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2015/16 Quality Improvement Plan for Mississauga Halton CCAC - Workplan
"Improvement Targets and Initiatives"
AIM
Quality
dimension
Safety
Effectiveness
Measure
Objective
To reduce falls
among long-stay
home care
clients
To reduce the
number of
unplanned ED
visits among
home care
clients
Measure/
Unit/ PopulaIndicator
tion
Percentage of
% / Adult long
adult long-stay
stay home
home care clients care clients
that have a fall on
their follow-up RAIHC Assessment
Percentage of
% / Home
home care clients Care Clients
with an
unplanned, lessurgent ED visit
within the first 30
days of discharge
from hospital
Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan
Change
Source /
Current
Period
Performance Target
HCD, RAI-HC
37.2
35.4
via LSAS / Oct
1, 2013 - Sept
30, 2014
HCD, DAD,
NACRS / Jul 1,
2013 - Jun 30,
2014
4.4
5.1
Target Justification
Recent performance
approaches this
target and being able
to sustain these gains
is the desired
outcome. NOTE: This
indicator is NOT
adjusted for risk
factors.
Consistently
outperforming the
provincial CCAC
average. MH CCAC is
committed to
sustaining its
performance and
views the target as an
upper limit rather
than increasing target
threshold based on
past performance,
and an uncertainty of
hospital impact.
Planned improvement
initiatives (Change Ideas)
1) Program for
Chronic/Complex Patient
Populations - Spread
Medication Management
within the organization for
complex, chronic and specialty
program patients.
Methods
[1] Formalize and document working
group structure. [2] Ensure education of
medication management program. [3]
Complete gap analysis. [4] Develop
action plan that ensures we met all tests
of compliance for Accreditation site
survey visit in 2017. [5] Monitor
establishment and progress of the
working group.
Process measures
Process measures at present would
include milestone monitoring until
the project charter and other
measures have been determined.
Goal for change ideas
100% of new complex, chronic
and speciality program patients
to have medication
reconciliation by Q2 2015/16,
with further plan for
organization roll out to be
approved.
2) Evaluate Rehabilitation
Programming - specifically
Physiotherapy model of care (3
streams and Rapid Recovery) to
validate patient's positive
improvement of functional
status, and a lower risk of falls.
[1] Develop and implement evaluation
process. [2] Collect data via patient
experience surveying; outcome
achievement via service provider scales
and outputs; and monitoring of costs and
service utilization. [3] Review results [4]
Integrate learnings into further
improvement opportunities.
Process measures at present would
include milestone monitoring until
the project charter and other
measures have been determined
Evaluate rehabilitation
programming - specifically
Physiotherapy model of care (3
streams and Rapid Recovery)
by Q2 2015/16.
1) Adopt and implement
evidence based pathways for
Chronic Obstructive Pulmonary
Disease (COPD) and Chronic
Heart Failure (CHF)
programming as an approach to
reduce the number of
unplanned ED visits and
improve the quality of life and
functional status of patients.
[1] Formalize and document working
group structure for COPD, and CHF. [2]
Ensure distribution and education on
pathways. [3] Complete gap analysis. [4]
Develop action plan. [5] Monitor
establishment and progress of the
respective working groups.
Process measures at present would Implement the COPD Pathway
include milestone monitoring until by Q3 of 2015/16, and the CHF
the project charter and other
Pathway by Q3 of 2015/16.
measures have been determined.
Page 1 of 4
AIM
Quality
dimension
Effectiveness
(cont'd)
Measure
Objective
To reduce the
number of
unplanned ED
visits among
home care
clients (cont'd)
To reduce
avoidable
hospital
admissions
among home
care clients
Measure/
Indicator
Percentage of
home care clients
with an
unplanned, lessurgent ED visit
within the first 30
days of discharge
from hospital
(cont'd)
Change
Unit/ Population
% / Home
Care Clients
Percentage of
% / Home
home care clients Care Clients
who experienced
an unplanned
readmission to
hospital within 30
days of discharge
from hospital
Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan
Source /
Current
Period
Performance Target
HCD, DAD,
4.4
5.1
NACRS / Jul 1,
2013 - Jun 30,
2014
HCD, DAD,
NACRS / Jul 1,
2013 - Jun 30,
2014
15.7
14.9
Target Justification
Consistently
outperforming the
provincial CCAC
average. MH CCAC is
committed to
sustaining its
performance and
views the target as an
upper limit rather
than increasing target
threshold based on
past performance,
and an uncertainty of
hospital impact.
Current performance
continues to show
MH CCAC as a high
performer in the
sector and our aim is
to maintain this
performance and to
sustain recent gains.
Planned improvement
initiatives (Change Ideas)
2) Lead the development and
implementation of the South
West Mississauga Health Link
(1/7 health links being planned
for Mississauga Halton area
and coordinated by the Health
Link Secretariat) and to
demonstrate a positive impact
of integrated care coordination
on this population, emergency
department and inpatient
utilization.
Methods
[1] Develop business plan. [2]
Develop/approve project charter and
associated project management process
requirements. [3] Current state analysis
and process mapping for future state. [4]
Determine data and metrics to be
collected and reported on. [5] Time
studies and analysis of patient flow. [6]
Ensure staffing plan alignment.
Process measures
Process measures at present would
include milestone monitoring until
the project charter and other
measures have been determined.
Goal for change ideas
South West Mississauga Health
Link to be implemented by Q4
2015/16.
3) Redesign care coordination
programming for
chronic/complex populations
to enable meaningful primary
care connections and reliable
care coordination practices
which have demonstrated to
reduce the need for unplanned
ED visits or inpatient
emergency experiences.
[1] Identify priorities for improvements in
coordinated care planning and care
delivery models; [2] Complete analysis to
confirm deployment plans for key
improvements; [3] Formalize project
structures for design and
implementation; [4] Monitor
implementation, measure results of
coordinated care planning
improvements.
Process measures at present would
include: a) rate of care coordinator
primary care connection; b) project
implementation milestones (to be
confirmed); c) Consistency in
understanding roles and
responsibilities across an integrated
community care team;
Coordinator care plan
completed for 90% of complex
patients within guidelines; care
conferencing rate is 75% for
complex population by Q4 FY
2015/16.
1) Partnership with Trillium
Health Partners to design a
new innovative approach to
transitioning patients from
hospital to home - Seamless
Transitions.
To design a process were care is wrapped
around the patient from admission
through to discharge and recovery at
home. Test with patients admitted on
two physician caseloads in the Medicine
program at THP-CVH. Quality
improvement cycles ("Plan-Do-StudyAct") will be utilized to assess and refine
the process during the test phases. Ongoing monitoring of data - lead and lag
measures - to determine whether change
idea is having the intended impact.
Key outcome measures:
readmission rate, return to
Emergency Department visit rate,
length-of-stay and patient
experience.
A replicable, scalable, patientcentered approach for hospital
to home transitions by Q4
2015/2016.
Page 2 of 4
AIM
Quality
dimension
Access
Client-centred
Measure
Source /
Current
Period
Performance Target
Ministry of
91.3
91.1
Health Portal
/ Oct 1, 2013Sept 30, 2014
Planned improvement
Target Justification
initiatives (Change Ideas)
Methods
Process measures
Goal for change ideas
Maintain current high Mississauga Halton CCAC will continue our current work processes and efforts to sustain our results in these areas and will continue to monitor
performance.
performance and initiate actions if we fall below current performance target.
5 Day Wait Time - % / Home
Nursing Visits: % Care Clients
of patients who
received their first
nursing visit within
5 days of the
service
authorization
date.
Ministry of
Health Portal
/ Oct 1, 2013Sept 30, 2014
96.2
95
Maintain current high Mississauga Halton CCAC will continue our current work processes and efforts to sustain our results in these areas and will continue to monitor
performance.
performance and initiate actions if we fall below current performance target.
To improve
Percent of home % / Home
client experience care clients who Care Clients
responded
"Good", "Very
Good", or
"Excellent" on a
five-point scale to
any of the client
experience survey
questions: i)
Overall rating of
CCAC services ii)
Overall rating of
management/han
dling of care by
Care Coordinator
iii) Overall rating
of service
provided by
service provider
OACCAC / Apr
1, 2013 - Mar
31, 2014
90.9
93
Continue to strive to 1) Share Care Council to
meet the target set in develop a Patient Caregiver Bill
2014/15 QIP.
of Rights internally and with
service providers as a
consistent commitment to a
positive patient experience.
Objective
To reduce
service wait
times
Measure/
Indicator
5 Day Wait Time Personal Support
for Complex
Patients: % of
complex patients
who received their
first personal
support service
within 5 days of
the service
authorization
date.
Change
Unit/ Population
% / Home
Care Clients
Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan
[1] Develop engagement opportunities.
[2] Collect qualitative and quantitative
data. [3] Review results. [4] Integrate
insights and noted opportunities into
care integration programming.
Process measures at present would
include: a) Milestone monitoring
until measures have been
determined; b) Quality of Content
to patient/caregivers.
1) Approve the Patient
Caregiver Bill of Rights May
31st, 2015. 2) Produce new
patient information package
reflecting the bill of rights
language by Q4 2015/16. 3)
Incorporate strategically
patient and care giver insights
into the design of Seamless
Transition work and to inform
"how it is going to work" by Q1
2015/16.
Page 3 of 4
AIM
Quality
dimension
Client-centred
(cont'd)
Measure
Objective
To improve
client experience
(cont'd)
Measure/
Indicator
Percent of home
care clients who
responded
"Good", "Very
Good", or
"Excellent" on a
five-point scale to
any of the client
experience survey
questions: i)
Overall rating of
CCAC services ii)
Overall rating of
management/han
dling of care by
Care Coordinator
iii) Overall rating
of service
provided by
service provider
Change
Unit/ Population
% / Home
Care Clients
Mississauga Halton CCAC 2015/16 Quality Improvement Plan - Workplan
Source /
Current
Period
Performance Target
OACCAC / Apr
90.9
93
1, 2013 - Mar
31, 2014
Target Justification
Continue to strive to
meet the target set in
2014/15 QIP.
Planned improvement
initiatives (Change Ideas)
2) Design a "neighbourhood
cluster model" of care service
delivery model as a means to
increase flexibility with
scheduling
3) Partnership with Trillium
Health Partners to design a
new innovative approach to
transitioning patients from
hospital to home - Seamless
Transitions.
Methods
Provide patients and families with
increased choice over personal support
scheduling; increase consistency of care
team; joint assessments with personal
support supervisor and care coordinator
Process measures
Implement target numbers for
chronic/complex patients end of Q1
FY 2015/16; Evaluate results across
following domains: patient
experience, cost effectiveness,
hospital avoidance.
[1] Develop and implement an evaluation Number of patients surveyed (to be
process. [2] Collect data from patient
determined).
experience by: a) phone call asking
questions about their transition of care
experience; and b) by surveying at
discharge (on the floor) asking questions
about their transition of care experience.
[3] Review results. [4] Evaluate the
effectiveness of the new survey sampling
approach.
Goal for change ideas
Pilot a "neighborhood cluster
model" for patients to provide
an increase in choice in
scheduling personal support
care by Q3 2015/16.
1) To develop a survey
sampling approach based on
results of phone and discharge
evaluation by Q1 2015/16. 2)
Based on the final sampling
plan strategy, to collect and
incorporate patient experience
data into potential
opportunities for improvement
by Q3 2015/16.
Page 4 of 4