Wilson Memorial General Hospital
April 1, 2011
This document is intended to provide public hospitals with guidance as to how they can satisfy the requirements related to quality
improvement plans in the Excellent Care for All Act, 2010 (ECFAA). While much effort and care has gone into preparing this document, this
document should not be relied on as legal advice and hospitals should consult with their legal, governance and other relevant advisors as
appropriate in preparing their quality improvement plans. Furthermore, hospitals are free to design their own public quality improvement
plans using alternative formats and contents, provided that they comply with the relevant requirements in ECFAA, and provided that they
submit a version of their quality improvement plan to the OHQC in the format described herein.
Wilson Memorial General Hospital 1
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
Part A:
Overview of Our Hospital’s Quality Improvement Plan
1. Overview of our quality improvement plan for 2011-12
VISION
Striving for healthy communities , now and in the future!
Wilson Memorial General Hospital’s vision, mission and values are supported by our strategic plan, which
is will reviewed and updated this year through a community engagement process. To incorporate
recommendations from the Excellent Care for All Act the Board of Directors of Wilson Memorial General
Hospital (WMGH) approved our Quality Improvement Plan (QIP) in March 2011. The foundation of this
plan is aligned with our strategic goals, our hospital report card, and annual planning submission.
The Quality Committee receives quarterly reports related to improvement initiative. Recomendations for
indicators and plans of action are encorporated from our safety and quality learning reports, and patient
and staff satisfaction surveys. To ensure the delivery of efficient and consistent evidenced based quality
care, WMGH uses a multidisiciplinary approach to review and analyze data to provide information which
will assist in improving outcomes and recognize opportunities to improve delivery of care to our patients.
Through our accountability framework and quality measurement system, our Board of Directors reviews
every quarter, our achievements of outcomes through key performance indicators reported in an
operational review. An annual review of the QIP will be achieved by the use of our hospital report card
encompassing four quadrants for review; financial perspective, client perspective, internal business
perspective, and innovation and learning. Administration realizes that accurate funding data will always be
a priority.
Wilson Memorial General Hospital and The McCausland Hospital have been leaders of integration within
the North West LHIN. In June 2008, the hospitals entered into a Joint Venture agreement for the purpose of
investigating and implement integration opportunities. To date the two hospitals have successfully
completed a number of integration initiatives including a joint management structure as of April 1st, 2010.
We will continue with this proactive approach to achieve operational efficiencies and the highest quality
client care.
2. What we will be focusing on and how these objectives will be achieved
Our QIP will focus on the four quadrants of the report card to complete an overall picture of performance.
By developing and implementing a thorough picture of organizational performance, the overall strategic
goals of the organization are monitored to achieve higher quality patient care with efficiency and cost-
effectiveness.
Optimize PATIENT SAFETY through effective communication
Client Perspective
Current Strategic Directions
To advance communication with internal and external providers in our community which fosters
collaboration for the delivery of integrated care to our clients
To ensure that Wilson Memorial General Hospital is committed to establishing a culture where
patients, staff and visitors safety is a priority
Wilson Memorial General Hospital 2
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
WE WILL:
1. Provide a safe, responsible obstetrical care in an environment that facilitates adoption of
evidence informed decisions and the development of clinical skills
Participation of > 80% of full time and part time nursing staff and physicians in MOREob
program
Obstetrical policies and procedures will remain updated to reflect SOGC best practice
guidelines as reflected by on line audit of policies and procedures.
2. Continue to provide a patient environment that is responsive to infection prevention and
control practices.
Infection rates are below provincial comparator rates
100% of Healthcare Provider (HCP) complete the core infection control competencies
Annual hand hygiene audits will reflect 15% improvement from the previous year.
3. Provide a medication processing and administration environment that supports professionals
to process and deliver medications safely, efficiently and consistently.
Medications errors that reach the patient will be reduced 10%
4. Implementation of venous thromboembolism prophalaxis (VTE) program to support best
practice guidelines for prevention of VTE’s
Greater than 80% compliance on completion of risk assessment tool for VTE on admitted
patients
100% of full time/part time nursing staff and physician participation in open order sets on
line
5. Reduce level of injury with falls to 11%
Continued implementation of 3 stars falls prevention program
6. Receive greater than 80% patients who recommend this hospital to their friends and family
7. Improve accessibility by increasing accessible bathrooms.
Improve QUALITY CARE through proactive analysis
Business Perspective
Our plan of action allows us to know how well the organization is running and whether we are meeting our
strategic goals and the mission of the facility. Each department submits monthly statistical data for
comparison quarterly. Analyzing the data provides information that will assist in improving outcomes and
recognize opportunities to improve delivery of services.
Current Strategic Direction
To enhance the delivery of healthcare services improving access for our clients, by developing a
model of delivery that promotes the concept “closer to home” whenever practical.
WE WILL:
Implement a culture of safety in an environment that adopts best practice initiatives and the
development of clinical skills.
1. Enter agreements with the NW LHIN that incorporate strategies that meet communities’ needs.
2. Network with area hospitals and healthcare providers to fully utilize resources to meet the
communities’ needs.
3. Review operational recommendations with the NW LHIN looking at improving efficiencies.
4. Work with the NW LHIN and community partners to achieve ALC targets as negotiated in the
HSAA.
5. Achieve Ontario Laboratory Accreditation in 2011.
Wilson Memorial General Hospital 3
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
Advance QUALITY IMPROVEMENT though leadership development
Innovation and Learning
Our hospital will improve the health of our communities through the provision of quality health care
services in a learning environment, working in collaboration with other health care providers.
Current Strategic Directions
Develop innovative strategies to attract and retain health care workers to our facility by becoming
the “employer of choice”; creating a healthy workplace that motivates retention.
Encourage high levels of staff performance through continuous development with a focus on safety,
best practices and the needs of the clients.
WE WILL:
1. Develop best practice in leadership development. We will use innovative strategies to advance
quality improvement.
2. Receive greater than 70% staff who recommend this hospital to their friends and family
3. Complete performance appraisals every two years to allow employees to reflect on their
professional practice and provide them with the opportunity to participate in professional and
personal development opportunities.
Ensure responsible FINANCIAL MANAGEMENT
Financial Perspective
Wilson Memorial General Hospital is committed to the development of a financially stable organization.
Current Strategic Direction
Maintain strong fiscal management practices
WE WILL:
1. Ensure total margin is in compliance with HSAA
2. Ensure current ratio is in compliance with HSAA
3. Develop a five (5) year capital plan and achieve annual approval from the Board of Directors
3. How the plan aligns with the other planning processes
This Quality Improvement Plan will be utilized to monitor our performance over time. The facilities
performance indicators reported in this document are used to track our progress, compare our progress
with provincial, regional, or national peers and to monitor our achievements. Most important of all, it helps
us to identify those areas that require improvements.
The foundation of this plan is not only aligned with our strategic goals, but our annual planning submission.
The plan also incorporates all required indicators and implements strategies from the North West Local
Health Integration Network, Northwestern Infection Control Network, Public Reporting from the Ministry
of Health and Long Term Care, Accreditation Canada, Canadian Institute for Health Information and the
Ontario Health Quality Council.
Wilson Memorial General Hospital 4
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
4. Challenges, risks and mitigation strategies
As a small rural northern hospital we will continue to be challenged by new legislation and mandated
requirements. We have limited human resources to commit to meeting these requirements.
Our northern communities are experiencing an out migration of our youth due to the lack of local
employment opportunities. Combined with an aging population and the loss of family or informal
caregiver these individuals have turned towards the hospital for additional support. This additional
demand for services continues to strain our limited resources.
Wilson Memorial General Hospital’s strategies will be clearly documented and distributed within our
organization. There will be a program of continuous education to support and empower our employees.
The Board of Directors are aware of the possibility of redistribution of our limited resources may be a
requirement for success.
Wilson Memorial General Hospital 5
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
Part B:
Our Improvement Targets and Initiatives
Please complete the “Improvement Targets and Initiatives – Part B” spreadsheet (Excel file). Please remember to include the
spreadsheet (Excel file) as part of the QIP Short Form package for submission to the OHQC (QIP@ohqc.ca), and to include a
link to this material on your hospital’s website.
Please see attached spreadsheet.
Wilson Memorial General Hospital 6
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
Part C:
The Link to Performance-based
Compensation of Our Executives
Purpose of Performance-based compensation:
1. To drive performance and improve quality care
2. To establish clear performance expectations
3. To create clarity about expected outcomes
4. To ensure consistency in application of the performance incentive
5. To drive transparency in the performance incentive process
6. To drive accountability of the team to deliver on the Quality Improvement Plan
7. To enable team work and a shared purpose
Manner in and extent to which compensation of our executives is tied to
achievement of targets
Our executives' compensation is linked to performance in the following way:
The executives of the hospital that will have their compensation linked to performance are the Chief
Executive Officer, the Chief Nursing Officer and the Chief operating Officer. Performance based
compensation will be based in the quality improvement indicators as shown below.
Indicator Below Floor Floor Level or 2011/2012 Target Full Success
Score = 0 pts. Maintenance of Score = 2 pts. Score = 3 pts.
Quality
Score = 1 pt.
Hand Hygiene Below 60% 60% to 70% 70% to 80% Over 80%
Overall Patient Below provincial 75% to 80% 80% to 85% Over 85%
Satisfaction Avg of 75%
Medication Errors that 36% or higher 36% to 26% 26% to 20% Below 20%
reach the patient
Total Margin More than 1% below Below H-SAA H-SAA obligation Over 1% better than
H-SAA obligation obligation but within achieved or up to 1% H-SAA obligation
1% better
While a total possible score is 12, successfully meeting objective of any of the above targets reflects an
individual score of 2 points. Therefore a total score for the four target of 8 points or more would provide
the full pay entitlement. A score under 8 would result in a proportionate reduction of 1/8 of performance
compensation for every point below 8.
The performance-based compensation for year 1 (2011/12) will be equivalent to 2% of compensation for
the CEO and 1% of compensation for all other executives. This is year one of a five year plan that will result
in the performance-based compensation equivalent to 10% for the CEO and 5% for all other executive in
year 5.
Performance-base compensation will be paid no later than sixty (60) days after year end (March 31), once
the annual results have been calculated. If an individual is in the position after the start of the year their
performance compensation will be paid in proportion to the time they occupied the position and the year
end result. If an individual leaves a position prior to year end their performance will be evaluated for the
against the quality improvement indicators below and any payment should be issue on or before their last
regular pay.
Wilson Memorial General Hospital 7
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0
Part D:
Accountability Sign-off
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/provider surveys, aggregated critical incident data, and patient safety indicators;
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.
Terry Fox Bill Gascon Paul Paradis
Board Chair Quality Committee Chair Chief Executive Officer
Wilson Memorial General Hospital 8
26 Peninsula Rd, Bag “W”
Marathon, ON
P0T 2E0