continuing care quality committee annual report …...continuing care quality committee annual...

Continuing Care Quality Committee

Annual Report to QSEC June 2015 - June 2016

CCQ Annual Report for QSEC June 2016 Page 1 of 20


Annual Report June 2015 – June 2016

Including 2015/16 Q2, Q3, Q4 updates as per CCQ Terms of Reference




Introduction

The Continuing Care Quality Committee (CCQ) is on target to achieve the Continuing Care Quality Management Framework (CCQMF) vision of “Individual’s and their families will access and receive quality safe continuing care services from a high performing, highly reliable Continuing Care system” within the next five years.1

The focused work of CCQ is related to the key enablers to move the CCQMF forward. Most specifically: governance; relationship building; quality management cycle focusing on managing risk; defining indicators of quality care; influencing a culture of transparency, and; knowledge transfer / knowledge translation tools.

Where we want to be: Where we are now:

CCQ Mandate2 Initiation Executing Monitoring & Controlling Mandate Achieved (closing)

1. Develop and recommend for approval, the implementation plan of the Continuing Care Quality Management Framework (CCQMF) for Alberta Health Services (AHS) and contracted providers with the intent to simplify and streamline quality improvement activities, monitoring and reporting of Continuing Care services.

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2. Identify situations, internal or external to AHS that may influence or impact the safety of individuals receiving continuing care services: a. Identify, categorize and prioritize issues for improvement that

impact quality of care and service or introduce risk within the continuing care system in Alberta,

b. Seek out, monitor and respond to quality and safety issues, and

c. Identify emerging knowledge and evidence, internal and external trends or innovations that may impact the quality of care and service leading to enhanced quality of life.

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3. Inform and support the development and implementation of key strategies / initiatives that directly or indirectly influence the ability to successfully provide high quality safe care and service

▲ 4. Assess and inform the resourcing, infrastructure, processes and

relationships required to facilitate continuous quality improvement in order to achieve desired outcomes including quality assurance, monitoring and auditing.

▲ 5. Prioritize strategies and initiatives that build capacity in quality

assurance and quality improvement for effective and efficient safe quality care.

▲ 6. Where appropriate, establish integrated working groups to

achieve the mandate of the committee. Develop project plans (if applicable), action plans, track progress and evaluate results.

▲ 7. Provide at least quarterly reports to QSEC that summarize key

issues, risks identified, arising follow-up actions and key quality indicator results for the previous quarter.

▲ Accomplishments and Highlights • Continuing Care Quality Monitoring Recommendations developed by CCQ’s working group (CC-Audits

Working Group). These Recommendations outlined the intent to improve and streamline auditing and assurance functions (quality monitoring) while at the same time increase Albertan’s confidence in the continuing care system. The work included:

1 Continuing Care Quality Management Framework (June 2014), pages 8 & 18 2 Continuing Care Quality Committee Terms of Reference, Continuing Care Quality Management Framework (June 2014), Appendix 3




o Analysis of the Current State of Quality Assurance and Auditing in the Continuing Care System (review of auditing and quality assurance functions, including Continuing Care Health Service Standards, Continuing Care Accommodation Standards, Accreditation and other quality monitoring and assurance functions, current roles, responsibilities, duplication and areas of gaps. An accompanying glossary with key auditing and quality assurance definitions);

o Jurisdictional Review (related but not limited to monitoring/audits, best practice reporting tools, performance measure, complaints management process, and self- assessments);

o Guiding Principles for the Future State of Quality Assurance and Auditing in Continuing Care to justifiably ground the proposed recommendations;

o Vision development for the future state of auditing and quality assurance in the Alberta Continuing Care System.

o This working group has completed its mandate • These Recommendations were presented and approved at QSEC on December 17, 2015 and signed off

by the Deputy Minister of Health on February 12, 2016. • The CC Quality Monitoring Recommendation implementation planning is underway, in collaboration with

AHS and Alberta Health.

• Continuing Care Quality Indicator Recommendations developed by CCQ’s working group (CC-Quality

Indicator Working Group). Progress of this work to-date includes: o August 2014- March 2015, two Environmental Scans were conducted and combined to form the

Consolidated CC-QIWG Quality Indicators and Public Reporting Environmental Scan, included: Continuing care quality measurement reporting mechanisms; and Jurisdictional scan of Quality Indicators;

o August 2014- March 2015 CC-QIWG established Guidelines and Criteria - In the identification and development of continuing care quality indicators, there are two levels of agreed upon guiding principles (i.e. Continuing Care Quality Management Framework Principles) and criteria (i.e. Criteria to Assess the Maturity of a Measure) that should be applied and met in decision making and implementation. After applying the guiding principles and criteria, the indicators are then classified by the Alberta Health Services’ (AHS) Risk Management Framework which helps to ensure comprehensive risk identification and management;

o The AHS QHI agreed-upon definition for a Quality Indicator was used in this work; o A Modified-Delphi methodology was employed to consolidate and build consensus on which

measures were a good reflection of quality (as per the HQCA definitions). This process resulted in filtering the initial 300 measures down to 50 measures. Quality Measurement Validation and Identification Focus Groups were held to identify future concepts of quality that should be measured in Alberta. Then two further consensus-building meetings were held to discuss which of the 50 measures would be recommended by the CC-QIWG for public vs. internal reporting. Lastly, RAI 2.0 Quality Indicator Expert panel finalized the Near-Future Quality Indicator Public Reporting Overview, twelve indicators are ready for detailed AHS public reporting; three indicators are under development, and; three indicators are not yet under development.

• These Recommendations were introduced to QSEC on February 25, 2016 and presented for approval to QSEC on April 28, 2016.




• Continuing Care Quality Management Report – providing an individual site/program-level report has been identified as a key enabler outlined in the CCQMF (page 16-17). This is intended to empower frontline care providers with timely access to consolidated, easy to understand site-level quality information. The intent is for all continuing care sites/programs (Home care- Home Living; Designated Supportive Living; Long Term Care Facility Living) to utilize this report to inform continuous quality improvement, with an ability to share regularly with all staff and bring forward to resident and family councils.

o This Quality Management Report (QMR) is not intended to be a definitive measure of quality of care, but rather to showcase areas of best practice where sites/programs are achieving above average results and identify areas of potential risk where sites/programs are below average.

o A pilot project with seven AHS LTC Facility sites in the North Zone trialed the QMR from April1 to June 30, 2016. The pilot was developed in collaboration with the North Zone. The learning from this pilot will inform the next steps in how and when this will be spread across continuing care.

• CCQ continues their established practice of a CCQ Meeting Overview summary for wide general

circulation after each meeting. These overview summaries are widely distributed via email, posted on AHS Insite (http://insite.albertahealthservices.ca/9466.asp under Continuing Care Quality Management Framework) and on the Continuing Care Desktop (www.ccdweb.ca) for access by Continuing Care contracted providers. As well, our associate members (i.e. ASCHA, ACCA) further circulate the Overviews in their provincial newsletters and post on their external websites.

• CCQ continues to value the commencing each meeting with a personal story. These personal stories have created discussion with intended take away key messages. The CCQ now has a record of twenty-one personal stories (eleven in 2014/15 and ten 2015/16) that could easily be used for case studies, review by other stakeholders and have strengthen the focus strategies to meet the mandate of CCQ (e.g. people powered approach, person-centred care, patient first strategy).

• CCQ features a Quality Improvement story at the majority of their meetings. These stories are required

to outline each step of the QI cycle following the AIW framework: defining the opportunity / issue, analysis of the issue, quality improvement steps, implementation and results. Summary hand outs are included in the monthly CCQ overview for wide distribution. CCQ now has sixteen documented QI stories (nine in 2014/15 and seven in 2015/16) which have been utilized to further quality improvement across the continuing care system.

• The Public Members (patient / family advisors, health advisory council members) are an integral part of the

CCQ and its work groups. They have established their credibility, they are seen and valued as equal members. Their input has driven critical conversations and has shifted direction of how we are approaching decisions. Since the commencement of CCQ, we have recorded over 400 volunteer hours from seven public members.

• As per the mandate of CCQ to identify situations that may influence or impact the safety of individuals

receiving continuing care services, CCQ members have been engaged in the following: o HQCA presented the findings from the 2014-2015 LTC Family Experience Survey. Through

discussion at CCQ following this presentation, HQCA engaged with CCQ in the development of a further measurement initiative pilot from the survey finding. This initiative is an in-depth

http://insite.albertahealthservices.ca/9466.asphttp://www.ccdweb.ca/




review with top-rated and lower-rated LTC facilities to identify the differences in family experience and the learnings that could be shared and inform continuous quality improvement.

o AHS 2014-2015 Continuing Care Health Services Standards Annual Report was presented and discussed

o 2016 Continuing Care Health Services Standards and Information Guide were presented by Alberta Health to gain an understanding of the content

• The Continuing Care Quality Management Framework has been extensively referenced (by permission from AHS) in the third Canadian edition of the “Nursing Leadership and Management” by Patricia Kelly and Heather Quesnelle, and published by Nelson Education: http://www.nelson.com/catalogue/productOverview.do?Ntt=Third+Canadian+Edtion%2C+Nursing+Leadership+and+management||1613151473716996899251087998831706590&N=197&Ntk=nelson%7C%7CP_EPI&Ntx=mode+matchallpartial

Future Direction CCQ members have acknowledged the need to complete their initial focus of work relating to determining quality indicators and a vision for quality assurance / auditing of the continuing care system. Through the development of the CCQ work plan, it has been identified that much of our future work has interdependencies with other work that is going on that may influence our work. There are plans underway to identify opportunities for collaboration and partnering the work priorities of the Seniors Health SCN, AH, Integrated Continuing Care Steering Committee (ICCSC). Appendices

A. Revised CCQ Terms of Reference (for approval), CCQ approved October 22, 2015 B. CCQ Membership C. CCQMF Logic Model Schematic D. CCQ Work plan, living document

http://www.nelson.com/catalogue/productOverview.do?Ntt=Third+Canadian+Edtion%2C+Nursing+Leadership+and+management||1613151473716996899251087998831706590&N=197&Ntk=nelson%7C%7CP_EPI&Ntx=mode+matchallpartialhttp://www.nelson.com/catalogue/productOverview.do?Ntt=Third+Canadian+Edtion%2C+Nursing+Leadership+and+management||1613151473716996899251087998831706590&N=197&Ntk=nelson%7C%7CP_EPI&Ntx=mode+matchallpartial




Appendix A




Appendix B Members Title, Division, Organization Chair Dr. James Silvius Medical Director, Community, Seniors, Addictions and Mental

Health (CSAMH), AHS Public Carla Helder Prairie Mountain Health Advisory Council Judy Brown Resident / Client / Family Advisor Linda McFarlane Resident / Client / Family Advisor Vacant Health Advisory Council member Frontline Laureen Bolin CCHSS Auditor, Central Zone Alberta Health Corinne Schalm Executive Director, Continuing Care Branch Cheryl Whitten Executive Director, Compliance and Monitoring Branch Pamela Renwick Acting Director, Compliance and Monitoring Branch Suzanne Maisey Manager, Quality Improvement, Continuing Care Branch Alberta Health Services Barbra Lemarquand-Unich Executive Director, Integrated Seniors & Community Care,

Calgary Zone Carol Anderson Executive Director, Seniors Health, Edmonton Zone Carolyn Dryden Director, Quality Outcomes, Community, Seniors, Addiction and

Mental Health (CSAMH) Claire McCrank Executive Director, Community, Seniors, Addiction and Mental

Health (CSAMH) Colin Zieber Executive Director Senior Health, South Zone Jeanine Kimura Director Performance & Risk Management, Carewest on behalf

of Carewest and Capital Care (wholly owned subsidiary) Leanne Dekker Senior Program Officer, Infection Prevention and Control Lori Sparrow Executive Director, Seniors Health, Central Zone Scott Fielding Senior Program Director, Seniors Health & Bone & Joint Health

SCNs Robyn Maddox Executive Director, Seniors Health, North Zone Ronda White Chief Audit Executive, Internal Audit / Enterprise Risk

Management Trudy Harbidge CCQ Program Advisor, Senior Director, Continuing Care

Quality, CSAMH Dr. Valerie Smith Medical Director, Seniors Health, Central Zone Other Key Stakeholders Donalda Farwell

Area Director- Edmonton, Bayshore Home Health on behalf of Alberta Continuing Care Association

Jeanette Leafloor Director of Member Relations, Alberta Seniors Communities and Housing Association (ASCHA)

Raymond Cormie CEO, Father Albert Lacombe Home (Society) on behalf of Alberta Continuing Care Association

Scott Baerg Senior Operating Officer, Covenant Health Vacant on behalf of Seniors Housing Society of Alberta Representative As of May 2016




Appendix C




Appendix D




IntroductionAccomplishments and HighlightsFuture DirectionAppendicesAppendix AAppendix BAppendix CAppendix D

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