Quality_Improvement_Plan_Shortform by ajizai


									Manitoulin Health Centre

Year 2011/2012

Manitoulin Health Centre    1
11 Meredith St. E.
Little Current, ON P0P1K0
         Part A:
         Overview of Our Hospital’s Quality Improvement Plan

         1. Overview of our quality improvement plan for 2011-12
         Manitoulin Health Centre’s Mission - “to contribute to the health and well-being of all who come to us in need”, and Vision -
         “dedicated to excellence in all we do” – to deliver on our Mission and align with our Vision, the organization requires a focus on
         both safety and efficacy. Our quality improvement efforts form an important mechanism for driving quality improvement.

         The Quality Improvement Plan for 2011-12 will focus on the use of indicators that are relevant to safety and efficacy.

         2. What we will be focusing on and how these objectives will be achieved
         Manitoulin Health Centre is a rural-remote, 2-site hospital corporation, serving the population of Manitoulin Island. Our core
         programs focus on delivering basic in-patient, emergency and ambulatory care to residents and visitors to the Island region.
         Our population includes 7 distinct 1 Nations communities. There are a large number of fragmented community providers that
         exist across this geography, along with a sparse distribution of CCAC resources.

         Our hospital organization will focus on indicators that are meaningful and aligned with our core programs and our regional
         situation. A focus on fostering and improving a culture of safety has existed at our hospital for over a year. This QIP will align
         with our existing quality initiatives, through our Quality Improvement Team, our Board’s Quality Assurance Committee and our

         The indicators selected for 2011-12 QIP include Hand Hygiene, Medication Reconciliation, Readmission Rates, ALC Days,
         Total Margin, Discharge Planning Meetings and ED Wait Times. A balance of safety and effectiveness indicators is presented,
         as well as those that will measure and drive improvement for key processes.

         All indicators selected are well aligned with the Mission, Vision and Core Programs of the organization, as well as reflective of
         the role played regionally by our hospital in relation to the other care provider stakeholders.

         3. How the plan aligns with the other planning processes

         The QIP is well aligned with other planning processes and quality initiatives across our local region and LHIN. Manitoulin
         Health Centre’s H-SAA obligations include the tracking and reporting of ALC rates. This is an extremely important focus for our
         LHIN and all local service providers, as our LHIN has one of the highest percentages of ALC activity in Ontario.

         Similarly, Readmission Rates have become one of the new target indicators across hospitals. The selected CMG’s that make
         up this indicator have a high degree of relevance for our local situation. Chronic disease morbidity and mortality across the
         North-East are higher than in other areas of the province. Thus, selecting indicators that track chronic disease readmissions is
         a logical focus for our organization.

         The fiscal performance of our hospital, as measured by the Total Margin, is also an important H-SAA indicator. The hospital
         must maintain a favourable financial position if it is to deliver on its Mission. It is therefore desirable to track and maintain this
         indicator at a healthy level of performance.

         4. Challenges, risks and mitigation strategies
         1.) Structural Resource Risk:
         Manitoulin Health Centre is a 2-site hospital, with a single board, management and leadership structure. The organization is
         very flat, with working managers complimenting front-line staff resources. The current structure does not include a separate
         lead individual for quality initiatives. Thus, the human resources required for the QIP initiatives must come from the Senior
         Management Team, Chief of Staff, Board QA Committee and Department Managers. The QIP will consume only a portion of
         their time and responsibilities.

Manitoulin Health Centre                                                                                                                          2
11 Meredith St. E.
Little Current, ON P0P1K0
         To mitigate this risk, clearly defined segmentation of the work activities will be determined and delegated across the above
         individuals, to provide role clarity and load sharing.

         2) Duplication of Efforts:
         There is a risk that the obligations created by the QIP may not mesh well with the existing efforts already underway at our
         organization, with respect to quality. A high expenditure of effort has already taken place to shape our quality mechanisms and
         reports, as well as roles and responsibilities for reporting of indicators, quality improvement oversight and feedback to staff.
         The introduction of the QIP may add confusion if it is not dovetailed into the existing efforts and structure.

         To mitigate this risk, as much of the existing format as possible will be left in place. The CEO and CNO will help coordinate
         these efforts along with the COS and the Chair of the Board’s QA Committee. Where new elements must be adopted,
         communication with all stakeholders will take place to help drive the acceptance of the new tools and mechanisms.

Manitoulin Health Centre                                                                                                                 3
11 Meredith St. E.
Little Current, ON P0P1K0
         Part B:
         Our Improvement Targets and Initiatives
         See the accompanying Spreadsheet for this Information.

Manitoulin Health Centre                                          4
11 Meredith St. E.
Little Current, ON P0P1K0
         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 Compensation of the Senior Executive Team of Manitoulin Health Centre, comprised of the CEO, CNO, CFO, Director of
         Human Resources and the Chief of Staff, is linked to the achievement of targets identified within the 2011/12 Quality
         Improvement Plan in the following manner:

         1) No existing mechanism was in place which meets the definition of a “pay-for-performance” system;
         2) A portion of all executive salaries has thus been placed at risk, payment of which is wholly dependant upon the following
         3) The following indicators shall each be weighted equitably against the pay at risk amount (25% each) as pay for performance
          a) Medication Reconciliation Rates at Discharge (Baseline 32%, Target 50%)
          b) Readmission Rates within 30 days for selected CMG’s (Baseline 19.5%, Target 15%)
          c) Total Margin (Baseline 3.7, Maintain at Greater than or Equal to 0)
          d) Hold Quarterly Discharge planning meetings (Baseline 50%, Target 100%)

         4) For those indicators with an identified target level of improvement, 3 (a)/(b)/(d), at least 50% of the identified improvement
         goal must be achieved before payment will be delivered. Lesser performance will result in the removal of that portion from
         5) For the Total Margin indicator, performance of greater than or equal to 0% must be determined to demonstrate compliance
         before payment will be delivered. A result below this level will result in the removal of that portion of the remuneration.

Manitoulin Health Centre                                                                                                                     5
11 Meredith St. E.
Little Current, ON P0P1K0
         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.

                            Michael Shain          Suzanne Norris                  Derek Graham
                             Board Chair        Quality Committee Chair         Chief Executive Officer

Manitoulin Health Centre                                                                                   6
11 Meredith St. E.
Little Current, ON P0P1K0

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