2015/16 Quality Improvement Plan for CCAC 2015/16 Quality

2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
AIM
Measure
Quality dimension
Objective
Measure/Indicator
Safety
To reduce falls
among long-stay
home care clients
Percentage of adult long-stay
home care clients that have a fall
on their follow-up RAI-HC
Assessment
Current
performance
Target
Target justification
36.10%
35%
Previously stated a
target of reducing falls
to 33% by 2017 based
on achieving
comparable
performance with
CCAC peers. Falls rates
locally and across the
province have
increased, likely related
to increase in age and
complexity of the long
stay population. Target
of 35% reflects these
changes and aligns to
current provincial
average rates of falls
Change
Planned improvement initiatives
(Change Ideas)
Methods
Process measures
Goal for change
ideas
Comments
1)Continue roll out of
standardized falls protocol for
complex seniors who have been
identified as high risk for falls
1) Continue implementation of standardized falls
protocol for complex patients at routine
reassessments
2) Support 30 day follow-up with patient by CC
3) Monitor reported falls for all complex patients "
% complex patients who triggered the falls CAP
on the RAI-HC, who have a service plan in
compliance with falls protocol (as of
reassessment) and have had a 30 day follow-up
from their Care Coordinator
80% of complex
patients identified
as high risk have a
falls plan in place
in line with falls
protocol by Feb
2016
A standardized protocol for
patients at high risk of falls
was developed and has been
tested with 30 complex
patients. 8 of the 12 patients
who have had a 6 month
reassessment continued to
have a falls plan in place and
reported fewer falls in the
previous 90 days. We are
aiming to expand to all
complex patients at risk of
falls and continue to
monitor the impact of
compliance to the protocol
and follow-up with patients
at 30 days.
2)Expand implementation of
standardized falls protocol to
Adult Chronic population
identified as high risk for falls
"1) Introduce falls protocol for adult chronic
patients at routine reassessents 2) Support 30 day
follow-up with patient by the CC 3) Monitor
reported falls for all adult chronic patients"
% adult chronic patients who have triggered the
falls CAP on the RAI-HC, who have a service plan
in compliance with falls protocol (as of
reassessment) and have had a 30 day follow-up
from their Care Coordinator
50% of adult
chronic patients
identifed as high
risk have a falls
plan in place in line
with falls protocol
by Feb 2016
Adult Chronic population are
a large population and have
a high rate of falls so we aim
to expand our falls protocol
to this group. The protocol is
implemented at 6 month
reassessments so we do
expect to reach at most half
of this population over the
next 9-12 months.
Page 1 of 4
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
Effectiveness
To reduce the
number of
unplanned ED visits
among home care
clients
Percentage of home care clients 9.6%
with an unplanned, less-urgent ED
visit within the first 30 days of
discharge from hospital
7%
3)Establish audit plan to manage
compliance to falls protocol
1) Develop audit plan including frequency of audits Audit process and reporting with appropriate
and percentage of charts to be audited
follow-up from managers is in place
2) Develop audit tool, and reports
3) Train auditors/managers and implement audit
and management follow-up"
100% complete by Support change in practice
Q4
and identify barriers to
change
Target in line with
1)Expand collection of local
provincial average
performance data by
performance for CCACs implementing ED-CCAC
notification system at remaining
hospital sites in the south east
region
1) Partner with the remaining two hospitals in the Data from remaining two hospital sites will be
south east to complete regional implementation incorporated into local ED visit indicator.
of an ED-CCAC notification system
2) Incorporate new data into local ED visit
indicators for monitoring and analysis
100% complete by Expanding our ED CCAC
October 2015
notification system was
identified in our last year's
improvement plan. We have
initiated this work in
partnership with local
hospitals and the LHIN, and
will complete it in the early
part of the coming year.
2)Investigate strategies to reduce
less urgent ED visits related to
skin/wound for short stay and
post-surgical patients
1) chart audit for patients who have presented to
ED with CTAS 4 or 5 for skin/wound and post
surgical complications
2) engagement with service providers and/or
patients
3) design and test a small scale intervention to
reduce ED visits 4) develop an indicator to
measure target population and monitor
% of Chronic Adult Seniors who present to ED by 1) planned change
month
to test by
November 2015 2)
tested intervention
by March 2016
with a single ED
dept
3)Investigate the linkage between
PSW service level and frequency
of ED visits for chronic senior
patients of CCAC.
1) Review of available research
2) Engage a small sample of patients to
understand the circumstances leading up to their
last ED visit
3) Develop a service intervention to test
4) Conduct a small test
5) Develop measurement system to evaluate
change and monitor for 6-12 months"
% of Chronic Seniors who present to ED by
month
Page 2 of 4
Reviewing ED presentations
in one of our geographic
areas indicates that
approximately 10% of less
urgent visits (CTAS 4&5) in
one of our regions are
related to skin/wound.
Some appear to be planned
but further investigation is
warranted.
Have test designed Initial analysis of the
and initiated by
available data related to ED
Feb 2016
visits for a 6 month period
highlights that chronic
seniors present to the ED at
a higher frequency. There is
some research to indicate
that different supports in
the home can prevent ED
visits and we aim to
investigate and test options.
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
Access
To reduce avoidable
hospital admissions
among home care
clients
Percentage of home care clients
who experienced an unplanned
readmission to hospital within 30
days of discharge from hospital
To reduce service
wait times
17.70%
17.70%
Maintain current
performance level
For the next fiscal year, we
are aiming to maintain
current hospital readmission
rates. No specific
improvement activities are
planned as we are
prioritizing efforts to reduce
unplanned ED visits, falls,
and wait times.
5 Day Wait Time - Personal
87.5%
Support for Complex Patients: %
of complex patients who received
their first personal support service
within 5 days of the service
authorization date.
87.5%
Maintain current
performance level
5 Day Wait Time - Nursing Visits: % 92.50%
of patients who received their first
nursing visit within 5 days of the
service authorization date.
94%
Target in line with
1)Further analysis to identify
provincial average
reasons why a small percentage
performance for CCACs of patients who are available for
service do not receive nursing
within 5 days
1)Routine monitoring of wait
times at Quality and Patient
Safety Committee
2)Assess risk of providing more
nursing service in a clinic setting
on wait times for patients.
Page 3 of 4
1) Develop a local measure for 5 day wait times
for PSW and implement a quarterly review
Local measure established and quarterly review Review in place by For the next fiscal year, we
implemented
December 2015
are aiming to maintain
current wait time for PSW
for complex patients. The
volume of patients whose
wait exceeded 5 day is very
low and predominantly
driven by the availability of
the patient. Since our
performance is currently
better than the provincial
benchmark, we are electing
to focus our efforts on other
improvement initiatives
"1) Audit 20% of patient charts for patients over a Primary reasons for delay identified with plans
six month period, who waited more than 5 days
for improvement in place
for nursing service but whose available date
indicates availability
2) consultation with nursing service providers on
process for booking first visits, and reasons for
delay with specific patients from audit "
100% completed Analysis of 6 months of wait
by September 2015 time data indicates that the
majority of patients who do
not receive nursing service
within 5 days are not
available within 5 days.
1) Audit 20% of patient charts in a six month
Risk level assessed and response plan developed 100% completed
period for patients who wait more than 5 days for
by September 2015
a nursing clinic appointment
2) Consultation with nursing clinic providers to
evaluate process for scheduling first visits, and
reasons for delay
We have recently opened
new nursing clinics in our
area and are providing
nursing care to a larger
number of patients in a
clinic setting.
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
Client-centred
To improve client
experience
Percent of home care clients who 93.9%
responded “Good”, “Very Good”,
or “Excellent” on a five-point scale
to any of the following client
experience survey questions
• Overall rating of CCAC services
• Overall rating of
management/handling of care by
Care Coordinator
• Overall rating of service
provided by service provider
93.9%
Maintain current
performance.
Equitable
To reduce variation
in service for long
stay patients with
similar needs
Standard Services for Long Stay
80.5%
Patients: Percent of active long
stay patients whose personal
support (PSW) services are within
established service guidelines
90.0%
Changes in service plan
occur during natural
reassessment
schedules. Target
acknowledges known
exceptions to the
standard.
Our performance in overall
satisfaction continues to be
very high. This year, we do
not have specific change
ideas targetted at shifting
overall satisfaction scores.
Instead, as part of our
strategic plan, we are
developing a patient
engagement program to
inform our improvement
activities and service design.
This will include testing
different methods for
engaging patients.
1)Implementation of Needs Risk
Indicator to establish standard
PSW service levels for all new
patients at contact assessment
1) Generate a needs risk indicator (NRI) for all new
patients at contact assessment, to guide service
plan
2) Implementation at contact assessment
2)Continue roll out of
standardized PSW service
guidelines for long stay patients
as part of scheduled
reassessment and service plan
adjustment
1) Reassess patient needs at scheduled
Percentage of patients on service prior to
reassessment date and adjust PSW service level to August 2014 whose PSW service units align to
align to needs based guidelines
guidelines.
Page 4 of 4
Percentage of new patients referred from
hospital whose weekly PSW service units aligns
to NRI based service guidelines for the first 2
weeks of service.
98% of new
patients from
hospital receive
personal support
services within
guidelines by
March 2016.
Current service standard
guidelines are based on
comprehensive needs
assessment at the first
home visit. The NRI guides
the initial service plan for
patients who receive service
upon discharge from
hospital in advance of home
visit. Baseline of 92% of all
new patients from hospital
receive standard service
levels.
90% of patients on
service prior to
August 2014 will
have PSW service
within needs based
guidelines by
March 2016
Implementation of needs
based PSW service level
guidelines started in August
2014. This change idea
pertains to continued roll
out through routine
reassessments. Target
allows for exceptions to the
guideline to meet the needs
of individual patients.