quality improvement plan (qip) narrative for...

1 Erie St. Clair Community Care Access Centre (CCAC)

712 Richmond St., Chatham, ON

Quality Improvement Plan (QIP) Narrative

for Health Care Organizations in Ontario

April 2015

3/31/2015

This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.



Overview

The Erie St Clair Community Care Access Centre (ESC CCAC) Quality Improvement Plan (QIP) for 2015/16 maintains the same provincial priorities as it did for the 2013/14 QIP, and we have added three local priorities. These priorities have been identified by our community as being relevant for our region. Our organization has undertaken a thorough process of consultation and engagement for the development of the Strategic Plan 2014/15 - 2016/17 in the past year, and the indicators that were identified have largely been incorporated into our plan and remain relevant for the coming years. This is particularly the case in terms of the Change Ideas in the QIP, which will extend beyond the current year. In addition to the correlation between the QIP and the Strategic Plan, the indicators also continue to align with our Accreditation requirements. ESC CCAC will be undertaking an Accreditation survey during 2015.

Integration and Continuity of Care

The ESC CCAC is working with multiple system partners across the region to provide the best care in the best environment for the residents of Erie St. Clair. In the coming year we will be building on the work established in prior years by working with our service providers to ensure patients are having their needs met and remaining in their home in the community for as long as possible. We are participating in a number of programs to promote integration and continuity of care. Two such programs are eNotification and establishing linkages between primary care and CCAC Care Coordinators through local Family Health Teams. We continue to work with our local hospitals and have initiated the roll out of eNotification - a process that will tell our Care Coordinators when a patient of ESC CCAC arrives in the emergency department or is admitted to hospital. This will provide an opportunity for Care Coordinators to work collaboratively with hospital staff to examine service plans and effectively support transitions and care so that the patient may return home, thereby avoiding a hospital stay and/or shortening their length of stay. ESC CCAC is also participating in a Chatham Health Link project whereby we have a dedicated Care Coordinator who meets with patients who are high users of hospital services to complete integrated care plans. The primary care liaison Care Coordinator works with these patients to establish common goals to assist them to stay out of hospital by working with the primary care practitioner and other community support agencies to support the patient safely in the community.

Challenges, Risks and Mitigation Strategies

A consistent challenge to monitoring quality initiatives is access to timely, meaningful data and how this data is used in decision making and improving the services and care we provide. The CCAC sector has access to a tremendous amount of data. Our challenge lies in how best to evaluate this information and determine what is meaningful for quality monitoring. Other potential challenges lie in how the CCAC and other health system partners work with our data. The CCAC works hard with hospitals, agencies and primary care to share data and information about our patients and services. Often, this information is from different systems and in different formats, and must be interpreted and further evaluated. The CCAC works to lessen the challenges and inconsistencies that are created by undertaking further integration of our information systems. These strategies are focused on developing safe and secure means of sharing information between other CCACs, hospitals and our community partners to provide for better patient care. This work is part of our strategic plan where we will



work to reduce the impact of chronic disease and be the partner of choice in care coordination, and we will enrich this work by engaging with patients, families and caregivers.

Information Management

The Erie St. Clair CCAC utilizes a web-based patient information management system, which plays an important role in allowing CCACs to provide quality care to all our patients. The Client Health and Related Information System (CHRIs), enables staff to access patient information and care plans from any location, ensuring safety and consistency in care delivery. Our information management systems continuously evolve and our connectivity is expanding to health system partners. During the past fiscal year, as noted above, we have begun the implementation of eNotification. In addition, we are implementing a process called eReferral. This is an electronic process whereby patient applications for Long-Term Care are processed electronically, eliminating the need for paper documents to be exchanged between ESC CCAC and the Long-Term Care homes in the region. This process provides improved efficiencies and ensures accurate, timely information is being exchanged. eReferral launched earlier this year in Sarnia-Lambton, and will be expanding to Chatham-Kent and Windsor-Essex this year. We will further expand our electronic communications this year with eHomecare - a new program which will initially focus on our palliative patient population.

Engagement of Clinicians and Leadership

ESC CCAC has reached out to the community of partners, patients and caregivers, staff, and stakeholders in the last year. We held sessions with 19 groups in over 26 different consultation sessions to leverage input to our question: "What would success look like for the CCAC?" Out of all the input received, we drafted our Strategic Directions and Enablers. This information was validated through Accountability Sessions in the community, and organizational goals and objectives were identified. The goals and objectives have been developed for each department to undertake. A subsequent accountability session will occur every fall in each region of Erie St. Clair to publicly demonstrate accountability for our work, and to check in with our various stakeholders to ensure we are on the right track.

Patient/Resident/Client Engagement

The ESC CCAC has identified Patient and Family Engagement as a key Strategic Direction for the next three years. Within the context of the Strategic Plan 2014/15-2016/17, we will be engaging with our community to learn from the patient experience and deliver Patient and Family Centred Care. This will be demonstrated by the increased involvement of patients and families in our operations, increased patient satisfaction, and reduced patient risk. In order to achieve the goals of our strategic plan, we have planned the following change ideas:

We have completed the organizational readiness assessment from the Institute for Patient and Family Centred Care (IPFCC), and have developed a plan to implement recommendations from the findings of our readiness assessment;

We are providing education for leaders, board members, volunteers, service providers and all staff related to Patient and Family Centred Care, and our organizational direction to focus on improving the patient and family experience;

We have established a Patient and Family Centred Care Council representative of our communities, who will be actively engaged in all aspects of our patient and family engagement initiatives;



We will complete a review of all policies and reference documents throughout all functional centres of our organization to ensure they are patient and family centred;

Through our patient and family satisfaction surveys, we will identify key areas of opportunity to improve the patient and family experience;

We will review the results from our employee engagement survey and will measure the impact of being patient and family centred on the job satisfaction of our staff;

We have developed the voluntary role of Patient Family Advisor (PFA) to provide opportunities for patients and families to be actively involved at committee, planning and work group tables of the CCAC;

We will be sharing patient and family stories as a mechanism to learn from the healthcare experience while respecting confidentiality of the individual(s);

We will ensure each ESC CCAC site and functional centre has access to at least one PFA as a resource for activities such as working groups, policy input and review, and interview panels; and

We will be reviewing the current process of obtaining patient and family feedback and will be implementing improved methods of obtaining this feedback in a more timely manner.

Our CCAC is committed to improving the patient and family experience and this will be demonstrated in our QIP metrics.

Accountability Management

The ESC CCAC leadership has identified specific corporate objectives associated with particular improvement objectives and has tied 2% of compensation to the achievement of targets. This performance-based compensation model applies to the management team of the CCAC, specifically individuals who manage staff, have budgetary responsibilities, have influence over performance management, or have a significant portion of their role in directing operations. The performance-based compensation model applies to each management team member equally, meaning that whatever the outcome achieved all team members receive the same compensation, from 0% up to 2%. This is consistent with performance-based compensation models adopted by the Hospital sector. These objectives are linked to the Quality Improvement Plan and the Strategic Plan 2014/15 - 2016/17. All objectives are outlined in the Quality Improvement Plan Workplan, and represent a portion of the overall 2% performance-based compensation, broken down as follows:

1. 0.5% for Increase in our Patient Satisfaction Score - 100% if target met; 50% if maintained; 0% if it drops

2. 0.5% for Achieving a Balanced Budget - 100% if total margin >0; and 0% if any deficit

3. 0.5% for Achieving our Corporate Goals and Objectives - 100% if all on target; 50% if 80% are on target or factors beyond control; 0% if completion below

80%. 4. 0.5% for Achieving Quality of Work-Life - Meeting or Exceeding Employee Engagement Survey Target

- 100% if all on target; 50% if 50% improvement; 0% if maintained or decline in performance. All staff are ultimately involved in the achievement of the targets, and tools and processes are in place for regular updates with respect to performance. This includes the ESC CCAC Balanced Scorecard and the Strategic



Deliverables which are updated on a regular basis on the CCAC public website. Updates are similarly provided to the CCACs Board of Directors. The CEO performance-based compensation relates to the accomplishment of the objectives noted above as well as the accomplishment of all annual goals and objectives across the organization. This information is posted on the Erie St. Clair CCAC corporate website at the following link: http://healthcareathome.ca/eriestclair/en/performance/Documents/MeasuringCEO_Performance.pdf.

Sign-off

I have reviewed and approved our organization’s Quality Improvement Plan

Board Chair Kathryn Biondi Quality Committee Chair Marshall Kern Chief Executive Officer Lori Marshall

http://www.healthcareathome.ca/eriestclair

http://healthcareathome.ca/eriestclair/en/performance/Documents/MeasuringCEO_Performance.pdf