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The Perley and Rideau Veterans' Health Centre

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Quality Improvement Plan 2017 - 2018

Quality Improvement Plan Narrative: The Perley and Rideau Veterans' Health Centre, 2017-2018

The Perley and Rideau Veterans’ Health Centre (Perley Rideau) is pleased to share its 2017-18 Quality Improvement Plan (QIP).  Perley Rideau’s primary focus is Excellence in Resident Care and Services.  Our commitment to quality is reflected in our vision to be “An advanced health centre for seniors which will be a valued, sustainable centre for quality care, serving the elderly and their families…” and in our supporting strategic plan. 
Perley Rideau is entering a period of significant challenge and opportunity.  The population of World War II and Korean veterans is declining.  As a result, Perley Rideau’s mandate to provide long-stay residential care for veterans of World War II and Korea will evolve.  Ontarians are aging and have more complex health needs.  Resources are limited.  The healthcare system must learn new ways of delivering higher quality care at lower cost.  Perley Rideau must determine how it can provide the highest value to its community.
The QIP is a roadmap to achieving excellence in resident care and services, while navigating challenges and opportunities in our environment.  Perley Rideau’s QIP is aligned with our annual operating plan and supported by our measurement and accountability systems.  This alignment allows us to effectively clarify priorities, direct resources, monitor progress and act on results.
The overall objectives of the 2017/18 QIP remain similar to 2016/17.  Maintaining focus will allow us to build on foundational work completed as well as sustain and spread improvements achieved during the previous QIP cycles (2015/16 and 2016/17).  Targets and change ideas for each priority area have been refined to reflect:
•       progress achieved in 2016/17;
•       the most recent performance data available from the Canadian Institute for Health Information, resident and family satisfaction surveys and our electronic health record;
•       input from residents, families, staff, leaders and external partners, including the MOHLTC.
Priorities are divided into 3 categories – priorities for focused action, moderate action and monitoring.  Please note that targets reflect a blended average for both our community and veteran residents.
Priorities for Focused Action:
1)      Reduce the percentage of residents who had a fall in the last 30 days from 20.6% to 19.5%
2)      Reduce the percentage of residents with worsening behavioural symptoms from 20.9% to 19.3%
3)      Reduce the percentage of residents who experienced worsening pain from 18.0% to 15.0%
Priorities for Moderate Action:
4)      Reduce the percentage of residents who had a worsening pressure ulcer from 5.8% to 4.8%
5)      Maintain or increase the percentage of residents who would positively recommend Perley Rideau to others (currently 88%, target at or above 85%).  Target of 85% remains unchanged for 2017/18, as Perley Rideau will focus on sustaining consistently high performance in this area.
6)      Maintain or reduce the number of potentially avoidable ED visits per 100 residents (currently 17.9, target at or below 23.0). Target of 23.0 set in 2016/17 is maintained into 2017/18 as Perley Rideau has not yet achieved sustained, actual results at or better than the targeted performance level.
Priorities for Monitoring (areas where Perley Rideau's performance over time is meeting benchmark levels):
7)      Maintain or reduce the use of daily physical restraints (currently 5.3%, target at or below 5.5%).  The target of 5.5% remains unchanged from 2016/17 as most recent data has not consistently been at or better than the targeted performance level.
8)      Reduce the inappropriate use of antipsychotics from 15.6% to 9.0%
Perley Rideau has identified modest improvement targets for 2017/18 in recognition that the standardized QIP indicators used for long-term care in Ontario are lagging indicators.  There is an approximate 1 year delay between current performance and reported performance.  The baseline data used for the 2017/18 QIP reflects performance for the time period October 2015 to Sept 2016.    We have adopted a 3-year cycle for our QIP, recognizing that a phased approach to change will increase the likelihood of sustained improvement.  We anticipate meaningful improvement will be achieved and maintained in each priority area by 2018/19.  Our 3-year targets are to be at, or better than the provincial average in all priority indicators.

QI Achievements From the Past Year
In 2016/17, Perley Rideau saw clinical improvement in some areas identified in the QIP; although metric improvement of the corresponding quality indicators is not yet evident. Highlighted below are some of the key improvements from 2016/17.
Reducing Resident Falls
Following the intensive improvement event (known as a Kaizen), the team tested and implemented an evidence-based fall assessment/screening tool (Scott Fall Screening Tool) and process across all 12 units. This tool will enable consistent and accurate identification of a resident's risk for falls, and help the interdisciplinary team to identify appropriate interventions to protect the resident.
The team has completed testing and refining the post fall huddle tool and process; testing revised team communication tools and mechanisms (e.g. medication cheat sheets for PSWs, transfer logos, structured discussion at care plan meetings, etc.) and developing resident/family education materials in partnership with residents and families.  In 2017/18, the team will focus on implementation and spread across Perley Rideau.

Assessing and Managing Responsive Behaviours
The QI team completed their analysis of current state through process mapping, clinical observation and use of RNAO's Best Practice Guidelines. The team identified two areas of immediate need: lack of an evidence-based tool and supporting process related to Behaviour Mapping, and lack of a standardized and evidence-based approach to managing high risk residents.  In 2016/17, the team tested, refined and implemented a revised Behaviour Mapping Tool and process across the facility.  The process for managing high risk residents was developed, but requires testing prior to implementation and spread.
Other achievements for this team include the development, testing and implementation of Antecedent, Behaviour, Consequence (ABC) meetings across the Health Centre.  These interdisciplinary meetings, which occur on an ad hoc basis, are facilitated by the Psychogeriatric Resource Nurse, and provide a forum for the care team to review and discuss the resident triggers, behaviours and interventions on all shifts. The meetings assist the care team in the assessment of Dementia, Delirium and Depression.  A focus for the ABC meetings is to assist the care team in creating an individualized approach and care plan to meet the needs of residents with responsive behaviours.
The team is also planning the spread of monthly resident high risk meetings across the Health Centre.  These interdisciplinary meetings have been very successful in identifying residents who are high risk for responsive behaviours. The discussion focuses on a team approach to identifying the residents triggers, interventions and follow up that is required by the team.
Pain Management
A Kaizen Event was held in spring 2016. In 2016/17, the team developed, tested and implemented an evidence-based pain assessment tool for use with cognitively impaired residents.  The team is now proceeding with refining and implementing the pain assessment tool for cognitively intact residents; the pain mapping tool; admission screening tool; educational materials; and non-pharmacological interventions list.
Comfort Care Rounds
Literature indicates that rounding on residents or checking on residents hourly makes a significant difference in residents’ perception of care as well as addresses care and safety concerns.  Specific benefits include decreased falls, decreased skin breakdown and improved resident satisfaction. Most importantly, residents receive better care.
Although front line staff have rounded on residents for quite some time, Perley Rideau identified the need to strengthen the overall structure of rounding to improve resident outcomes. Comfort care rounding involves eight specific steps performed hourly with each awake resident. In 2015/16, Comfort Care Rounding was piloted on 3 units. Following the pilot, significant improvements were made to the education prior to roll-out across the facility.  This included the development of a Comfort Care Rounding video series, interactive Skills Labs, and finally, 1:1 coaching by a Rounding Champion.  Comfort Care Rounding was fully implemented across the facility in 2016/17 (March 2017). Perley Rideau is now focused on sustaining this practice.

Palliative and Therapeutic Harmonization (PaTH)
PaTH is a process that helps older people and their families understand their health status and guides them through the process of making health care decisions that protect their best interests and quality of life.  It is a frailty-informed philosophy of care that can be used across the healthcare continuum.  Perley Rideau piloted PaTH on two residential units in 2016/17, and although some issues were identified, many positive outcomes were identified.  Notably, family members that participated in the pilot were pleased with the process and felt more informed, empowered and supported in making health care decisions for their loved one. Work is underway to address some of the lessons learned from the pilot and plan for further testing and implementation of PaTH across the facility in 2017/18.

RNAO Best Practice Spotlight Organization (BPSO) 
BPSO is a designation program developed by the RNAO to work with health care facilities, in order to create evidence based cultures in the work place. In May 2016, Perley Rideau was accepted into the program as a pre-designate, and must achieve very specific milestones over the next 3 years to be granted full designation. During this time, Perley Rideau will work with the RNAO and other BPSOs to implement four Best Practice Guidelines addressing the areas of Falls, Pain Management, Pressure Injuries and Caring for Residents with Delirium, Dementia and Depression.  Participation in this rigorous program will increase Perley Rideau's capacity to support the implementation and sustainability of evidence based practice at an accelerated pace.

Population Health
Perley Rideau is a seniors’ care organization with 450 long-term care beds; 250 beds dedicated to care for World War II and Korean War veterans, and 200 beds available to members of the general community, of which 34 are designated convalescent care. Perley Rideau leverages a number of data sources to better understand residents' needs and to inform clinical quality improvement initiatives.  This includes its electronic health record (PointClickCare), internal incident reporting system, as well as quarterly CCRS e-report data. Improvement initiatives focus primarily on clinical issues that directly impact residents' quality of life, such as minimizing risk of falls, skin breakdowns, and pain management.
Perley Rideau's strategic direction is focused on evolution into a true seniors’ village, where most of the needs of the elderly can be met within the community, including help at home, nutrition, safety, access to primary care, healthy living choices, companionship, opportunities for social activities and learning. Perley Rideau works collaboratively with local organizations to leverage its expertise and expand services across the continuum of care to better meet the needs of seniors in the community.

As legislated by the Long Term Care Homes Act, the Perley Rideau admits all potential residents that meet the outlined criteria for admission to a long term care home, regardless of ethnicity, sexual orientation, income, etc.  The Perley Rideau makes every effort to meet the needs of non-English speaking residents, which includes using pictorial communication tools during daily care delivery, having staff or volunteers translate during physician visits and care conferences, and accessing translation services through the consulate as required. 

Integration and Continuity of Care
Perley Rideau’s strategic plan, entitled “Creating a Seniors’ Village” calls for new models of care and collaboration across the continuum to provide residents, clients, tenants and the broader community with high quality, cost effective care and services.  We are working with numerous partners to advance integration and continuity of care.   Highlights include:

Partnership between The Perley Rideau Veterans’ Health Centre, The Ottawa Hospital and the Champlain CCAC to establish a Sub-Acute unit for care of the Frail Elderly (SAFE collaborative)
S.A.F.E is focused on providing restorative, frailty informed care to seniors following an acute hospital stay to enable their timely and safe return to the community.  The proposed program includes intense collaboration between an acute care hospital and long-term care home, with the hospital providing enhanced diagnostic (lab and medical imaging) and physician support in a long-term care setting.  These supports would be available to both short-stay sub-acute patients and long-stay residents, with a focus on building capacity and improving continuity of care for frail seniors.  If successful, this initiative will decrease the risk of extended hospitalization for frail patients (ALC), minimize the risk of hospital-acquired complications, improve resident quality of life, decrease ED wait times and provide cost savings for the health care system and patients/families.

Expansion of the Seniors’ Village
The Seniors’ Village at Perley Rideau continues to grow and evolve with a goal of integrated services for seniors that will meet the majority of their health and social needs.  In 2015, several primary care physicians working in the long-term care home began offering house call medical services to tenants on our campus.  A dermatology clinic also opened.  In 2016, Perley Rideau continued to work in partnership with the University of Ottawa Health Service, to open a comprehensive primary care clinic to meet the needs of both our Seniors’ Village residents and members of the broader community. Perley Rideau also initiated a formal partnership with the University of Ottawa’s Faculty of Health Sciences to launch an interprofessional health clinic and research institute. It is anticipated that the primary care and interprofessional clinics will be operational in 2017.

Seniors’ Quality Leap Initiative (SQLI)
SQLI is a collaborative of 14 leading long-term care and seniors’ care organizations across North America who are committed to improving quality through benchmarking, common improvement initiatives, sharing and learning.  SQLI members are currently focused on improving pain management, minimizing use of antipsychotics and resident quality of life.

Access to the Right Level of Care - Addressing ALC Issues
As highlighted above, Perley Rideau is currently partnering with The Ottawa Hospital (TOH) and the Champlain LHIN to establish a Sub-Acute unit for care of the Frail Elderly (SAFE collaborative). Once established, this collaborative will improve the outcomes for hospitalized frail seniors by proactively addressing the conditions that contribute to ALC before the deconditioning associated with prolonged hospitalization is experienced.  This will enable TOH to reduce its ALC population, thus allowing beds that are currently dedicated to ALC clients to be repatriated to acute care. This collaborative has the capacity to transform how major acute care hospitals change how they treat older patients at risk of ALC and deconditioning (early assessment, collaboration with LTC).

Engagement of Clinicians, Leadership & Staff
Clinicians, leaders and staff have been engaged throughout the development of the QIP and continue to be engaged in its implementation.  QIP teams are comprised of inter-professional staff working at the point of care, with support from leaders and a quality improvement consultant.  Performance data and improvement work are regularly shared during town halls, staff meetings for both registered and non-registered staff, Medical Advisory Committee, working committees, and leadership meetings.  Performance data are also posted on resident care units and updates provided in our newsletter. 
During the initial development and subsequent updates of the QIP, staff and leaders were asked to identify priorities for improvement and feedback was solicited regarding proposed change ideas. QIP teams with support from leadership, set targets based on a review of internal and provincial data, benchmarks (if available), and an understanding of the potential for improvement (based on current practice and best practice).
The entire management team and Board of Directors reviews quality performance quarterly, including the status of key QI initiatives.  Each QIP team presents an in-depth review of their work annually to the Board of Directors Quality and Safety Committee. 

Quality improvement goals are aligned with leaders’ annual performance objectives, cascading from the CEO to supervisory staff.  Quality improvement is the CEO’s highest priority objective.

Resident, Patient, Client Engagement
Perley Rideau has three active councils focused on resident and family experience - the Veteran Residents Council, the Community Residents Council, and the Family and Friends Council (FFC).  The councils are a valuable forum for collaboration and engagement.  The leadership team and councils enjoy a positive and productive relationship.  Members of the Management team are invited to, and attend, all council meetings.  In addition, at least one Executive leader attends all meetings of the FFC Executive.  The Chair of the FFC is a member of the Board Quality and Safety Committee.  The Chair of the Veteran Residents Council is a member of the Veteran Liaison Committee.

The Management team routinely seeks feedback and involvement from the councils regarding various aspects of the Perley Rideau’s operations such as the annual resident/family experience surveys, annual budget, operating plan and quality improvement priorities.   Co-design methods have been used, particularly for designing communication tools. In an effort to further engage residents and family members in quality improvement activities, a Resident and Family Advisor Program was piloted during the summer of 2016. The goal of this program is to promote resident and/or family participation on all of Perley Rideau's QI projects, and other initiatives, as appropriate.  In 2017/18, work will focus on developing policies, procedures and educational material to support the program.
A draft of the QIP was brought forward to the FFC as well as the Veteran and Community Residents Councils for discussion and review.  Feedback was very positive, and members’ priorities for improvement are reflected in the final QIP, particularly regarding resident and family experience.

Staff Safety & Workplace Violence
Perley Rideau is committed to providing a safe and healthy work environment for staff.  As such, the Perley Rideau has a number of measures in place to minimize the risk of incidents, appropriately address all reported incidents, and prevent re-occurrences. 
1) Robust policies and procedures that cover all aspects of staff safety, including a comprehensive Violence Prevention policy. This policy outlines the key measures in place to monitor, address and prevent workplace violence, including regular education for staff, prompt investigation and follow-up of all incidents, identification and communication of hazardous situations, as well as implementation of corrective actions.  Roles and responsibilities are clearly outlined within the policy, which is revised annually.
2) An active Joint Occupational Health and Safety (JOHSC) committee. Perley Rideau's JOHSC has a mandate "to identify, assess and control workplace hazards and make recommendations to the workplace to prevent injuries and illnesses". The JOHSC achieves this mandate through regular review and discussion of workplace incident data, and annual completion of a workplace violence risk assessment tool. The JOHSC will either address an issue directly (as appropriate), or make recommendations to the Management Team when further actions are required to minimize identified risks. The JOHSC plays an integral role in the development, implementation and reviews of Perley Rideau's Violence Prevention Policy.
3) Regular discussion of Safety-related issues at the Management level.  Safety is included as a standing item on the Management team's bi-weekly agenda. 

Contact Information
Melissa Norman
Performance Improvement Consultant
Phone: 613-526-7170 ext. 2448