Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario.
Quality Improvement Plan
The Quality Improvement Plan (QIP) for 2016/17 will be the third QIP created for St. Patrick’s Home of Ottawa. Our Mission is to continue the ministry of Christ as a Catholic, long term care home dedicated to providing compassionate services to persons of all religions and cultures throughout our community.
The Quality Improvement Plan for St. Patrick’s Home in 2016/17 will continue to strongly align with the priorities outlined in our 2015/16 QIP. Although there were significant improvements made in a number of quality indicators, for example, our restraint reduction initiative achieved an all-time low of just under 10%, from an historical high of almost 50% 2 years ago, there are other indicators requiring more improvement initiatives. Pressure ulcers will continue to be a priority on our QIP in 2016/17 as we target a reduction in the percentage of residents who had a stage 2 to 4 pressure ulcer that worsened. The continued use of our smart bed surfaces from BAM labs will afford us the opportunity to monitor a resident’s activity while in bed and alert staff to pre-scheduled turning and repositioning interventions, which should reduce the worsening of pressure ulcers.
In the area of falls management, we will continue to advocate for the maximum use of appropriate mobility aids and devices and have made the process to request such devices more user friendly and timelier by instituting an electronic referral process through our clinical software Point Click Care (PCC). We will also continue to provide refresher education to registered staff on timely and accurate completion of the new Post Fall Assessment that was created in 2015, while increasing the monitoring and auditing of those particular assessments for completion. The Rehab/Restorative team will also provide refresher education with the front-line staff on the various restorative programs that specifically target those residents who have a higher risk of falling.
There is a need for continued focus on the reduction of the use of agency staff. The key focus will be on scheduling tools and practices that facilitate appropriately resourcing our nine Resident Home Areas (RHAs) with St. Patrick’s Home staff. St. Patrick’s Home will endeavour to continue reducing the number of agency hours contracted through external partnerships (Less than 1%). The use of our own permanent, temporary and casual nursing staff (PSWs, RPNs and RNs) provides our residents with a continuity of care that should be afforded to all LTC residents.
We will continue with our structured approach to hiring and orientation but will also attempt to increase the caliber of potential candidates by reaching out to specific colleges and schools and raising awareness of our need for professional, qualified nursing staff. Notable change ideas for 2016/17 include hiring booths and job postings at local colleges and posting the need for staff with HRDC’s job bank. We will also re-establish relationships with local colleges to bring nursing students back into the home. Finally, we will undertake a system review of the scheduling office to maximize efficiency and increase integration of the various tools used daily.
To further align with the long-term care sector priorities, St. Patrick’s Home will continue our initiative to further reduce the use of antipsychotics for those residents that do not have a diagnosis of psychosis. Since we are already well ahead of the provincial average on this indicator, our objective is to modestly improve on our antipsychotic use to a new target of 15%.
The percentage of residents with worsening bladder control was not an indicator that we were able to improve upon in 2015/16 as one change idea did not get implemented and the other one did not gain traction once rolled out. Although scheduled toileting plans/routines were not implemented as planned it will remain on our QIP as a priority for 2016/17 as we refocus our efforts and re-establish a more robust Continence Committee. A new Continence Assessment Tool (CAT) titled “Bladder and Bowel Continence Assessment” was created and implemented in 2015, however, many registered staff brought forward concerns that the new assessment tool was too exhaustive and took too long to complete. We are suggesting a new streamlined CAT be created and more formal education be provided in 2016/17. A continence program lead will be assigned the analysis piece in order for the tool to be effective.
Slight gains were made in 2015 related to resident experience. This was based on the percentage of residents who agreed with the resident satisfaction survey statement “I would recommend this nursing home to others”. While we did not meet our target of 90% we will aggressively move on new change ideas to meet this goal in 2016/17.
Ensuring our residents enjoy the best possible experience during their time at St. Patrick’s Home is a priority for our staff, volunteers and management. To this end, we feel that implementing a truly integrated Person-Centred philosophy of care is the best way to achieve this objective. Although St. Patrick’s Home has always supported a person-centred philosophy of care, 2016 will see this take root much more substantially. To launch this initiative a group of 9 staff, made up of both management and front-line workers from various departments attended the Pioneer Network conference (A gold standard in Person-Centred Care) in Chicago in August, 2015. This group brought back an incredible amount of new ideas and energy geared towards Person-Centred care, which they are sharing with all staff through a series of 1-day education workshops which will run until April, 2016.
QI Achievements From the Past Year
St. Patrick’s Home of Ottawa saw improvements on several fronts in 2015/16 including falls; agency use related to 2 of the 3 nursing positions; the taste of meals as well as daily physical restraint use. We also continue to maintain an antipsychotic use much lower than most LTC Homes and have made modest gains on the area of resident experience and satisfaction, as gauged by our annual resident satisfaction survey.
As previously mentioned, our Home has made positive gains on the percentage of residents who had a fall over the last year, albeit minimal, we do consider this a huge success as we continue to reduce our physical restraint use.
Nursing staff working closely with our Rehab/Restorative Team have done a great job in analyzing the needs of our residents in terms of their required mobility aids and devices. Electronic referrals have been newly implemented via Point Click Care and the necessary aids/devices promptly provided. A little more work needs to be done to ensure these aids and devices are readily available to the residents where and when they need them, once delivered. Although registered staff have been educated on how to complete the new and improved Post Fall Assessment, some work remains on the side of auditing and follow up to ensure compliance in completing this assessment on time and accurately.
St. Patrick’s Home saw improvements on 2 of the 3 nursing positions in terms of agency use in 2015. Agency hours for PSWs improved by 1.1% while agency hours for RPNs improved by 1.8%. Agency hours for RNs did not improve as we saw an increase in March, April and May of 2015 which set us up for failure early on. Overall, RN agency hours for 2015 were up by 4.0% year-over-year. 2 of our 3 change ideas worked according to plan but staffing of the scheduling office remains a work in progress.
A PSW float pool was created for both days and evenings where we had 2 float PSWs available on days and 1 on evenings. The float PSWs were utilized for sick calls and replacement of staff where required. Having the float PSWs on-hand and ready to be deployed did make a positive impact to the staffing but this impact was eroded by other issues.
A more standardized approach was implemented with regards to our hiring and orientation process. A regularly scheduled interview and orientation schedule was established and will be maintained in 2016. This change idea was helpful in maintaining our staffing levels, however, the caliber of potential candidates did limit the number of new hires we were able to bring onboard.
The final 3 phases of our restraint reduction initiative went extremely well in 2015. We felt that by dividing the process into “phases” it gave staff periods of time throughout the year to work toward smaller more attainable goals. Overall, we drastically reduced our restraint use from a high of 22% in early 2015 to an alltime low of just under 10% in early 2016. Although we were just shy of our 8% objective we are extremely pleased with the work done by all staff, residents and their families on reducing our restraint use from an historical high of almost 50% just over 2 years ago.
Education and training for both staff and families continued in 2015 related to our least restraint policy and suggested alternatives to restraints. No falls occurred as a direct result of any restraint being removed.
Based on the percentage of residents that responded positively to the statement “My meals are tasty”, St. Patrick’s Home decided to include this item as an additional indicator on our QIP. 65.3% of residents either agreed or strongly agreed with the above statement in 2014. We set an internal target of 75% for this same indicator in 2015 and fell short of this objective by less than 1%. We are extremely pleased with the 8.8% increase achieved in this area and will aim to meet the 75% this year by implementing some of the change ideas that we did not have a chance to roll out last year such as the full taste panel across all Home areas as well as the cooks touring the resident home areas (RHAs).
Finally, St. Patrick’s Home joined a deprescribing project with The Ottawa Hospital to review guidelines on Benzodiazepines, Proton Pump Inhibitors and Antipsychotics. While we did see a small reduction in the use of antipsychotics it was not significant enough to lower our use of antipsychotics overall. Our antipsychotic use still remains well below the provincial average of 25%, as we continue to maintain a rate just under 17%.
Integration and Continuity of Care
St. Patrick’s Home will refocus its efforts in 2016/17 to reduce the incidence of potentially avoidable ED visits. We will focus on residents experiencing signs and symptoms of disease processes that could be managed internally by recognizing specific flags or triggers early on. Ongoing staff education and mentoring for PSWs, RPNs and RNs for early symptom identification and expedited treatments will play an integral part of our plan to reduce potentially avoidable ED transfers.
Engagement of Clinicians, Leadership & Staff Our QIP will be posted internally for all staff to review and become familiar with as we strive for buy-in and subsequent support across the home. Priority targets such as the restraint reduction initiative and the falls prevention program will require direct staff involvement and support on all clinical levels from our frontline PSWs to the RPN Leads on each RHA. Oversight and guidance from the RNs as well as the management and leadership team is an integral factor that will contribute to our ongoing success.
A regular review of the QIP Indicators will be included in the RHA House Council meetings for review by all staff, as well as one of the key performance evaluations.
Resident, Patient, Client Engagement Resident engagement has been and continues to be a priority this year for St. Patrick’s Home as we aim to solicit feedback from our residents on several fronts in order to improve quality of care and services offered. Our resident satisfaction survey, completed in Q4 2015 provided us with valuable feedback across many important areas such as nursing, recreation and pastoral services as well as dietary and nutritional needs; overall building maintenance and housekeeping. Having reworked our resident satisfaction survey in 2014 and using the same tool in 2015, gave us valuable comparative data year-over-year that we are now using to refocus efforts in certain areas such as our resident experience and overall satisfaction. Our goal is to continue with special events, both on and off the Resident Home Areas (RHAs), implement better tracking and feedback on the overall taste of the food and to solicit more direct involvement from our residents, both in terms of the resident satisfaction survey as well as the various quality improvement initiatives across the Home.
At the heart of our quality improvement initiatives is our data, which can be used to form baselines to measure and monitor quality of care as well as a mechanism to review trends and statistics over time or at any given point. Data used for quality improvement initiatives come from various sources including the resident’s electronic medication record, custom user-defined assessments, RAI MDS assessments (Quarterly and Annually), Point of Care (PSW) documentation, care plans, resident surveys, CCRS eReporting (CIHI), QIA (internally driven indicators), as well as HQO and the MOHLTC. Data from all sources is reviewed at regular intervals at various forums including, but not limited to RHA House Councils; Leadership and Quality Team Meetings; Quality Improvement and Risk Management Committee; Care Plan Reviews; PSW and Nursing Practice Meetings; Professional Advisory Committee as well as Pharmacy and Therapeutics and Infection Prevention and Control Committee meetings. Data is compiled and reported in various formats, streamlining processes and avoiding duplication where possible.
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Monique has recently joined St. Pat’s Home Team as the Vice President of Nursing. Monique brings with her over 25 years in the long-term care sector and has experience in all the clinical areas. She received her Degree in Nursing with a concentration in Gerontology in 2002. Prior to joining St. Pat’s she held the position of Director of Care for 15 years at local long-term care home.Monique Patterson