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 Quality Improvement Plan

 

What is a Quality Improvement Plan (QIP)?

The Quality Improvement Plan (QIP) outlines our priorities and goals for improving quality and patient safety in the organization. Most importantly, it is a commitment to our community.

The Excellent Care for All Act (ECFAA), which was passed in 2010, requires all hospitals in the province to develop and publicly post an annual QIP to assist hospitals in further improving the quality and safety of the care we provide. Long-term care (LTC) facilities are also required to develop an annual QIP.

The annual QIP is one component of our broader corporate quality and patient safety program, and is comprised of two parts:

  1. Narrative: A brief overview of the organization's key quality improvement priorities for the upcoming year. It sets the overall context for the detailed descriptions of selected indicators and targets contained in the Work Plan.
  2. Work Plan: A detailed table that outlines our improvement targets and planned initiatives that will drive improvement in the indicators.

How is the Quality Improvement Plan (QIP) developed?

The QIP is developed in consultation with various groups within the organization to get a well-rounded perspective that represents the organization's challenges and goals for the upcoming year.

In addition to several discussions with senior leaders across the organization, other key contributors include: the Quality and Program Effectiveness Committee of the Board, our corporate Quality Improvement and Patient Safety Committee, and Patient Services Committee. Patient representatives sit on two of these committees, and provide input from the patient perspective. The Patient and Family Partnership Council has also been engaged to provide feedback on the initiatives in the QIP.

Our 2017/18 Quality Improvement Plan (QIP)

The selection of the 2017/18 indicators reflects our Strategic Plan, and is intended to address what is most important to our surrounding community in terms of quality, access and sustainability. These are aligned with the Quality Dimensions at Health Quality Ontario (HQO).

The 2018/19 QIP priority indicators for the hospital:

THP Strategic Plan Goal

HQO Quality Dimension

Goal

2017/18 Priority Indicator

Target

Quality

Patient Centered

We will improve the experience of patients and families who trust us with their care.

Patient Survey Results- "Would you recommend this hospital to your friends and family?"

≥80%
Quality

Effective

We will optimize capacity within our hospital through delivering the right care in the most appropriate clinical setting, addressing our capacity challenges while maintaining high quality of care for patients.

Emergency Department Admission Rates
LOS Index 1

≤11%

≤1

Quality

Safe

We will focus on the safety of our staff through continued engagement and awareness of a healthy and respectful workplace.

We will continue to improve the safety of care we provide by focusing on three core clinical practices: injurious falls, pressure ulcers, and medication reconciliation on discharge.

Increase the reporting of Workplace Violence Incidents

People Engagement

 

≥744

≥65.5%

Quality

Safe

We will focus on the safety of our staff through continued engagement and awareness of a healthy and respectful workplace.

We will continue to improve the safety of care we provide by focusing on three core clinical practices: injurious falls, pressure ulcers, and medication reconciliation on discharge.

Pressure Ulcers

Injurious Falls

Medication Reconciliation at Discharge

≤4.8%

≤1.6%

≥85%

Access

Timely

We will sustain access to our services by managing emergency department wait times for admitted patients

Emergency Department Wait Times for Admitted Patients

≤39 hours

Sustainability

Efficient

We will maintain our sustainability through achieving a balanced budget

Hospital Total Margin (GAAP)2

≥-0.4

1 LOS Index is defined as the actual acute length of stay (LOS) divided by expected acute HIG LOS for typical cases. Exclusions include deaths, sign-outs, transfers, neonates and patients in mental health beds. (Source: CIHI DAD)

2 Hospital Funding for 2018/2019 had not been confirmed at the printing of this document


The 2018/19 QIP indicators for Long Term Care at Trillium Health Partners3:

THP Strategic Plan Goal

HQO Quality Dimension

Goal

2017/18 Priority Indicator

Target

Quality

Resident Centered

To Increase overall satisfaction

Resident Survey Results- “I would recommend this site or organization to others”

100%

To increase the number of residents who feel listened to

Resident Survey Results- “How well do the staff listen to you?”

≥80%

To increase the number of residents who feel able to speak up about the Home

Resident Survey Results- “ I can express my opinion without fear of consequences”

≥90%

Effective

To reduce potentially avoidable ED visits

Number of emergency department (ED) visits for modified list of ambulatory care sensitive conditions per 100 long-term care residents

≤12%

Safe

We will reduce the number of falls for our residents

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

≤9%
To decrease potentially inappropriate antipsychotic medication use Percentage of residents receiving antipsychotics without a diagnosis of psychosis. ≤8.8%

To decrease the occurrence of pressure ulcers

Percentage of residents who developed a stage 2 to 4 pressure ulcer or had a pressure ulcer that worsened to a stage 2, 3 or 4 since their previous resident assessment

≤4.8%

3 There are 21 Long Term Care (LTC) beds at Trillium Health Partners which are located at the McCall Centre of the Queensway


 

For our 2018/19 Quality Improvement Plan, please click here »

For our 2017/18 Quality Improvement Plan, please click here »

For our 2016/17 Quality Improvement Plan, please see below:

For our 2015/16 Quality Improvement Plan, please see below:

For our 2014/15 Quality Improvement Plan, please see below:

For our 2013/14 Quality Improvement Plan, please see below: