Quality Improvement and Patient Safety Plan Health Sciences North / Horizon Santé-Nord

2012-2013

www.hsnsudbury.ca

Part A: Overview of Our Hospital’s Quality Improvement Plan

Purpose of this section: Quality Improvement Plans (QIPs) are, as the name suggests, all about improvement. They are an opportunity for hospitals to focus on how and what to improve, in the name of better patient-focused care. As such, they will be unique documents, designed by, and for, each individual hospital. Overall, a QIP should be seen as a tool, providing a structured format and common language that focuses an organization on change. The QIP will drive change by formalizing a plan and facilitating shared dialogue to support continuous quality improvement processes. This introductory section should highlight the main points of your hospital’s plan and describe how it aligns overall with other planning processes within your hospital and even more broadly with other initiatives underway in your hospital and across the province. In addition, this section provides you with an opportunity to describe your priorities and change plan for the next year. Please refer to the QIP Guidance Document for more information on completing this section.

[In completing this overview section of your hospital’s QIP, you may wish to consider including the following information:  Provide a brief overview of your hospital’s QIP.  Describe the objectives of your hospital’s QIP and how they will improve the quality of services and care in your hospital.  Describe how your plan aligns with other planning processes in your organization.  Describe how your plan takes into consideration integration and continuity of care.  Describe any challenges and risks that your hospital has identified in the development of their plan.]

Introduction

Health Sciences North/Horizon Santé-Nord (HSN) is an academic health sciences network that is devoted to health, not sickness. Core to our mission is the delivery of the highest quality of patient care, in an environment focused on innovation and research, teaching and learning. The primary focus of our quality and patient safety plan is aimed at ensuring that the population we serve experiences, no needless death; no unnecessary waiting; no needless pain or suffering; no waste; no helplessness in those served or being served and no one left out.

We are a network of integrated facilities and programs working together for the benefit of our patients, communities, physicians, researchers, staff, and learners in the areas of prevention, diagnosis, treatment and care. Based on our core values we actively engage patients; families; staff, physicians and our community partners in finding innovative solutions to the issues and challenges that we face in our service area.

As part of our continued commitment to being open and transparent to the communities we serve and furthering our efforts to provide the best patient care, we are pleased to provide the patients and families we serve with our 2012-13 Quality Improvement and Patient Safety Plan.

How do we plan to improve the quality of services and care in our organization?

Health Sciences North views improving the quality of care and services provided to the population it serves as our primary purpose. This core value is incorporated in our systematic approach to defining our long-term strategic objectives and our annual business planning processes. Our quality improvement/patient safety plan allows us to articulate and execute on our key corporate-wide focus improvement priorities.

The Board and senior team has adopted and uses the IHI Execution framework as described in figure 1.

Figure 1: HSN Execution Framework1

Achieve Strategic Goals

Manage Local Develop Human Improvement Resources

The quality improvement focus areas described in our plan are driven by the needs of the patients/families and communities that we serve; a review and analysis of the perceived internal needs of HSN balanced with the external priorities expressed by our LHIN, the Ministry of Health and Long- term Care.

It is the Board and Senior Leadership Team’s intent that HSN will be able to:

 Deliver on the system-level aims that are outlined in this plan through the coordination of a defined number of projects that have been aligned with our budgetary strategies.

 Ensure that there is appropriate local management and monitoring of performance to support the achievement and sustainability of our strategic aims across the organization in an environment where staff feel engaged and energized in their daily work.

 Develop and maintain the right mix and number of staff and physician partners who have the capacity and capability to provide leadership for improvement activities and ensure the development of a culture of continuous improvement at all levels of the organization.

To ensure that the organization effectively moves through the process from setting improvement goals to ensuring results the Board and Senior Leadership Team has made the commitment to a rigorous and disciplined approach of:

 Identifying ambitious performance goals for the key improvement opportunities identified;

1 Nolan TW. Execution of strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement 2007. (Available on ww.IHI.org)

 Developing a selection of evidence informed projects to support the realization of each area identified;

 Identifying and deploying the appropriate and necessary resources that will support the execution of the work outlined;

 Establishing an oversight process that will guide, support, monitor the improvement work all levels of the organization.

What are the Objectives for the Health Sciences Quality Improvement/patient Safety Plan

Figure 2 summaries the four (4) Figure 2: HSN FY- 2012/13 Quality Improvement Priorities improvement priority areas that the The HSN four (4) key quality improvement priorities Board and Senior Leadership Team are as follows: have selected to focus on for this 2012/13 Quality and Patient Safety Plan. • Priority Area 1: Zero Harm to Patients as a Figures three (3) through six (6) provide Result of Care a high-level overview of the initiatives • Priority Area 2: Improve Access to Care and that the organization will pursue in order to improve its performance in these key Services areas and how the Board and Senior • Priority Area 3: Improve the Patient Experience Leadership team intends to provide with Care oversight of the execution of the • Priority Area 4: Reduce Avoidable Admissions/ improvement initiatives from the Macro to Micro levels of the organization. Readmissions to Hospital

Each figure describes the key strategic and focus measures that will be reviewed to monitor performance and progress towards goals. The figures also provide an overview of the key tactics or evidence informed change ideas that the organizations plans to test and execute over the next fiscal year.

HSN Building the Enabling Foundation for Excellence

In order to successfully execute the improvement initiatives delineated in this plan we must reinforce and strengthen our foundational approaches to quality and process improvement. To this end we will create and maintain rigorous performance monitoring systems to ensure that:

 All gains achieved related to Accreditation Canada standards and required organizational practices are maintained and we continue in a “survey ready” state.  We integrate Lean Systems thinking into our strategic and business planning processes.  We design and consistently use a defined organization-wide approach to performance (process) improvement and that staff, physician, care partners and board members will all be knowledgeable of this approach and the tools/techniques appropriate to their role in the organization.  We design and consistently use a management system for improvement.

These approaches are aimed at assisting HSN to realize two key states that are pre-requisites in creating the type of organization that can achieve the performance agenda that we outlined in this plan:  1) A truly patient-centered organization where patients and families are engaged in meaningful ways that allow each patient/family to be involved in their own health care and have a health system that is responsive to their needs, is respectful and works with them in a collaborative manner; that engages them as strategic partners in governance and engages them in the design, delivery and evaluation of health care programs and services

 2) Quality of work-life for all staff.

What we will measure to know that we are moving towards our desired state? For staff and physician partners: Turnover and retention rates, overtime hours, work life pulse survey, staff satisfaction; annual patient safety culture survey, utilization of employee family assistant program. For Organizational Health: Financial and risk management data For Patients and Families: See Priority Focus Area #3

Guide to the priority area maps:

Figure 3: Priority Focus Area 1

Compliance with evidence informed care bundles for VTE, Reduce Adverse Events Reduction of Adverse Drug Events (Medication Reconciliation); Sepsis AIM: Zero Harm to and Surgical checklist Patients as a Result of Care Reduce harm by reducing the Compliance with evidence informed care bundles & prevalence & incidence of management strategies for MRSA, Healthcare Acquired C‐Diff, VRE, Prevention of Surgical Infections Site; infections, and VAP Hand Hygiene

What we will measure to know that an improvement has occurred? Strategic Level: HSMR (Hospital standard mortality ratio) will be at or below 100 by 4th quarter FY 2012/13 Program and Unit Level: Rate and Process Indicators for Adverse drug events; Medication Reconciliation at admission and discharge, VTE, Prohibited Abbreviations, compliance with the surgical checklist, Incidence of HAI - MRSA, Clostridium difficile, VRE, central line blood stream infections, surgical site infections, ventilator associated infections, compliance with hand hygiene (See Part B: for our improvement targets and details of the associated planned initiatives)

Glossary: HSMR = Hospital Standardized Mortality; MRSA = Methicillin‐resistant Staphylococcus aureus; VTE = Venous thromboembolism; C‐Diff = Clostridium Difficile Infection; VRE = Vancomycin Resistant Enterococcus; VAP = Ventilator Associated Pneumonia; HAI = Hospital Acquired Infections

Figure 4: Priority Focus 2

What we will measure to know that an improvement has occurred? Strategic Level: Reduce the Average Length of Stay in ER for Admitted Patients by 10% by the 4th quarter FY 2012/13. Program and Unit Level: Process Indicators to monitor the flow of patients through the emergency department, numbers and flow of patients through the diagnostic imaging department, number and time it takes for patients to receive their hip and knee replacements (See Part B: for our improvement targets and details of the associated planned initiatives)

Figure 5: Priority Focus 3

What we will measure to know that an improvement has occurred? Strategic Level: Increase the result for the NRC Picker question, “Overall, how would you rate the care and services you received at the hospital?" by 10% improvement by 4th quarter of FY 2012/13. Program and Unit Level: Using NRC Picker, a series of corporate wide patient experience surveys, with special focus on the Emergency department scores and other key items e.g. overall satisfaction with care and by department, pain management (See Part B: for our improvement targets and details of the associated planned initiatives)

Figure 6: Priority Focus 4

Enhanced admission assessment for post‐hospital needs; with a focus on creating a "Senior Friendly Improve transitions Hospital" Patient and Family Centered handoff communication; Post‐Hospital discharge followup, along the continuum including "Virtual Ward"; Collaborate with the LHIN of care and CCAC and other key external partners to improve discharge planning and the transfer of information at AIM: Reduce discharge Avoidable Admissions/ Improve the care provided to patients Implement evidence informed population based care Readmissions living with long‐term models (i.e. inpatient and out patient components) for to Hospital (chronic) conditions conditions (Diabetes, Congestive Heart Failure; Chronic (Diabetes, Congestive Obstructive Pulmonary Disease Heart Failure; Chronic Obstructive Pulmonary Use standardized protocols and/or Order Sets Disease)

What we will measure to know that an improvement has occurred?

Strategic Level: Increase enrollment in the CHF and COPD Chronic Disease Management Clinics by 25% for high risk patients by the 4th quarter of FY 2012/13 and Implement the care transition service by the 4th quarter of FY 2012/13. Program and Unit Level: ALC (Alternate Level of Care days, Readmission rates within 30 days for selected high volume CMGs, Process measures for key long-term conditions. (See Part B: for our improvement targets and details of the associated planned initiatives)

How does this plan align with Other HSN Planning Processes?

As HSN progresses in realizing its academic mandate the leadership team is adopting the principles of quality as a business strategy. There are eight criteria that HSN has integrated into it overall strategic and business planning processes as displayed in figure 7, including:

A. Understanding and clearly articulating the purpose of the organization B. Viewing the organization as a system C. Measurement of the system D. Developing a system to obtain information E. Planning for improvement F. Managing improvement efforts G. Using an improvement methodology H. Developing a management system for improve

Figure 7: HSN Approach to Strategy Deployment

The consistent use of this process ensures that the organization takes in consideration all related external and internal factors that impact their ability to provide the care and services of the population that they serve including:

 Hospital Service Accountability Agreement (HSAA)  Multi-Sector Service Accountability Agreement (M-SAA)  Partner hospitals, community providers and the Northeast Community Care Access Center (NECCAC).  Requirements related to the Excellence Care for All Act (2010) and the Public Hospital Act.

What are the challenges and risks that that have been considered in the development of this plan?

In the developing this plan, the Board and Senior Leadership has been guided by their review of the context of care delivery for HSN in Northern Ontario, the changing environment in the entire Ontario healthcare system; including the current changes underway to the funding structures .

The key risks and/or challenges that have been identified are:

A. The population of Sudbury and the Northeast is aging and with this aging population the proportion of frail elderly in the population is expanding and thus increasing the demand for acute and community-based services. B. There are an increasing number of persons living in Sudbury and the Northeast diagnosed with long-term conditions that can be resource intensive, especially when there aren’t enough of community-based services to support them and enable them to better self- manage their conditions. C. Like many organizations across the province we struggle with the consistent compliance with standard work and policy, a need to develop more capability and capacity around performance improvement. D. As described in the report; “Enhancing the Continuum of Care” which was submitted to the Ministry of Health and Long-term Care in November 2011, “Ontario’s current funding structures do not provide hospitals with strong incentives to invest in improved care transition processes to reduce patient readmission, once a patient is discharged, the hospital is no longer technically accountable for their care.” This fact drives home the need for better integration and ease of flow for patients as they attempt to navigate across the disparate parts of the health system. The mechanisms to support this need are still evolving.

Our key approaches to mitigating these challenges and risks are:

A. To create an organization that is flexible and that is deeply rooted in the ability to provide evidence informed consistent care to the population that we serve. B. To find intentional ways to engage our patients/families and community partners as active decision makers in the design and delivery of care services provided C. To engage patients and families especially those living with long-term conditions to design and deliver the most cost-efficient and effective care delivery models of self-care. D. To advocate and collaborate with the LHIN and other community partners who provide care along the continuum to truly move towards reducing the barriers and lowering the boundaries between parts of the “system” so that patients are able to move along the continuum of care in a more efficient and cost effective way and care can always be provided in the most appropriate place to the patient’s care needs. To use Quality as our Business Strategy; which requires us to have a rigorous ongoing process for monitoring our progress towards goals, allows us to more easily identify any new potential risks in our environment and is driving us towards the realization of organization that; (1) is fiscally responsible; (2) provides care that is satisfactory to the patients served and that reflects the best science; and (3) engages staff, physicians and other care partners in a way that will support innovation and a culture of continuous improvement.

Part B: Our Improvement Targets and Initiatives

Purpose of this section: Please complete the “Part B - Improvement Targets and Initiatives” spreadsheet (Excel file). Please remember to include the spreadsheet (Excel file) as part of the QIP Short Form package for submission to HQO ([email protected]), and to include a link to this material on your hospital’s website.

PART B: Improvement Targets and Initiatives - 2012/13 Key: Mental Health and Addictions (MHA) Ramsey Lake Health Centre (RLHC) OPC (Out-patient Centre) 41, chemin du lac Ramsey Lake Road Sudbury, ON P3E 5J1 = Less than Target = Moving toward Target = On Target AIM MEASURE CHANGE Quality Dimension / Alignment with Objective Outcome Measure/Indicator Current Performance 2nd Quarter Performance Baseline Target for Target Justification Priority HSN Priorities (3rd Quarter) 2012/13

Planned Improvement Initiatives (Change ideas) Methods and Process Measures Goal for Change Ideas (2012/13) Comments Dimension: Safety Zero Harm to Patients Reduce Clostridium Difficile CDI rate per 1,000 patient days: Number of patients newly MHA = 0 MHA = 0 MHA = 0 <0.33 Provincial 2 (1) Develop and implement Antibiotic Stewardship Are developed and reported at Are developed and reported at the Monitor monthly at the program level and Infection (CDI) diagnosed with healthcare-associated CDI, divided by the RLHC = 0.6 RLHC = 0.56 RLHC = 0.013 Benchmark Process; (2) Implement/monitor effective cleaning of the the program level and to the program level and to the reported to the Infection Control number of patient days in that month, multiplied by 1,000. OPC = 0 OPC = 0 OPC = 0 environment for clients/patients/residents that have Performance Leadership Performance Leadership Committee. Committee & the Performance Leadership Average for Jan-Dec 2011, consistent with publicly reportable CDI; (3) Adoption of PIDAC’s Best Practices for Committee. Committee at least quarterly. patient safety data. (Oct to (Jul to (Jan to Environmental Cleaning for Prevention and Control of Dec 2012 ) Sep 2012 ) Dec 2011) Infections.

Zero Harm to Patients Reduce incidence of VAP rate per 1,000 ventilator days: The total number of newly 1.82 0.93 0 0 Theoretical Best * 3 (1) Implement the Ventilator Bundle; (2) Make the Are developed and reported at Are developed and reported at the Monitor monthly at the program level and Ventilator Associated diagnosed VAP cases in the ICU after at least 48 hours of process for delivering all bundle elements more the program level and to the program level and to the reported to the Infection Control Pneumonia (VAP) mechanical ventilation, divided by the number of ventilator days (Oct to (Apr to (Jan to reliable. Performance Leadership Performance Leadership Committee. Committee & the Performance Leadership in that reporting period, multiplied by 1,000. Average for Jan- Dec 2012) Jun 2012) Dec 2011) Committee. Committee at least quarterly. Dec. 2011, consistent with publicly reportable patient safety data.

Zero Harm to Patients Improve provider hand Hand hygiene compliance before patient contact: The number of 77 67 65.41 > 75% Provincial 2 (1) Facility specific hand hygiene campaign; (2) Are developed and reported at Are developed and reported at the Monitor monthly at the program level and hygiene compliance times that hand hygiene was performed before initial patient Benchmark Implement a multifaceted intervention consisting of: the program level and to the program level and to the reported to the Infection Control contact multiplied by 100-Jan-Dec. 2011, consistent with publicly (Oct to (Jul to (Apr to Education for health care providers about when and Performance Leadership Performance Leadership Committee. Committee & the Performance Leadership reportable patient safety data. Dec 2012) Sep 2012) Mar 2011) how to clean their hands with visual reminders; (3) Committee. Committee at least quarterly. Focus on each target group (physicians, nurses, etc.) addressing specific barriers to hand hygiene in staff work groups.; (4) Senior management support and commitment to make hand hygiene an organizational priority; (5) Patient engagement; (6) Environmental changes and system supports i.e. alcohol-based hand rub at the point of care, hand care program, visual flags for empty dispensers; (7) Ongoing monitoring and observation of hand hygiene practices, with feedback to health care providers.

Zero Harm to Patients Reduce rate of central line Rate of central line blood stream infections per 1,000 central 0 0 0 0 Theoretical Best * 3 (1) Hand hygiene; (2) Maximal barrier precautions upon Are developed and reported at Are developed and reported at the Monitor monthly at the program level and blood stream infections line days: Total number of newly diagnosed CLI cases in the ICU insertion; (3) Chlorhexidine skin antiseptics; (4) Optimal the program level and to the program level and to the reported to the Performance Leadership after at least 48 hours of being placed on a central line, divided (Oct to (Jul to (Jan to catheter site selection with the avoidance of using the Performance Leadership Performance Leadership Committee. Committee at least quarterly. by the number of central line days in that reporting period, Dec 2012) Sep 2012) Dec 2011) femoral vein for central venous access in adult patients; Committee. multiplied by 1,000. Average for Jan-Dec. 2011, consistent with (5) Daily review of line necessity with prompt removal of publicly reportable patient safety data. unnecessary lines.

Zero Harm to Patients Reduce rates of death and The Surgical Safety Checklist : Number of times all three phases 99.0% 99.7% 99% 100% Established 2 (1) Assess for spread for use of the surgical checklist in Are developed and reported at Are developed and reported at the Monitor monthly at the program level and complications associated of the surgical safety checklist was performed ('briefing", Standard of Practice applicable areas outside of the OR; (2) Continue patient, the program level and to the program level and to the reported to the Performance Leadership with surgical care "timeout" and "debriefing") divided by the total number of (Oct to (Jul to (Apr to physician and staff engagement strategies. Performance Leadership Performance Leadership Committee. Committee at least quarterly. surgeries performed, multiplied by 100. Jan-Dec. 2011, consistent Dec 2012) Sep 2012) Dec 2011) Committee. with publicly reportable patient safety data.

*Note: Provincial Average (October to December 2011) Published: February 26, 2013 - VAP (Ventilator Associated Pneumonia): 1.26 - CLI (Central Line Blood Stream Infections): 0.48 AIM MEASURE CHANGE Quality Dimension / Alignment with Objective Outcome Measure/Indicator Current Performance 2nd Quarter Performance Baseline Target for Target Justification Priority HSN Priorities (3rd Quarter) 2012/13

Planned Improvement Initiatives (Change ideas) Methods and Process Measures Goal for Change Ideas (2012/13) Comments Dimension: Effectiveness Zero Harm to Patients Reduce unnecessary deaths HSMR: Number of observed deaths/number of expected deaths x 113 104 101 100 National Benchmark 1 (1) Working group sanctioned to analyze HSN data and (1) Percentage of Surgical (1) Goal 95% SSI 1 - Percentage of Monitor monthly at the program level and in hospitals 100. FY 2010/11, as of December 2011, CIHI. make additional specific recommendations to the action Patients with Timely Surgical Patients with Timely reported at least quarterly to the (Apr to (Apr to (Q4 FY 2010/11 to plan; in addition to the current focus of managing Prophylactic Antibiotic Prophylactic Antibiotic Medication Administration Improvement Nov 2012) June 2012) Q2 FY 2011/12) infections including (CLI, CAP, SSI, VRE). Administration. Administration. Team and Performance Leadership Committee. (2) Prevent adverse drug events by Medication (2) Medication Reconciliation (2) Goal: 75% Medication Reconciliation at Admission & Discharge. at Admission & at Discharge. Reconciliation at Admission & 100% at Discharge. (3) Sepsis Protocol and Antibiotic Stewardship.

(4) Implement VTE protocol. (4) Use of VTE Pre-printed (4)Goal >90% VTE % Pre-printed VTE order. orders on chart. Dimension: Access Improve Access to Care Reduce wait times in the ED ER Wait times: 90th percentile ER Length of Stay for Admitted 34.4 49.9 39.0* <8 Hours Provincial 1 In the ED: (1) Increase See and Treat hours; (2) Create (1) ED: PIA compared to Goal 5.5 hours ED: PIA compared to Monitor monthly at the program level and patients. Q3 2011/12, NACRS, CIHI. Benchmark navigational video; (3) Performance Huddles; (4) Nurse Admits @ 0700 hours; (2) Admits @ 0700 Hours (2) Goal 36% reported to the Performance Leadership (Q3 2011/12) Navigator; (5) Additional decision makers; (6) Clinical %LWBS compared to Admits @ %LWBS compared to Admits @ 0700 Committee at least quarterly. (Oct to (Jul to Decision Unit. 0700 hours; (3) New ED Hours; (3) 70.4% New ED Footprint:% Dec 2012) Sep 2012) Footprint:% Non-Admitted Non-Admitted CTAS IV-V (Feb 2012) CTAS IV-V (Feb 2012)

Inpatient Unit: Improve access through (1) Bed Empty; (2) Compliance ((1) Goal 60 (Regular clean)/ 90mins improvements to patient flow, for example: with the " Cut the Band Wave (Terminal clean) - Bed Empty Time (1) Use of visual management; (2) Bullet Rounds in the Hand; SOW" (2) Goal 80% Compliance with the " Inpatient Unit; (3) Ed Whiteboard to connect ED & Cut the Band Wave the Hand; SOW". Inpatient Units; (4) Bed Empty & Cut the Band Wave the Hand; (5) 5S Units & storage of materials near to point of care. (6) Spread applicable solutions to all applicable programs/units

Improve Access to Care CT Scans CT Wait Time - 90th percentile wait times for Diagnostic CT Scan. 49 56 41.75 28 days** Provincial 2 (1) Spread applicable solutions from MRI PIP: CT waitlist Are developed and reported at Are developed and reported at the Monitor at the program level and report at Benchmark monitored, Radiologists protocolling children and the program level and to the program level and to the least quarterly to the Performance Oct to (Jul to (Jan to specific adult exams to MRI to redcue radiation dose, MI Performance Leadership Performance Leadership Committee. Leadership Committee. In addition, we are Dec 2012) Sep 2012) Dec 2011) participating in Surgical Lean with Senior CT tech as lead. Committee. working in conjunction with our LHIN to MRI Lean principles being slowing transferred to CT. (2) ensure that we have a second MRI which Reallocated staffing to increase service levels; (3) Staffed will enable us to broaden the types of MRI weekends meet ER demand, increase public accessibility, services we can provide to and reduce less efficient callbacks. Northeastern Ontario.

Improve Access to Care MRI MRI Wait Time - 90th percentile wait times for Diagnostic MRI 41 38 110.25 28 days** Provincial 2 (1) MRI PIP - Spread and Sustain Key solutions including Are developed and reported at TBD Developed and reported at the Scan. Benchmark defined data elements, standardized process and flow, the program level and to the program level and to the (Oct to (Jul to (Jan to revamped screening tools, Standardized work, revamped Performance Leadership Performance Leadership Committee. Dec 2012) Sep 2012) Dec 2011) patient education, revamped physician forms, Committee. Elimination of waste, handoffs, non patient focused activities. (2) Medical Imaging is looking at minimum staffing requirements in key areas to ensure metric is preserved. MRI has capacity to further reduce MRI wait times.

Improve Access to Care Hip Replacement Hip Replacement Wait Time - 90 the percentile wait times for 243 194 166.75 166 days Internal 3 (1) Continue implementation of end to end evidence Maintain the Provincial Maintain the Provincial Orthopeadic Monitor at the program level and report at HIP Replacement Surgery. Target based care delivery model for patients receiving hip Orthopeadic Scorecard, review Scorecard, review at the program least quarterly to the Performance (Jul to (Apr to (Jan to replacements. (2) The Wait Time Coordinator will at the program level and level and report to the Quality Leadership Committee. Sep 2012) Jun 2012) Dec 2011) Provincial continue to monitor the data to ensure that "Dates report to the Performance Performance Committee. Benchmark affecting Readiness to Treat" are captured. Leadership Committee. (182 days) Improve Access to Care Knee Replacement Knee Replacement Wait Time - 90th percentile wait times for 285 258 228.25 200 days Internal 2 (1) Continue implementation of end to end evidence Maintain the Provincial Maintain the Provincial Orthopeadic Monitor at the program level and report at Knee Replacement Surgery. Target based care delivery model for patients receiving knee Orthopeadic Scorecard, review Scorecard, review at the program least quarterly to the Performance (Jul to (Apr to (Jan to replacements. (2) Senior Administration along with the at the program level and level and report to the Quality Leadership Committee. Sep 2012) Jun 2012) Dec 2011) Provincial NELHIN continue to lobby the Ministry for an increase in report to the Performance Performance Committee. Benchmark our Volumes. (3) The Wait Time Coordinator will Leadership Committee. (182 days) continue to monitor the data to ensure the proper usage of "Dates affecting readiness to treat."

Note: Published: February 26, 2013 * Revised Baseline for Q3 2011/12 as per Decision Support. Original value: 14.3 ** The MOHLTC Wait Times website lists 28 Days for CT and MRI as the provincial target (July 2012). The original wait time for both CT and MRI was 30 Days. Refer to: CT Wait Times: http://www.waittimes.net/Surgerydi/en/Data.aspx?view=0&Type=0&Modality=3&ModalityType=5&city=Sudbury&pc=&dist=0&hosptID=0&str=&period=0&expand=0 MRI Wait Times: http://www.waittimes.net/Surgerydi/en/Data.aspx?view=0&Type=0&Modality=3&ModalityType=4&city=Sudbury&pc=&dist=0&hosptID=0&str=&period=0&expand=0 AIM MEASURE CHANGE Quality Dimension / Alignment with Objective Outcome Measure/Indicator Current Performance 2nd Quarter Performance Baseline Target for Target Justification Priority HSN Priorities (3rd Quarter) 2012/13

Planned Improvement Initiatives (Change ideas) Methods and Process Measures Goal for Change Ideas (2012/13) Comments Dimension: Patient-Centered Improve the Patient Experience Improve patient satisfaction NRC Picker: "Overall, how would you rate the care and services 94.4% 92.1% 93.36% 94.00% Ontario Best 1 (1) Increase the voice of the patient and family in the (1) NRC Picker: (1) NRC Picker: Monitor at the program level and report at you received at the hospital?" Performing design of care and services through the creation of a Percent of patients who Improve by at least 10% the Percent least quarterly to the Performance There are 4 possible responses: Excellent, Very Good, Good, (Jan to Patient Advisory Council to the CEO; along with a received answers they could of patients who received answers Leadership Committee. Fair and Poor. Only the Excellent, Very Good and Good (Jul to (Apr to Sept 2011) network of program specific councils (2) Use NRC understand when they asked they could understand when they responses count towards the percentage calculation. Sep 2012) Jun 2011) Picker, a series of corporate wide patient experience important questions from: a) A asked important questions from: (a) A surveys to measure and monitor patient satisfaction – nurse in the hospital; and (b) a nurse in the hospital; and (b) a doctor will be including Ambulatory Care Patients in the NRC doctor in the hospital; (2) to in the hospital; (2) to (4) Measures & Picker quarterly surveys (3) Emergency Department PIP (4) Measures & Goals TBD - at Goals TBD - at the completion of (Process Improvement Project) and improved the completion of program program design communication with patients, specifically: a. Providing design simplified discharge instructions using plain language b. Informing patients about expected wait time and reasons for delay (4) Improve staff and provider customer service and interpersonal skills (5) Enhance the organization-wide approach to collecting and analyzing patient feedback (6) Enhance the organization approach to educating patients/families on their role in patient safety (7) Collaborative Care Model

Improve the Patient Experience Improve patient satisfaction NRC Picker: "Would you recommend this Emergency Department 45.0% 45.3% 35.57% 40.00% Ontario Average 3 (1) ED PIP; (2) Simplified discharge instructions using (1) See measures for ED (1) See measures with goal for ED NRC Picker data is monitored quarterly at in the emergency department to your friends and family?" plain language; (3) Inform patients about expected wait related improvement work for related improvement work for the program level and in addition data There are 3 possible responses: Definitely yes, Probably yes, No. (Jan to time and reasons for delays; (4) ED Psychiatry consult included in the access included in the access dimension; (2) collected locally at least monthly is Only the definitively yes responses count towards the percentage (Jul to (Apr to Sept 2011) liaison pilot. dimension; (2) Percent of Improve by at least 10% Percent of reviewed on an ongoing basis. calculation. Sep 2012) Jun 2011) patients who were able to patients who were able to understand explanations about understand explanations about test test results received on results received on discharge from discharge from the ED; (3) & the ED; (3) & (4) Other measures TBD (4) Other measures TBD

Dimension: Integrated Reduce Avoidable Reduce unnecessary time Percentage ALC days: Total number of patient days designated as 14.47% 14.50% 32.0%* 17.00% LHIN Target 2 (1) Virtual Ward; (2) Senior Friendly Hospital; (3) Partner Are developed and reported at Are developed and reported at the Monitor monthly at the program level and Admissions/Readmissions spent in acute care ALC, divided by the total number of inpatient days. Q2 2011/12, with CCAC's Home at Last and Wait at Home Programs; the program level and to the program level and to the reported to the Performance Leadership DAD, CIHI. (Jul to (Apr to (Q2 2011/12) (4) Emergency Performance Improvement Project Performance Leadership Performance Leadership Committee Committee at least quarterly. Sep 2012) June 2012) Committee Note: HSN Recognizes that to effectively impact these two indicators, they must work with providers across the system. Reduce Avoidable Reduce unnecessary hospital Readmission within 30 days for selected CMGs to any facility: 16.55% 13.53% 15.8% 13.00% Methodology 1 (1) Continue with the implementation of the Chronic (1) NRC Picker: Percent of (1) NRC Picker: Percent of patients HSN is partnering with our LHIN and Admissions/Readmissions readmission The number of patients with specified CMGs readmitted to any defined by the disease management clinics focused on CHF, COPD and patients who know: who know: NECCAC, the Community Service facility for non-elective inpatient care within 30 days of MoHLTC Diabetes; (2) Implement a system for risk scoring for • Danger signals to watch for • Danger signals to watch for after Sector and Long-Term Care providers to discharge, compared to the number of expected non-elective patients at high risk admissions; (3) Use of standardized after going home; • Purpose of going home; • Purpose of improve access to post acute care. Unless readmissions - discharge follow-up protocols. and re: engineer the medications; • How to take medications; • How to take there is improvement in how the overall discharge process to have a SOW; (4) Medication medications; • Side effects of medications; • Side effects of system functions, that is increased Reconciliation at Discharge; (5) Transitional Discharge medications to watch for; • medications to watch for; • When to community-based capacity to allow the (Jul to (Apr to (Jan to Unit pilot and Discharge follow up nurse(enhanced When to resume usual resume usual activities; (2) Increase effective flow of patients across the system Sep 2012) Jun 2012) Dec 2011) discharge prep and linkages for patients to transition to activities; (2) Increase enrollment in the CHF and COPD and to ensure that patients receive the community care); (6) Implement the care transition enrollment in the CHF and Chronic Disease Management Clinics best care in the best environment; HSN service; (7) Ensure that each CDM Clinic has defined COPD Chronic Disease by 25% for high risk patients; (3) Goal - will find it difficult to meet the process and outcomes measures with an associated Management Clinics by 25% TBD Decrease the Hospital admission performance targets described here. defined reporting schedule. for high risk patients by the rate per 100,000 population for: 4th quarter of FY 2012/13; (3) • COPD; • CHF; • Diabetes. Hospital admission rate per 100,000 population for: • COPD; • CHF; • Diabetes.

Note: Published: February 26, 2013 * Revised Baseline for Q2 2011/12 as per Decision Support. Original value: 36.10% Part C: The Link to Performance-based Compensation of Our Executives

The purpose of performance-based compensation related to ECFAA is to drive accountability for the delivery of quality improvement plans (QIPs). By linking achievement of targets to compensation, organizations can increase the motivation to achieve both long and short term goals. Performance-based compensation will enable organizations to ensure consistency in the application of performance incentives and drive transparency in the performance incentive process. Please refer to Appendix E in the QIP Guidance Document for more information on completing this section of the QIP Short Form. The guidance provided for executive compensation is also available on the ministry website. Manner in and extent to which compensation of our executives is tied to achievement of targets The Excellent Care for All Act, 2010 requires that the compensation of the Chief Executive Officer, Chief of Staff, Chief Nursing Executive and any senior executive who reports to the CEO be linked to the achievement of performance improvement targets laid out in an organization's Quality Improvement Plan (QIP). The following table details positions included and how the executives' compensation is linked to performance. Position Percent of Salary at Risk Chief Executive Officer 5% of base salary Chief of Staff 5% of base salary Chief Operating Officer 2.5% of base salary Chief Nursing Executive 2.5% of base salary Vice President Research 2.5% of base salary

Performance Allocation Plan for 2012/13 General Terms 1) All measures listed below are equally weighted 2) The indicators apply equally to all affected members of the Senior Management Team Priority Area 1: Zero Harm to Patients A. Effectiveness: Achieve a HSMR (hospital standardized mortality ratio) to equal as a Result of Care or below 100 by 4th quarter of FY 2012/13

Priority Area 2: Improve Access to B. Access: Reduce the Average Length of Stay in ER for Admitted Patients by Care and services 10% by the 4th quarter FY 2012/13 Priority Area 3: Improve Patient C. Patient-centered: Increase the result for the NRC Picker question, “Overall, Satisfaction how would you rate the care and services you received at the hospital?" by 10% improvement by 4th quarter of FY 2012/13

Priority Area 4: Reduce Avoidable D. Integrated: Increase enrollment in the CHF and COPD Chronic Disease Admissions/ Readmissions to Hospital Management Clinics by 25% for high risk patients by the 4th quarter of FY 2012/13 E. Integrated: Implement the care transition service by the 4th quarter of FY 2012/13

Approach for Incentive Payout Available Incentive

Minimum threshold achieved (same as previous year) 50% Improved over previous year (but target not achieved) 80% 2012/13 target achieved 100%

Note: This section is presented as a DRAFT only as the HSN System for Executive Compensation and Performance Pay is under review. Any changes to the specific measures or method for calculation will be completed and posted by the end of the first quarter of FY 2012-13.

Part D: Accountability Sign-off

[Please see the QIP Guidance Document for more information on completing this section.]

I have reviewed and approved our hospital's Quality Improvement Plan and attest that our organization fulfills the requirements of the Excellent Care for All Act. In particular, our hospital's Quality Improvement Plan:

1. Was developed with consideration of data from the patient relations process, patient and employee/service provider surveys, and aggregated critical incident data 2. Contains annual performance improvement targets, and justification for these targets; 3. Describes the manner in and extent to which, executive compensation is tied to achievement of QIP targets; and 4. Was reviewed as part of the planning submission process and is aligned with the organization's operational planning processes and considers other organizational and provincial priorities (refer to the guidance document for more information).