Page 357 - CEO Orientation

Quality Committee of the
Board
Briefing Note – Agenda Item #4.0

Item: Quality Improvement Plan (QIP) 2017-18 Q3 Reports
Lead(s): P. Nord , M. MacLeod & D. Sinclair Date: February 6 , 2018

Purpose: Decision Consultation  Information

Background: 2017-2018 QIPs were submitted for Providence Healthcare (Hospital and
Cardinal Ambrozic Houses), St. Joseph’s Health Centre and St. Michael’s
st
Hospital to Health Quality Ontario on April 1 , 2017.
Reason: Performance against QIP target is to be monitored on at least a quarterly basis.
Information & Providence Healthcare
Expectations: Providence’s QIP for the Hospital is focused on:
 Improving patient satisfaction with their overall experience;
 Improving Functional Independence Measure (FIM) efficiency (i.e.
improve rehabilitation outcomes) on A3 & B3 Rehab beds; and
 Reducing harmful falls for Geriatric and Medical Rehab inpatients.

The Cardinal Ambrozic Houses of Providence QIP is focused on:
 Reducing worsening pressure ulcers;
 Improving the dining experience; and
 Reducing falls

Providence is on track to meet its targets for improving FIM efficiency in the
Hospital and reducing falls and pressure ulcers in the Houses.

Providence is not on track to meet targets for improving patient satisfaction with
overall experience and reducing harmful falls in the Hospital.

Overall Experience
Providence has implemented all of the change ideas and most of the
mitigation strategies that may have had a positive impact on
performance. Although our Q3 target was reached, a detailed analysis
of the data shows that performance has been declining on average
0.76% quarter over quarter since 2015/16. While we set an
improvement target to improve our baseline performance of 64.9% to
66.2% by end of Q4 as a stretch goal, we now believe that this target
was set too high. We continue to implement the change ideas and
identify new mitigation strategies to help improve performance.

Falls
Falls reduction performance target was narrowly missed in Q3 (by 0.02 harmful
falls/1000 patient days). There were eight harmful falls across A4 and B4; six of
which were mild in nature (e.g. skin abrasion). A review of the harmful falls that
occurred indicate that fall risk assessments were completed on all of the patients
and falls prevention and harm reduction interventions were in place for all the