amount of compensation at risk in 2015/16 is 2.5%. As there was no pay for performance plan in place at the time of the Government’s freeze on Executive Compensation, the at-risk compensation is deducted from the salary of each Senior Team member and repaid if the goals are achieved.

Goals have been chosen from the Safety and Effectiveness quality dimensions. The three goals chosen – improving the quality of medication reconciliation on admission to the Medical/Surgical unit; maintaining a balanced operating budget position; and preventing falls– reflect the organization’s commitment to safe, high quality care and fiscal accountability. In addition, data for each of these three measures is readily available for the purpose of monitoring performance throughout the year and the Senior Team has the ability to directly influence the outcome.

Achievement of the goals is measured on a 5 point scale, with 3 being acceptable performance. If the Team achieves an average score of 3 or greater across the goals, each member will be paid 100% of the at-risk compensation. If the Team achieves an average score of 2, each member will be paid 50% and at an average score of 1, the Team will receive none of the at-risk compensation.

2015/16 Senior Management Team Performance Goals and Structure

Domain Indicator and Target % of Salary Linked to Achievement of QIP Target Scale AGH FVM

Safety

Improve the average Medication Reconciliation (MedRec) Quality Score at admission on the Medical/Surgical unit

from 70% to 73.5% FVM: establish baseline and

set performance target. National benchmark is 73%

5 ≥76.5% ≥B+8.5%

4 75% to 76% B+7% to B+8%

3 73.5% to 74.5% B+5% to B+6%

2 63.5% to 73% B+1% to B+4%

1 ≤63.5% ≤B

Safety

Reduce the percentage of patients/residents who had a fall in the last 30 days on Complex Continuing Care

unit from 13.5% to 12.9% at FVM from 8.65% to 8.5%

5 ≤10.9% ≤6.9%

4 11.9% to 11% 7.9% to 7%

3 12.9% to 12% 8.5% to 8%

2 18% to 13% 13.7% to 8.6%

1 ≥17.9% ≥13.7%


Domain Indicator and Target % of Salary Linked to Achievement of QIP Target Scale AGH FVM

Effectiveness

Achieve balanced financial position on consolidated operating income. QIP target for 2015/16 is 0

5 greater than 1.5% surplus

4 0.6 % to 1.5% surplus

3 is 0.5% deficit to 0.5% surplus

2 0.6% to 1.5% deficit

1 deficit of 1.5% or greater

Accountability Sign-off

I have reviewed and approved our organization’s Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act.

______________________________ ________________________________ _____________________________________ Paul Virgin Cindy Hobbs Mary Wilson Trider (Board Chair) (Board Quality Committee Chair) President & Chief Executive Officer (AGH) Administrator (FVM)


2015/16 Quality Improvement Plans for Ontario Long Term Care HomesImprovement Targets and Initiatives

AIM MEASURE CHANGE

Quality dimension

Objective Measure / Indicator Unit / Population Source / PeriodCurrent

PerformanceTarget

PerformanceTarget justification

Planned improvement initiatives (Change Ideas)

Methods Process MeasuresGoal for change ideas

(2013/14)Comments

Track the training of staff using the Learning Management System (LMS).

Percentage of FVM staff-trained on Universal Falls Precautions.

100% by Mar. 31, 2016.

Conduct a quarterly audit of patient charts to identify percentage of patients with Universal Falls Precautions in place.

Percentage of FVM residents with Universal Falls Precautions in place.

50% by Dec. 31, 2015

75% by Mar. 31, 2016.

Review pressure ulcer risk scores and identify resident specific interventions/changes to care plans at the Home Area monthly meetings.

The number of residents reviewed each month for pressure ulcers at the Home Area meetings.

100% by Mar. 31, 2016.

Audit a sample of care plans monthly for evidence of resident specific pressure ulcer interventions. Present findings at Home Area monthly meetings.

Percentage of care plans with evidence of resident specific pressure ulcer interventions.

75% by Dec. 31 2015.

100% by Mar. 31, 2016.

Restraints: Percentage of residents who were physically restrained (daily) %/Residents

CCRS, CIHI (eReports) /

Q2 FY 2014/15

12.98% 12.33%5% decrease from

baseline.

Review and strengthen the ordering protocol for restraint application.

Review of ordering protocol conducted with findings reported to the Quality Improvement & Risk Management (QIRM) Committee.

Review complete and findings reported to QIRM.

Review complete and findings reported to

QIRM by Dec. 31, 2015.

Fairview Manor , 75 Spring Street, Almonte, ON KOA 1AO

Review and analyze data to gain a better

understanding of skin and wound issues and

opportunities.

Provide staff with opportunities for education

and training on best practices related to

pressure ulcer identification.

Huddle with the care team to identify required

changes to the care plan.

Implement Universal Falls Precautions for all FVM residents.

Provincial Score 13.8%

(Q2 FY 2014-15)8.5%

Falls: Percentage of residents who had a recent fall (in the last 30 days).

This indicator is not risk-adjusted and represents a rolling four quarter average.

%/Residents


Q2 FY 2014/15

Provincial Score 3.3% (Q2 FY 2014-15)

SAFE

TY

8.65%

Reduce Worsening of Pressure Ulcers

Reduce Falls

Reduce the Use of Restraints

Pressure Ulcers: Percentage of residents who had a pressure ulcer that recently got worse.


%/Residents


Q2 FY 2014/15

1.69% 1.5%

AIM MEASURE CHANGE

Quality dimension


PerformanceTarget




(2013/14)Comments


Audit of order protocol compliance conducted monthly and reviewed at the Home Area monthly meetings.

Percentage of restraint orders that comply with order protocol requirements.

75% by Dec. 31 2015.

100% by Mar. 31, 2016.

Improve the quality of medication reconciliation upon admission

Medication Reconciliation Quality Score at admission: The average Medication Reconciliation (MedRec) Quality Score at admission (Medical/Surgical Unit).

% / All Medical- Surgical Unit inpatients

Safer Healthcare Now Metrics / July 2014

Obtain baseline

rate.

Target to be determined.

The National Benchmark is 73% (Dec. 2014).

5% increase over baseline.

Provide all FVM Nurses with education on how to conduct a Best Possible Medication History (BPMH) and assess their competency post education.

BPMH education and quiz to be added to orientation for FVM nursing new hires.

Track FVM nurses' (full-time and part-time, including new hires) completion of BPMH learning module. Tracking method to be determined.

Percentage of Nurses who successfully complete BPMH education and quiz.

Percentage of Nurses who complete BPMH education and quiz within 2 weeks of start date.

75% of Nurses by Dec. 31, 2015.

100% of Nurses by Mar. 31, 2016.

Improve organizational financial health

Total Margin (consolidated): Percentage by which total corporate (consolidated) revenues exceed or fall short of total corporate (consolidated) expenses, excluding the implact of facility amortization in a given year.

%/N/aOHRS, MOH / Q3 FY 2014-15

-0.6%Greater than or equal to

0%

Hospital Service Accountability

Agreement requirement.

Continue to identify opportunities for revenue generation.

Continue to review efficiency of operations.

Review and analyze data to gain a better understanding of continence patterns and toileting plans (continence care) requirements.

Review continence care issues and requirements for each resident during the monthly Home Area meetings.

The number of residents reviewed each month for continence care at the Home Area meetings.

100% by Mar. 31, 2016.

Develop resident specific continence care interventions for inclusion in care plans.

Audit a sample of care plans monthly for evidence of resident specific continence care interventions. Present findings at Home Area monthly meetings.

Percentage of care plans with evidence of resident specific continence care interventions.

75% by Dec. 31 2015.

100% by Mar. 31, 2016.

EFFE

CTIV

ENES

S

Reduce Worsening Bladder Control

Incontinence: Percentage of residents with worsening bladder control during a 90-day period.


%/Residents


Q2 FY 2014/15

9.86%

Provincial Score 19.2%

(Q2 FY 2014-15)

5% decrease from baseline.

10.38%

AIM MEASURE CHANGE

Quality dimension


PerformanceTarget




(2013/14)Comments

RESI

DEN

T-CE

NTR

ED

Receiving and utilizing feedback regarding resident

experience and quality of life.

"Overall Satisfaction"

Resident Satisfaction: Percentage of residents responding to "Would you recommend this nursing home to others?" with "yes definitely"

%/ResidentsIn-house

survey / FY 2014-15

Yes Definitely =

84.8%

Yes Probably =

15.2%

Yes Definitely 85%

Strengthen the communication shared with residents and families during care conferences to support their understanding of clinical services provided (e.g. physio therapy).

Invite residents and families to provide feedback regarding information they received during their care conference. Document feedback within care conference summary note.

Percentage of care conference notes with feedback documented.

100% by Mar. 31, 2016.

Provide ongoing staff education and mentoring to monitor for signs of deterioration, such as dehydration, to identify problems earlier.

Evidence of inservices provided to RNs, RPNs and PSWs related to signs of deterioration.

Evidence of inservice(s) provided

Percentage of staff who attend the quarterly inservices.

Inservice (s) provided.

75% by Mar. 31, 2016.

Identify alternate ways to provide early treatment for common conditions, including congestive heart failure and chronic obstructive pulmonary disease.

Alternate ways to provide early treatment of common conditions, supported by best practice, presented to the QIRM Committee then disseminated to staff via the above inservices.

Evidence of Alternate ways to provide early treatment for common conditions endorsed by QIRM Committee.

Complete by Mar. 31, 2016.

5.59%

Reduce Potentially Avoidable

Emergency Department Visits

INTE

GRA

TED

Avoidable Emergency Department Visits: Number of emergency department (ED) visits for modified list of ambulatory care sensitive conditions (ACSC) per 100 long-term care residents.

MOHLTC will provide organizations with this data via LTCHomes.net

%/Residents

Ministry of Health Portal / Q3 FY 2013-14 - Q2 FY 2014-

15

5.0%Provincial Score 23.82% (Oct. 1, 2013-Sept. 30,

2014)

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2015/16 - Almonte General Hospital · 2015/16 Fairview Manor 75 Spring St., Almonte, ON., ... (QIP) is driven by the ... Staff recognize the importance of offering ice in a way that