Readmission Rate for Congestive Heart Failure Patients … · Objective Measure/Indicator Target...

Objective

Measure/Indicator Target justification In order to reflect the change ideas as identified

in this year's QIP, the target identified aims to

measure improvement achieved by March 2017.

The goal is to reduce the relative risk of

readmissions for CHF patients to St. Michael's by

10% which equates to an absolute risk of 2%

Unit / Population Target 20.1%

Source / Period Current performance (Baseline) 22.1%

Planned improvement

initiatives (Change Ideas)Methods Process measures Goal for change ideas Comments

1)Implement a General

Internal Medicine Rapid

Assessment Clinic (RAC)

a. Map workflow to support the implementation of the

General Internal Medicine (GIM) Rapid Assessment

Clinic (RAC)

b. Map workflow to support transition of GIM patients

from the emergency department (ED) to rapid

assessment clinic (RAC)

c. Conduct mock trial of RAC with GIM physicians to

understand and optimize flow of patients

d. Develop criteria and algorithm to support appropriate

referrals

e. Develop process to track number of patients with

primary diagnosis of CHF who are transitioned from ED

to RAC

• Algorithm to support appropriate

referral process to RAC created

• % of GIM physicians identified who

participate in RAC trial

• Number of patients with primary

diagnosis with CHF who are referred

to RAC


referrals implemented in the ED by

September 2016

• 100% of GIM physicians identified

participated in RAC trial by

September 2016

• Set baseline values between

implementation of RAC to March

2017

2)Use of risk-assessment tool

to identify and support

patients at high-risk for

readmissions

a. Identify how tool is currently being used on GIM

b. Identify opportunities to optimize use of tool,

including an increase in supports for CHF patients at

higher-risk of readmission

c. Incorporate tool with change ideas aimed at improved

integration with St. Michael's Family Health Team (FHT)

• % of CHF quality based procedure

patients where risk-assessment tool

was used on GIM

• % of CHF quality based procedure

FHT patients who had follow up

appointment scheduled within 7 days

• 100% of CHF quality based

procedure patients on GIM identified

by risk-assessment tool

• 75% of CHF quality based

procedure FHT patients who had

follow up scheduled within 7 days at

the family health team

Improvement work will be aligned with Family

Health Team transitions to home change idea in

order to ensure a cohesive workflow throughout

the discharge process.

3)Family Health Team (FHT)

transitions to home

a. Member of clerical team receives daily list of FHT

patients discharged from SMH and phones them to

book a follow-up appointment

• Perform chart audit of patients • Increase % of patients who are

discharged from medical service at

SMH who are seen by a FHT MD or

NP within 7 days

This project is ongoing and is being led by SMH

FHT. To ensure a comprehensive approach to

readmissions, all readmission change ideas will

be integrated with one another to improve

continuity of care.

4)Integrated communication

between General Internal

Medicine and FHT physicians

a. Use ONE Mail directory to create two-way

communication system between St. Michael's FHT and

GIM physicians

b. When a patient is admitted to GIM an email will be

sent to SMH FHT provider to open-up communication

link and will provide an update on patient status

• % of FHT staff who agree or

strongly agree that use of ONE Mail

communication supports better

patient care

• % of GIM staff who agree or



patient care

• 75% of FHT staff who agree or



patient care by March 2017

• 75% of GIM staff who agree or




The goal of this change idea, is to share

information between GIM and FHT physicians

bringing the family physician into the care plan

earlier in the patient's stay.

Change

Readmission Rate for Congestive Heart Failure Patients (CHF)Reduce readmission rates for patients with CHF

Risk-Adjusted 30-Day All-Cause Readmission Rate for Patients with CHF (QBP cohort) to St.

Michael's facility

% / CHF QBP Cohort

DAD, CIHI / Four quarters Oct 2014-Sept 2015

Objective

Measure/Indicator Target justification In order to reflect the change ideas as identified in this

year's QIP, the target identified aims to measure

improvement achieved by March 2017. The goal is to

reduce the relative risk of readmissions for COPD

patients to St. Michael's by 10% which equates to an

absolute risk of 2%


Source / Period Current performance (Baseline) 26.4%

Planned improvement


1)Implement a General

Internal Medicine Rapid

Assessment Clinic (RAC)

a. Map workflow to support the implementation of the

General Internal Medicine (GIM) Rapid Assessment Clinic

(RAC)

b. Map workflow to support transition of GIM patients

from the emergency department (ED) to rapid

assessment clinic (RAC)

c. Conduct mock trial of RAC with GIM physicians to

understand and optimize flow of patients

d. Develop criteria and algorithm to support appropriate

referrals

e. Develop process to track number of patients with

primary diagnosis of COPD who are transitioned from ED

to RAC


referral process to RAC created

• % of GIM physicians identified who

participate in RAC trial

• Number of patients with primary

diagnosis with COPD who are

referred to RAC


referrals implemented in the ED by

September 2016

• 100% of GIM physicians identified

participated in RAC trial by

September 2016

• Set baseline values between

implementation of RAC to March

2017

2)Use of risk-assessment tool

to identify and support

patients at high-risk for

readmissions

a. Identify how tool is currently being used on GIM

b. Identify opportunities to optimize use of tool,

including an increase in supports for COPD patients at

higher-risk of readmission

c. Incorporate tool with change ideas aimed at improved

integration with St. Michael's Family Health Team (FHT)

• % of COPD quality based procedure

patients where risk-assessment tool

was used on GIM

• % of COPD quality based procedure

FHT patients who had follow up

appointment scheduled within 7 days

• 100% of COPD quality based

procedure patients on GIM identified

by risk-assessment tool

• 75% of COPD quality based

procedure FHT patients who had

follow up scheduled within 7 days at

the family health team

Improvement work will be aligned with Family Health

Team transitions to home change idea in order to ensure

a cohesive workflow throughout the discharge process.

3)Family Health Team (FHT)

transitions to home

a. Member of clerical team receives daily list of FHT

patients discharged from SMH and phones them to book

a follow-up appointment

• Perform chart audit of patients • Increase % of patients who are

discharged from medical service at

SMH who are seen by a FHT MD or

NP within 7 days

This project is ongoing and is being led by SMH FHT. To

ensure a comprehensive approach to readmissions, all

readmission change ideas will be integrated with one

another to improve continuity of care.

4)Integrated communication

between General Internal

Medicine and FHT physicians

a. Use ONE Mail directory to create two-way

communication system between St. Michael's FHT and

GIM physicians

b. When a patient is admitted to GIM an email will be

sent to SMH FHT provider to open-up communication

link and will provide an update on patient status

• % of FHT staff who agree or



patient care

• % of GIM staff who agree or



patient care

• 75% of FHT staff who agree or




• 75% of GIM staff who agree or




The goal of this change idea, is to share information

between GIM and FHT physicians bringing the family

physician into the care plan earlier in the patient's stay.

Readmission Rate for Chronic Obstructive Pulmonary Disease (COPD)Reduce readmission rates for patients with COPD

Risk-Adjusted 30-Day All-Cause Readmission Rate for Patients with COPD (QBP cohort) to St.

Michael's facility

% / COPD QBP Cohort

DAD, CIHI / Four quarters Oct 2014-Sept 2015

Objective

Measure/Indicator Target justification SMH has the 6th highest participation rate

with the equity survey in the TC LHIN,

however there is opportunity to further

increase our rate and thus our available

equity data.

Unit / Population Target

90.0%

Source / Period Current performance 90.0%

Planned improvement


1)Continued collection of

equity survey data

a. Ongoing collection of equity survey data

with family team (FHT) patients, Ambulatory

clinic patients, emergency department

patients, first day surgery patients and direct

admit in-patients

b. Create and implement plan for

sustainability for collection of equity survey

data within Emergency Department (ED)

c. Initial analysis of equity data to identify

improvement opportunities to inform future

quality initiatives

• Equity survey collection rate for

FHT patients, Ambulatory clinic

patients, emergency department

patients, first day surgery patients

and direct admit in-patients

• Equity survey collection rate

within the ED

• Plan for sustainability of equity

survey data collection in the ED

created

• Initial analysis of equity data

completed

• 90% of those approached

complete the equity survey for

FHT patients, Ambulatory clinic

patients, emergency department

patients, first day surgery patients

and direct admit in-patients

• Baseline of participation rate of

equity survey for ED patients

created

• Summary of equity

opportunities and results created

by March 2017

St. Michael's has the 6th highest

participation rate with the equity survey in

the TC LHIN and this change idea aims to

support continued collection of equity data

throughout the organization.

EquitySustain equity data collection

Participation Rate for Equity Survey: The number of patients approached to

participate in collection of equity data who completed the survey

% /Family , Ambulatory Clinic, Emergency Department, First Day Surgery Patient

and Direct Admit In-Patients

Hospital collected data / April 2016 - March 2017

Objective

Measure/Indicator Target justification As a new survey is being implemented to capture

patient feedback (NRCC), we will be unable to

compare results between the two sources. This

year will be used to understand our current

state, develop a baseline and internal discharge

satisfaction measures.

Unit / Population TargetDeveloping Baseline

Source / Period Current performance Developing Baseline

Planned improvement


1)Optimize the use of

discharge toolkit components

on Orthopaedic and Trauma

Neurosurgery Units

a. Assemble improvement working group

b. Identify gaps and opportunities to improve both

on unit processes and off unit processes related to

discharge planning

c. Plan and test improvements to discharge

planning, including improved communication tools

d. Monitor impact using performance data

• % of patients with an Estimated Date of

Discharge(EDD) entered within 24hrs of

admission

• % of patients who agree or strongly

agree they feel more prepared for

discharge after the implementation of

the discharge toolkit

• % of patients who received

preadmission EDD information

• 80% of patients have a Estimated Date

of Discharge entered within 24hrs of

admission

• 75% of patients who agree or strongly

agree they feel more prepared for

discharge after the implementation of

the discharge toolkit

• 75% of patients received

preadmission EDD information

Improvement work will be aligned with Patient

Oriented Discharge Summary(PODS) to ensure a

cohesive workflow throughout the discharge

process.

2)Implementation of Patient

Oriented Discharge

Summary(PODS) on

Orthopedic and Trauma

Neurosurgery Units

a. Work with multidisciplinary team to create

standardized PODS content for Orthopedics and

Trauma Neurosurgery units

b. Develop service specific content in the

electronic discharge system

c. Build teaching capacity in Orthopedic and

Trauma Neurosurgery staff through "Teach back"

training to enhance use of the PODS tool

d. Implement PODS tool for patients discharged

from the Orthopedic and Trauma Neurosurgery

Services

• % patient satisfaction scores related to

discharge questions on new NRC survey

• % of patients discharged that received a

Patient Oriented Discharge Summary on

Orthopedic and Trauma Neurosurgery

Units

• % of full and part time nurses on


Units to receive "Teach back" patient

education training

• Develop baseline for patient discharge

satisfaction utilizing the new NRC tool

between April 2016 - March 2017

• 80% of patients discharged received a

Patient Oriented Discharge Summary on


Units

• 70% of full and part time nurses on


Units receive "Teach back" patient

education training

3)Develop method to collect

timely discharge satisfaction

data to inform the creation of

internal discharge satisfaction

measures

a. Conduct an internal and external review for best

practice

b. Identify question and delivery options for

patient discharge satisfaction surveys

c. Plan and test patient discharge satisfaction

collection on a small scale

d. Evaluate and improve new method for timely

discharge satisfaction data

e. Analyze data to determine best internal

measures for discharge satisfaction

• Identify method for collecting patient

discharge satisfaction feedback

• Develop content of patient discharge

satisfaction collection tool

• Create a plan to implement collection

of timely discharge satisfaction data

• Develop internal measures for

discharge satisfaction

• Identify method for collecting patient

discharge satisfaction feedback by July

2016

• Develop content of patient discharge

satisfaction collection tool by July 2016

• Implement collection of timely

discharge satisfaction data by

September 2016

• Internal measures for discharge

satisfaction developed by September

2016

In order to understand the patient's perspective

of improvement initiatives, a more timely

feedback mechanism is required. Therefore we

are committed to finding a new solution and also

developing our own internal measures for

discharge satisfaction.

Discharge Patient SatisfactionImprove patient discharge satisfaction

Discharge Patient Satisfaction: Patient satisfaction related to continuity & transition

% / All acute patients

NRC Picker / To be established

4)Develop a robust reporting

processes across discharge

continuum

a. Review of current patient flow and discharge

process indicators

b. Develop recommendations for refined

indicators and illicit feedback from staff

c. Develop mechanism and timeframes for

providing performance data

d. Explore structure to best support data sharing,

including implementing performance boards

e. Implement changes

• Refined patient flow and discharge

process indicators and targets identified

• New performance reports created and

disseminated to units

• Units with Performance Boards

implemented

• Refined patient flow and discharge

process indicators and targets identified

by July 2016

• New performance reports created and

disseminated to units by August 2016

• Performance Boards implemented

and updated according to a standard

process on Orthopaedic and Trauma

Neurosurgery Units by May 2016

In order to provide the units with more

insightful, timely feedback on the tests of

change, Performance Boards will be

implemented across all the units involved in a

2016/17 QIP project.

Objective

Measure/Indicator Target justification This target is an internal benchmark. We have

based this on the improvement our previous

change ideas have led to in other clinical areas. A

10% improvement is expected based on this

year's work.

Unit / Population Target 7.19

Source / Period Current performance 8.00

Planned improvement


1)Implement post fall debrief

tool and process on Trauma

Neurosurgery Unit (9CC)

a. Assemble improvement working group

b. Agree on a standard process/ timelines for

use of Standard Review Template following a

fall with harm

c. Devise evaluation plan to review efficacy of

template

• Determine baseline completion

rate for Standard Review process

• Set target for completion of

Standard Review process

• Baseline completion rate of

Standard Review process identified

by November 2016 • Target for

Standard Review completion, set by

December 2016

The 2016/17 Falls improvement work will focus

on Trauma Neurosurgery Unit (9CC) and General

Internal Medicine Unit (14CC) as two units with

the highest in-patient falls rates. The goal is to

refine the process for using a Standard Review

Tool on the pilot units before spreading it to the

rest of the hospital.

2)Improve identification of

patients at risk for falling

a. Ensure falls risk assessment is completed

upon admission for all patients

• % of patients screened within

24hrs of admission to all inpatient

units

• 95% of patients screened within

24hrs of admission to all inpatient

units

3)Implement strategies to

reduce falls for at risk

patients

a. Implement intentional hourly overnight

rounding on Trauma Neurosurgery Unit (9CC)

b. Implement individualized care plans for

patients screened at risk for falls on Trauma

Neurosurgery Unit (9CC) & General Internal

Medicine Unit (14CC)

c. Explore technology options (e.g. lowered

beds, bed alarms) for patients screened at risk

for falls

• Number of falls per 1000 patient

days

• Number of falls per 1000 patient

days for patient who have been

screened as at risk for falls

• Completion of care plans for

patients identified at risk for falls

on Trauma Neurosurgery Unit

(9CC) & General Internal Medicine

Unit (14CC)

• Reduce falls by 10% on Trauma

Neurosurgery Unit (9CC) by March

2017

• Reduce falls by 10% on General

Internal Medicine Unit (14CC) by

March 2017

• 75% of patients identified at risk,

have a completed care plan for

Trauma Neurosurgery Unit (9CC) &

General Internal Medicine Unit

(14CC), by March 2017

After successfully testing the practice of

intentional rounding for General Internal

Medicine Unit (14CC) over the past year, the

initiative will be extended to Trauma

Neurosurgery Unit (9CC) to examine if similar

results can be achieved.

4)Provide key performance

data to General Internal

Medicine (14CC) and Trauma

Neurosurgery (9CC) Units

a. Design performance board template

b. Implement Performance Boards on Trauma

Neurosurgery Unit (9CC) & General Internal

Medicine Unit (14CC)

c. Design standardized process for updating

the performance board

• Units with Performance Boards

implemented

• % of staff who agree, or strongly

agree that the performance board

supports improved

communication of performance

data

• Performance Boards implemented

and updated according to a standard

process on Trauma Neurosurgery

Unit (9CC) & General Internal

Medicine Unit (14CC) by May 2016

• 75% of staff who agree, or strongly

agree that the performance board

supports improved communication

of performance data, by January

2017

In order to provide the units with more insightful,

timely feedback on the tests of change,

Performance Boards will be implemented across

all the units involved in a 2016/17 QIP project.

FallsAvoid patient falls

Falls rate: Number of falls in General Internal Medicine and Trauma

Neurosurgery per 1,000 patient days in General Internal Medicine and Trauma

Neurosurgery Units

% / General Internal Medicine and Trauma Neurosurgery inpatients

Hospital collected data / January - December 2015

Objective

Measure/Indicator Target justification Focused improvement efforts on the intensive

care units (ICUs) aim to shift the culture. This

is expected to provide some overall

improvement (5% for each ICU) this year, but

support creation of foundational change

culture for future improvements.

Unit / Population Target67.0%

Source / Period Current performance63.6%

Planned improvement


1)Focused efforts in the

intensive care units (ICUs)

aimed at improving

appropriate glove use

a. Assemble improvement working group with

representation from four ICU's

b. Conduct current state analysis with focus on culture and

common reasons for hand hygiene moment 1 misses

c. Plan and test strategies for improving processes around

glove use and providing peer feedback

d. Conduct staff education and training to support culture

change

e. Monitor hand hygiene opportunities and compliance

data

• Development of multi-disciplinary

working group including: nursing,

health disciplines, management and

medical staff

• Moment 1 hand hygiene compliance

in the four ICUs

• Rate of moment 1 hand hygiene miss

related to glove use

• Working group assembled,

monthly meetings booked by April,

2016

• 5% point improvement in hand

hygiene compliance in each ICU by

March 2017

• 10% reduction in misses related to

glove use by March 2017

The goal is to create a forum for discussion about

changes made on each unit and their perceived and

real impacts on hand hygiene compliance. This

should support dissemination of key change ideas to

support a culture shift.

2)Implement a Peer Auditor

Program

a. Develop a program for formal training and certification

of front line staff and managers as "Hand Hygiene

Ambassadors"

b. Garner feedback from frontline and leadership staff

c. Embed best practice with a focus on proficiency using

the HandyAudit tool and providing feedback to peers/staff

• Peer auditing curriculum developed

• # of units with one front-line staff

certified as a peer auditor

• # of peer auditors completing at least

one audit per month

• Curriculum developed by April

2016

• 80% of units have at least one

certified peer auditor by December

2016

• 75% of certified auditors perform

at least one audit per month by

March 2017

Following the positive reception of the On-the-spot

feedback trial, the peer auditing program aims to

provide front line staff with information regarding

when, where, how and why they are missing hand

hygiene. It will also encourage front line

participation in hand hygiene improvements efforts,

which could positively influence culture change.

3)Explore opportunities to trial

an electronic solution for real-

time feedback

a. Assess and compare available electronic solutions for

real-time feedback

b. Select and implement an electronic solution to provide

real-time hand hygiene compliance data

• Develop pilot implementation plan

to support introduction of real-time

feedback

• Develop plan to evaluate pilot of real-

time feedback solution

• Pilot of real-time feedback

solution implemented by October

2016

• Complete evaluation of real-time

feedback solution by March 2017

This solution aims to provide information to units in

real-time as to their current rate of hand hygiene.

This is valuable information that can be actioned

immediately should a reduction in compliance be

identified.4)Provide key information to

units regarding their Hand

Hygiene performance for

moment 1

a. Meet with inpatient units to review data, set targets and

action plans for 2016/17

b. Disseminate monthly performance reports reflecting

unit specific targets, challenges/barriers and common

misses to units

c. Collect and share hand hygiene misses information for

intensive care units as part of monthly reporting

d. Performance Boards implemented with a standard

process to update, on four ICUs

• # of units with moment 1 compliance

target selected

• # of units receiving monthly

compliance reports

• # ICU's receiving moment 1 misses

data

•# of units with Performance Boards

implemented

• 100% of inpatients units with

moment 1 compliance target

selected by April 2016

• 100% of units receiving monthly

reports by April 2016

• 100% of ICUs receiving monthly

details regarding moment 1 misses

by April 2016

• Four ICUs with Performance

Boards implemented and updated

according to a standard process by

May 2016

In order to provide the units with more insightful,

timely feedback on the tests of change, Performance

Boards will be implemented across all the units

involved in a 2016/17 QIP project.

Hand HygieneReduce hospital acquired infection rates

Number of times that hand hygiene was performed before initial patient contact

during the reporting period, divided by the number of observed hand hygiene

opportunities before initial patient contact per reporting period, multiplied by 100.

% / Health providers in the entire facility

Publicly Reported, MOH / Jan 2015 - Dec 2015

Objective

Measure/Indicator Target justification The average BPMH completion for the last 4

quarters has been 72.7%. The focus this year

is not to actively improve performance but

to maintain the current rate.


Source / Period Current performance 73.0%

Planned improvement


1)Build an electronic

Medication Reconciliation

(eMedRec) solution

a. Assemble working group to inform

electronic medication reconciliation tool

b. Identify current state workflow and data

requirements to support implementation of

electronic medication reconciliation tool

c. Design and test electronic medication

reconciliation tool with frontline users

d. Modify based on user feedback

e. Implement tool and plan for spread

• Process maps of relevant

medication reconciliation

workflows

• # of identified staff for

participation in user testing

• New electronic medication

reconciliation tool created

• Process maps of relevant

medication reconciliation

workflows completed by

September 2016

• 100% of identified staff

participated in user testing

• New electronic medication

reconciliation tool implemented

by March 2017

This work will be led by the IT department

and Quality & Performance team will

provide support as needed for

implementation of the eMedRec solution.

2)Support ongoing

completion of BPMH on

admission (Inpatient Units)

a. Modify performance reports to:

i) reflect BPMH completion (vs. medication

reconciliation)

ii) categorize elective surgical patients who

had their BPMH completed in the pre-

admission facility (PAF)

b. Develop engagement and communication

strategy with the surgical areas with high

numbers of elective PAF patients

c. Introduce manual chart audits to assess for

quality of BPMH and medication

reconciliation

• % of admitted patients with

BPMH completed

• Baseline for quality assessment

collected through audit process

• Performance reports adjusted

to contain revised metrics

• 73% of admitted patients with

BPMH completed by March 2017

• Baseline quality assessments

for BPMH and medication

reconciliation completed for each

unit by December 2016

• Revised performance reports in

place by September 2016

The new methodology will categorize the

results based on the area that completed

the BPMH. For elective surgical patients, the

BPMH is completed in PAF and not on the

unit by the admitting service. The

performance reports and rates for each

service will now reflect this differentiation

and will be a more accurate reflection of the

BPMH and medication reconciliation

processes that occur on surgical services.

3)Support Medication

Reconciliation process on

Mental Health Unit

a. Continue to monitor monthly BPMH and

medication reconciliation completion rates on

Mental Health

b. Disseminate monthly performance rates to

the Mental Health Quality Committee

• % of admitted patients with

BPMH completed

• 80% of patients admitted to

Mental Health with BPMH

completed achieved by March

2017

The Quality & Performance team will

continue to maintain and support the

improvement efforts made by the Mental

Health program with BPMH completion and

medication reconciliation processes for

admitted patients.

Medication ReconciliationMaintain the current rate of best possible medication history completion on admission

Best possible medication history(BPMH) completion: The total number of

patients with a best possible medication history completed as a proportion of

patients admitted (excluding Labour & Delivery and NICU)

% / All inpatients (excluding L&D and NICU)Salumatics / October - December 2015

Objective

Measure/Indicator Target justification This is an internal target that aligns with our

Hospital Services Accountability Agreement

as well as factoring in foreseen challenges

with our corporate redevelopment project

that will periodically impact bed availability.

As such, our target reflects consideration of

these challenges.

Unit / Population Target 23.0 hrs

Source / Period Current performance 23.1 hrs

Planned improvement


1)Smooth admissions from

emergency department

(ED) to General Internal

Medicine (GIM) throughout

the day

a. Create implementation plan to support

revised bed footprint for GIM

b. Assemble improvement working group

consisting of GIM frontline and leadership

staff

c. Define standards for bed-empty time

including support service roles

• Implementation of revised bed

footprint for GIM

• Standards developed for bed-

empty time

• Bed-empty time from ED to GIM

• Implementation of revised bed

footprint by December 2016

• Bed-empty time standards in place

by October 2016

• 10% improvement in Bed-empty

time from ED to GIM by March 2017

Our GIM unit has the highest volume of

admissions from the emergency department.

These strategies will assist in finding ways to

efficiently transition patient from the

emergency department to the floor. A

collaborative approach by both GIM and ED

will further facilitate our efforts.

2)Improve surge

management practices

a. Evaluate current surge management policy

and practice

b. Refine criteria for surge management and

define responsibilities for stakeholders

involved

c. Plan and Test changes to surge

management practice

d. Evaluate impacts of revised surge


• Revised policy and criteria for

surge management developed

• Implement revised surge


• Develop evaluation criteria for

new surge management policy

and practices

• Revised policy and criteria for surge

management in place by September

2016

• Evaluation criteria and

methodology developed for use by

January 2017

Having the ability to pro-actively respond to

increases in bed occupancy is reliant on

actionable surge management practices and

policies. This includes decision making aides

and clear role accountabilities.

3)Optimize daily flow

processes

a. Garner feedback from staff regarding

current process for daily bed management

meetings

b. Develop process improvements for daily

bed management meetings

c. Explore opportunities to utilize existing

electronic solutions to provide patient flow

dashboard

• Revised daily bed management

structure developed

• % of staff who agree, or strongly

agree that the revised structure

has positive impact on

management of daily patient flow

• Identified electronic patient

flow dashboard tool

• Revised daily bed management

structure in place by September 2016

• 75% of staff agree, or strongly agree

that the revised structure has positive

impact on management of daily

patient flow

• Implement electronic patient flow

dashboard tool November 2016

Embedding daily patient flow best practices

will assist in providing more timely

movement of patients throughout the

hospital.

Emergency Department Wait TimeReduce wait times in the ED

ED Wait times: 90th percentile ED length of stay for Admitted patients

Hours / ED patients

CCO iPort Access / January 2015 - December 2015

4)Refine existing daily


related to Alternate Level

of Care (ALC) on General

Internal Medicine (GIM)

a. Develop process for regular review of ALC

patients

b. Develop method to promote early

engagement of patients and families

c. Design and test ALC escalation algorithm

• Regular review process for ALC

developed

• % of ALC days compared to

patient care days on GIM

• ALC escalation algorithm

created and tested

• Regular review process for ALC in

place by August 2016

• 10% improvement in ALC days

compared to patient care days on

GIM

• ALC escalation algorithm created

and tested by October 2016

These strategies are focused on reducing the

highest proportion of ALC patients within the

organization.

Readmission Rate for Congestive Heart Failure Patients … · Objective Measure/Indicator Target...

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