BEFORE YOU BEGIN…
As part of the ECFAA Legislation, the annual quality improvement plan must be developed having regard to:
- The results of the surveys (patient and staff - if available)
- Data relating to the patient relations process
- Aggregated critical incident data
Please ensure this information is reviewed and considered in the process of developing your plan.
Helpful hints for how to review this information are provided in the guidance document.
Link to Online Updates
Key messages Technical Information
PART B: Improvement Targets and Initiatives
Measures (columns B-F) –There is a core set of Current performance: What is your organization’s current performance data/rate? A
measures identified within this spreadsheet. This is timeframe is specified within the table for core indicators.
to ensure alignment, consistency and Performance goal 2011/12: At the end of the improvement initiative, what is the
standardization of reporting. There is however, an outcome your organization expects to achieve?
expectation that measures will be added that align Priority: Only indicators assigned as Priority 1 require a change plan (columns G-K).
with your own hospital and regional priorities Please see the guidance document for more information.
Change plan (columns G-K) – These columns should High-level improvement plan: This section defines the details of the quality
be completed where you have flagged a measure as improvement initiative. Hospitals are required to complete the change section for all
Priority 1 (column F). Understanding that hospitals high priority (1) initiatives.
do not all have the same priorities, we expect these Methods and results tracking: Include your measures/current data (i.e. process
plans to be developed with your own hospital's measures) as appropriate
priorities in mind. Change priorities should be Target for 2011/12: All Priority 1 indicators must have a target defined for
focused on areas where improvement is necessary. 2011/2012. Organizations should aim to review their existing data over time to set
“stretch targets” on a select number of objectives. Please see the Guidance
document for more information on target setting.
Target justification: Why was the specific target selected? i.e. is the target based on
research literature; best practice; provincial or other defined benchmarks; scientific
evidence; organizational targeting exercise?
Comments: If there are any additional comments that you would like to make about
the initiative, please indicate these here.
PART B: Improvement Targets and Initiatives
Centre for Addiction & Mental Health, 1001 Queen Street West, Toronto
AIM MEASURE CHANGE
Methods and Target
Quality Outcome Current Performance Priorit Improvement Results Target for Justificatio
Dimension Objective Measure/Indicator Performance Goal 2011/12 y Initiative Tracking 2011/12 n Comments
Safety Improve % hand hygiene N/A 1000 audits 2 CAMH is part of the Handy audit To be Best Practice
provider hand compliance to be Handy Audit Project project determined Evidence
hygiene determined which is designed to participation generated via
compliance develop more reliable Monthly review CAHO handy
evidence based targets of audits audit project
for hand hygiene.
Reduce % of clients who have N/A 90% 2 Refine and random chart 90% Best Practice We are just in the process of
medication medication implement the audits & Internal refining our process.
errors reconciliation process for org. Therefore, we do not have
targeting current performance data.
completed on medication
exercise
admission reconciliation on
admission.
Development of Random chart To be Best Practice Measurement methodology is
indicators to assess audits determined & Internal currently being developed.
the quality of the direct org.
admission medication targeting
reconciliations. exercise
Reduce use of # of unique clients in 1.93% 2.00% 1 We have a Each aspect of Specific Best Practice This is a priority initiative for
mechanical mechanical restraints comprehensive the strategy has targets vary & Internal CAMH. The patient population
Restraints divided by # of unique initiative aimed at tracking with the org. is such that some restraint
clients in the period restraint reduction methods built in. strategy. targeting use is expected (hence the
focusing on staff exercise 2%) but our goal is prevention
(includes emergency
education, policy and reduction of time spent in
room patients) as per
revision, staff and restraints.
our BSC client debriefing to
learn from incidents,
and development of
alternatives to
restraints.
Effectiveness Improve Total Margin 2.41% 0.52% 3
organizational (consolidated): Percent
financial health by which total corporate
(consolidated) revenues
exceed or fall short of total
corporate (consolidated)
expense, excluding the
impact of facility
amortization, in a given
year. Q3 2010/11, OHRS
Access Reduce wait Amount of time in minutes N/A 30 mins 1 Increase physician New system to Under 30 Internal org. This is a new initiative and
times in the ED from presenting in the ED presence and support be implemented. mins targeting thus current data is not
to completion of triage. in ED in the evening exercise available.
hours.
Review of physical
space and patient flow
process.
Enhanced staff
education re: triage.
Patient Improve Patient % of patients who 76.69% 77.00% 2 Continue to work with We are CAMH has a strong
Centred Satisfaction answered "yes" to the Accreditation Canada maintaining relationship with client
following question on to refine survey tool the target at empowerment and family
discharge: "If you needed and re-implement. Our current level councils and funds their
treatment again would you aim will be to increase as this was representation on key
choose to come back to sample size. the first year committees including Clinicial
this hospital?" of data Quality Committee of the
collection Board.
with a new
instrument.