Mackenzie Health 1 10 Trench Street Richmond Hill, ON L4C 4Z3

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

1/3/2018

This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein.

Mackenzie Health 2 10 Trench Street Richmond Hill, ON L4C 4Z3

Overview

Mackenzie Health is committed to improving quality and patient safety and our 2018/19 Quality Improvement Plan continues to support our journey to “create a world class health experience”. Our key areas of focus have been chosen including feedback from our patients and ensuring our guiding principles of “teamwork, accountability and safety” are at the forefront of all improvement plans. Our commitment to ensuring timely access to care to all those within our community and supporting smooth transitions through the healthcare system, supports our mission to “relentlessly improve care to create healthier communities”.

We are devoted to ensuring the best possible patient experience and striving to be an organization that our employees are proud to work for. In order to improve the patient experience, we are continuing with the strategies put in place during the fiscal year 2017/18 across the organization and highlighting a new format of patient satisfaction surveying that is capable of capturing real time data. In doing so, we can monitor trends and implement improvements in a timely manner which will promote our efforts on improving the patient experience with a wide variety of strategies that includes a focus on excellent service and patient safety.

The 2018/19 Quality Improvement Plan is our pledge to strive for excellence in the services that we provide our patients, their families and our community throughout the coming year and as we prepare for the opening of our second hospital site in 2020. Describe your organization's greatest QI achievements from the past year

Mackenzie Health is proud to be focused on quality improvement activities every day and over the past year; many achievements have supported our focus. There have been many achievements motivated by our desire to increase patient safety and improve the patient experience. In July of 2017, Mackenzie Health implemented a state of the art Electronic Medical Record called Epic which will support our goals in advancing our culture of patient safety. With our new electronic clinical environment, we have the opportunity to leverage real-time data to review program quality against metrics with information that was not previously available in a paper environment. One of our focus areas is on ensuring the tools and processes are in place for our clinical teams to utilize information to support best practices, learn from every situation and to proactively prioritize future opportunities for patient safety improvement.

The implementation of Epic continues to support our “Back to Basics” bundles which includes improvement initiatives at the unit level and include head to toe assessments, patient rounding, transfer of accountability, partnerships with patients and families and medication safety practices. Key safety initiatives include documentation at the bedside including implementing a closed loop medication system. These efforts are advancing our culture of patient safety, positioning us to deliver excellent quality care; every patient; every time.

The organization continues to focus our “It Takes Two” campaign launched in 2016 that embeds actions

ensuring all staff accurately identifies patients with each and every treatment interaction. This year, we

reminded our team that positive patient identification ‘Still’ Takes Two.

Mackenzie Health 3 10 Trench Street Richmond Hill, ON L4C 4Z3

This year we implemented Patient and Family Advisors, we have begun to embed additional patient advisors across the organization who will engage with co-creation of organizational initiatives along with quality improvement. With patients as our partners in care, we are confident we can design a system where the patient experience is “world class”.

Alignment

Our QIP for 2018/19 continues to align with our current five year strategic plan. It reflects our quality and safety balanced score card directions as well as our programmatic score card indicators. The development of this year’s indicators have included many factors including feedback from our patients and families, patient safety incident trending data, our current performance of quality & patient safety indicators and the Joint Centres initiatives. We have proposed six indicators we feel reflects strategically important work we are doing to improve quality care and make a difference for our patients. Objective: Safety Mackenzie Health has chosen to continue with the indicator of Clostridium Difficile rates (CDI) for 2018/19. During 2017/18 we incorporated specific actions that have allowed us to reach and exceed our current. We see the importance of carrying this forward through the coming year with a stretched target. This indicator is also a Joint Centre initiatives indicator that allows us to work collaboratively on standardizing efforts across the healthcare system to increase patient safety. Objective: Safety Mackenzie Health has chosen to maintain the indicator of Workplace Violence from 2017/18 that looks at Workplace violence that has led to lost days of the employee. We have also included the mandatory indicator for Workplace Violence for 2018/19. This indicator is also a Joint Centre initiative that allows us to work collaboratively with other organizations in the standardization of actions relating to prevention of workplace violence. Objective: Safety Mackenzie Health has chosen to maintain a custom built indicator of Patient Safety incidents relating to mislabeling of specimens. During 2017/18 we have made positive steps to reduce the labeling specimen issues in our Procedural unit and we see the importance of carrying this forward through the coming year and spreading our lessons learned through quality improvement activities that will specifically address this important issue throughout the organization. Objective: Safety The indicator of Falls Rate Organizational will assist us to develop strategies supporting our Falls Prevention Program and increasing patient safety. Objective: Effective Mackenzie Health has chosen a new indicator Pressure Injuries Skin and Wound Assessment. This indicator will assist us to develop strategies supporting our Pressure Injury Program and increasing patient safety as pressure injuries (stage 3 or higher) are considered Never Events. At Mackenzie Health we will focus our improvement strategies on completing Skin and Wound Assessments in our new electronic medical record to prevent pressure injury occurrences.

Mackenzie Health 4 10 Trench Street Richmond Hill, ON L4C 4Z3

Resident, Patient, Client Engagement and Relations

We believe bringing patients and family’s perspectives to co-designing services is a valuable method of engagement. This year we embarked on our continued partnership with patients and families, by embedding Patient Advisors into our Program Quality Committees encouraging patient and family perspectives in co-creation health care at Mackenzie Health. In line with our philosophy of continuous process and quality improvement and strategic priority that specifically focuses on the patient experience on what matters to patients. Mackenzie Health has launched MyChart, an online health management service where patients can set up, manage and share access to their personal health records. MyChart is accessible from anywhere at any time through the internet, giving patients access to their personal health records at any time. Patient and Family Advisory members were essential in the development and creation of the MyChart design and product ease of use. Collaboration and Integration Mackenzie Health is a proud member of the Joint Centres initiatives. The Joint Centres is a unique

partnership between seven large community hospitals including Mackenzie Health, Markham Stouffville

Hospital, Michael Garron Hospital, Humber River Hospital, North York General Hospital, Southlake Regional

Health Centre and St. Joseph’s Health Centre. The objectives are to: seek and share innovative ideas that

improve service delivery and/ or value across the system, serve as a living laboratory to demonstrate

innovation, provide a forum for the rapid execution of new ideas, technologies, products and processes to

improve system performance and create opportunities for shared innovation, learning and knowledge

transfer among the member organizations, their staff and physicians.

The Joint Centres hospitals have worked on a number of improvement initiatives that have focused on

clinical and administrative process changes designed to improve care through collaboration and innovation.

Past projects include reduction of C-difficile infections and reduction of C-Sections which as of 2017/18 have

moved into a sustainability and monitoring phase at each hospital supported by Joint Centres communities

of practice. In addition, Choosing Wisely – an Adopting Research to Improve Care (ARTIC) Program

supported project that has targeted the reduction of unnecessary tests will conclude at the end of March

2017.

Active projects that the member hospitals will continue to collaborate on in 2018/19 include:

the prevention of workplace violence through development and implementation of a common

approach to risk identification and care planning (alert for behavioural care protocols and

processes)

the reduction of harm classified as Never Events beginning with prevention and management of

pressure injuries through awareness raising, reliable application and auditing of an agreed upon set

of always events and patient and family engagement

These on-going projects continue to reflect the commitment of the Joint Centres hospitals to working

together to develop, implement and spread leading practices and innovative solutions to improve care for

the patients and families they serve.

Mackenzie Health 5 10 Trench Street Richmond Hill, ON L4C 4Z3

Engagement of Clinicians, Leadership & Staff

We have built a strong organizational support system of quality and safety engagement for the organization that begins with focused attention on patient centered care. At the board level, we review quality and patient safety at our Quality Safety and Risk Committee. All hospital leaders are engaged at our Hospital Quality Committee where members discuss safety reviews and quality indicators. Each program actively participates at our program quality committees that gather important feedback at the unit council level. Our front line staff are also engaged in reviewing quality and safety at the unit level using simple tools such as the quality boards that hold important initiatives used to increase safety across the organization. Access to the Right Level of Care - Addressing ALC Mackenzie Health partnered in the Reactivation Care Centre, collaboration between hospitals in the Central LHIN to increase bed capacity and address demands of our growing community. This new facility has been specifically designed to provide patients who no longer need acute care with specialized, reactivation care in a setting that best supports their care journey. Workplace Violence Prevention

Mackenzie Health is committed to the prevention of workplace violence across the continuum of care, including staff, patients, volunteers and visitors. A multidisciplinary Hospital Workplace Violence Committee ensures a safe environment and takes every reasonable effort to identify all potential sources of violence with the focus on eliminating or mitigating risk. In 2018 we are focusing on identifying risk and triggers to prevent violence in the workplace. Our work with the Joint Centres Spread Project continues to develop and evolve to make our hospital a safe and transparent place for everyone at Mackenzie Health. Performance Based Compensation Mackenzie Health has a comprehensive executive performance based plan that has been in place for many years. The plan exceeds the requirements for the Quality Improvement Plan (QIP) as it includes Director level positions and above. The Mackenzie Health performance based plan is linked to the achievement of strategic goals and objectives which includes QIP targets. Total compensation, which is benchmarked to market rates of peer hospitals, equals base salary plus performance based pay, also referred to “at risk” pay. The at risk pay component is:

up to 20% of base pay for the President and Chief Executive Officer (CEO)

up to 15% of base pay for Senior Management reporting directly to the CEO (Executive Vice President & CAO, Executive Vice President & COO/CNE, Vice President, Strategy and Redevelopment, Chief Human Resources Officer and Chief Communications & Public Affairs Officer)

Up to 15% of base pay for the Chief of Staff (COS)

Mackenzie Health 6 10 Trench Street Richmond Hill, ON L4C 4Z3

As well, all management staff and physicians with management responsibilities complete an Accountability Agreement incorporating corporate strategic targets, program targets and individual targets. The Accountability Agreement objectives align with the Quality Improvement Plan. Contact Information Linda Gravel Director, Quality, Patient Safety & Risk 905-883-1212 ext. 7265 Linda.Gravel@MackenzieHealth.ca Sign-off I have reviewed and approved our organization’s Quality Improvement Plan Tony Ianni Board Chair _______________ (signature) Sheila Neuburger Quality Committee Chair _______________ (signature) Altaf Stationwala President &Chief Executive Officer _______________ (signature)