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
Collingwood General and Marine Hospital
459 Hume Street, Collingwood ON L9Y 1W9
Please do not edit or modify provided text in Columns A, B & C
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
Reduce incidence of VAP rate per 1,000 ventilator days: the total number of newly diagnosed VAP Remain below
Ventilator Associated cases in the ICU after at least 48 hours of mechanical ventilation, divided by the ON
Pneumonia (VAP) number of ventilator days in that reporting period, multiplied by 1,000 - Average 0.00 3
performance
for Jan-Dec. 2010, consistent with publicly reportable patient safety data benchmark
Improve provider hand Hand hygiene compliance before patient contact: The number of times that hand
Increase 11/12
hygiene compliance hygiene was performed before initial patient contact divided by the number of
performance by
observed hand hygiene indications for before initial patient contact multiplied by 50% 2
15% of 09/10
100 - 2009/10, consistent with publicly reportable patient safety data
performance
Reduce rate of central line Rate of central line blood stream infections per 1,000 central line days: total
blood stream infections number of newly diagnosed CLI cases in the ICU after at least 48 hours of being Remain below
placed on a central line, divided by the number of central line days in that ON
0.00 3
reporting period, multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with performance
publicly reportable patient safety data benchmark
Avoid new pressure ulcers Pressure Ulcers: Percent of complex continuing care residents with new pressure
ulcer in the last three months (stage 2 or higher) - FY 2009/10, CCRS N/A N/A N/A
Avoid falls Falls: Percent of complex continuing care residents who do not have a recent prior
history of falling, but fell in the last 90 days - FY 2009/10, CCRS N/A N/A N/A
Improve provider hand Hand hygiene compliance 'All Moments' inclusive: The number of times that 1) CGMH Awareness Campaign includes scheduled Completion Audit -
hygiene compliance hand hygiene was performed for 'All Moments' inclusive divided by the number of innovative methods to raise awareness regarding hand 90% schedule
observed hand hygiene opportunities multiplied by 100 - 2009/10 hygiene compliance (ie. 'It's OK to Ask?', 'Take a completion rate
TARGET
'Moment" etc.) Targeting exercise to aim
Increase 11/12 Achieve
2) Hand Hygiene Training, designed monthly training Hand Hygiene for incremental
by 10% of Performance Goal Inclusion of 'All Moments of Hand Hygiene' important to
62% 1 packages, provides Hand Hygiene instruction for new Education accomplishment toward
09/10 2011/12 overall safety.
staff as well as staff education for ongoing competency. completion rate attainment of long term
performance (* linked to
>80% (f/t & p/t) goal in following year
compensation)
3) CGMH Hand Hygiene Video, created 'in-house' Video completion
facilitated by staff and Physicians will be utilized as part by end April 2011
of the 'Awareness Campaign'
Formal Medication Percentage of Admitted Patients receiving Med Rec: Total number of admitted
Med Rec for
Reconciliation process for patients receiving Medication Reconciliation divided by the total number of
11.3% >80% Admitted 2
Admitted Patients admitted patients. - Q3 2010/11 - MediTech Reports - Med Rec
Patients
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety
Effectiveness Reduce clostridium difficile in
unnecessary deaths CDI rate per 1,000 observed deaths/number patients newly diagnosed - FY
HSMR: number of patient days: Number of of expected deaths x 100 with Remain below
N/A N/A N/A
associated diseases (CDI)
hospitals hospital-acquired CDI, divided by the number of patient days in that month,
2009/10, CIHI ON
0.16 2
Reduce unnecessary hospital Readmission 1,000 Average for Jan-Dec. 2010, consistent with publicly
multiplied by within- 30 days for selected CMGs to any facility: The number of performance 1) ED/FHT EMR Access Project provides the hospital ED Consistent secure
readmission reportable patient safety datareadmitted to any facility for non-elective inpatient
patients with specified CMGs benchmark physicians with secure access to the community records access to FHT EMR
care within 30 days of discharge, compared to the number of expected non- of patient's rostered with the local FHT 24h in the ED. completion rates -
(Medical,
The patient is visit ed by a Senior Manager/designate to aim for 90%
Surgical and TARGET Achieve
apologize for the extended wait in the ED and open applicable patient Exceed annual Inpatient
Obstetrics) Performance Goal
enable an dialogue regarding the current patient flow visits Average for Ontario
77.1% Annual avg. 10% 1 2011/12
constraints. Community Hospital
above ON (* linked to
performance in NRC Picker
Community 3) Patient Relations Process framework and public web Framework and compensation)
Hospital page redesign. Clearer guide and more visible 'buttons' Web updates
Inpatient avg. will be incorporated to facilitate public access. completed by Sept
2011
4) Service Specific Patient Satisfaction review by Monitor indicators -
Leadership and communicated to staff to increase aim for current
awareness and focus departmental initiatives based on departmental bench
patient feedback or higher
In-house survey (if available): provide the percent response to a summary
question such as the "Willingness of patients to recommend the hospital to friends N/A N/A N/A
or family"
FINAL QIP 11/12
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark
AIM MEASURE CHANGE
Quality Current Performance Methods and results
dimension Objective Outcome Measure/Indicator performance goal 2011/12 Priority Improvement initiative tracking Target for 2011/12 Target justification Comments
Safety Reduce clostridium difficile CDI rate per 1,000 patient days: Number of patients newly diagnosed with Remain below
associated diseases (CDI) hospital-acquired CDI, divided by the number of patient days in that month, ON
0.16 2
multiplied by 1,000 - Average for Jan-Dec. 2010, consistent with publicly performance
reportable patient safety data benchmark