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March 23, 2011
Part A:
Overview of Our Hospital’s Quality Improvement Plan
Our Hospital Quality Improvement Plan is centered on increasing the effectiveness of health interventions that we provide while continuing to deliver an exceptional healthcare experience to all who seek our support. Our Plan is a blend of initiatives that will result in changes in how we perform selected aspects of our work, and how we engage with our clients to increase their personal responsibility for achieving positive health outcomes. These initiatives will increase our ability to deliver the best possible level of service with the highest levels of quality, safety, person-centered care and positive health outcomes.
Our focus on increasing “near-miss” self-reporting will strengthen our employee engagement and sense of empowerment in re-designing parts of our work processes, procedures, practices or tools to better address potential impediments to higher levels of quality, safety and employee satisfaction.
As a small hospital, we are often required to transfer critically–ill patients to other facilities. Our focus on addressing medication reconciliation on all such transfers will ensure better continuity of patient care and better continuity of care regarding medications.
The focus on reducing the total number of inpatient days that are designated as Alternate Level of Care will reduce the time that a frail patient is inappropriately retained in hospital due to a lack of community-based options for care. This will increase the safety and effectiveness of caring for these patients and allow a more effective utilization of acute-care resources across the broader health system.
The implementation of a heart failure care pathway will ensure the best standard of care for these patients. This pathway is a regional initiative that will improve patient outcomes and help prevent re-admissions.
Our commitment to increased outreach to our clients who are addicted to tobacco products,will facilitate empowerment and support for individuals needing to assume more personal responsibility for their health outcomes.
Our effort to connect with CTAS level 3-4 patients who leave our Emergency Department without being seen by a physician will reduce the medical risks associated with their decision to leave and increase their potential to access the services that they need.
Our commitment to ongoing financial health is a recognition that it is only through the effective stewardship of our available resources that we are able to deliver the services so valued by our clientele.
The hospital is accountable to the province and the LHIN for key metrics and deliverables as part of its annual funding allocation agreements (H-SAA). It has a recently-updated Strategic Plan valid through to April 2012 from which are generated annual Operating Priorities for the organization and for the executive team. These commitments are tracked quarterly and reported through one or more of its Balanced Scorecard, its H-SAA reports to the LHIN, and its operational reporting through Board Committees to its Board of Directors. All initiatives in the Quality Improvement Plan are consistent with plans identified in at least one of these other planning and reporting processes.
The greatest challenge we face as a small hospital is ensuring the availability of the necessary threshold number of employee and leadership resources to achieve the various components of this plan. Critical to this success will be our ability to integrate the ownership and responsibility for these plans and the component tasks into the day-to-day work of all employees.. The recent launch of our Site Quality Committee will help address this ownership issue. Leadership will be tasked with effective resource utilization to ensure that the highest priority outcomes are adequately staffed for success.
The challenge on the near-miss reporting will be to ensure the perceived rewards for identification and reporting exceed the perceived pain and risk of disclosure for such reporting. This has been taken on as an early task by our new employee-dominated Site Quality Committee.
The risk on our ALC initiative arises from the limited community-based infra-structure and resources that are inherently less available in smaller rural areas to provide safe and acceptable community-based care . There is the additional reality that even these programs will generate patient “graduates”, who can no longer be cared for in the community, but who may still not require acute-level care. The hospital is the “de-facto” fall-back option for many families who are either unable or unwilling to care for their frail family member. Our ongoing support for the existing community-based Aging @ Home initiative and our commitment to the implementation of CCAC’s Home First Program will provide some risk mitigation opportunities.
The adoption of our health improvement and monitoring initiatives will be subject to the receptiveness of the community to the personal health accountability message, and will depend on our ability to be creative in motivating people to take responsibility for their own health. Our continued community outreach in health promotion is targeted at addressing this required attitudinal challenge.
The risk of not achieving the total margin objective is linked directly to the lack of any indication on available funding for 2011 -12 until well into the 2011-12 fiscal year, and the low potential to achieve in-year cost savings in a budget heavily dominated by salary costs.
Part B:
Our Improvement Targets and Initiatives
Please see the enclosed spreadsheet for the Quality Improvement targets for 2011-12.
Part C:
The Link to Performance-based
Compensation of Our Executives
Please see the attached spreadsheet to see how our executives' compensation is linked to performance against this performance improvement plan.
Part D:
Accountability Sign-off
I have reviewed and approved our hospital's Quality Improvement Plan and attest that, I believe that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan:
