Page 358 - CEO Orientation

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

patients who were identified as high risk. The majority of falls occurred as a
result of patients disregarding instructions to ask for assistance when mobilizing.
It is important to note that despite being significantly off target in Q1,
performance for Q2/Q3 combined is below target at 0.92 harmful falls/1000
patient days. Change ideas will continue to be implemented new mitigation
strategies to help improve performance identified.

Dining Experience in the Houses
There is no data for improving the dining experience in the Houses. Surveys were
conducted in Q2 and Q3. Results are still pending and are tabulated by The
Alliance Group in order to benchmark and will be ready in late February or early
March. Performance will be reported in Q4 for this indicator.

St. Joseph’s Health Centre
St. Joseph’s QIP is focused on:
 Improving the patient experience;
 Reducing emergency department (ED) length of stay (LOS) for admitted
patients;
 Reducing healthcare associated C. difficile infection rates;
 Increasing documented medication reconciliation on admission;
 Preventing workplace violence and responsive behaviours; and
 Reducing hospital acquired pressure injuries.

Patient Experience
The percentage of positive responses from the patient experience survey
question: “Would you recommend?” continues slightly below target at 65.1%
positive. Survey completion rate remains above target.

EDLOS for Admitted Patients
Performance in ED LOS remained slightly above target in Q3 at 15.8 hours and
15.5 hours year to date. The performance target for this metric is 15.2 hours.

C. Difficile
As of the end of Q3, C. difficile was below target for the year at a rate of .24
which is below our target of less than .32. Hand hygiene rates are well below
target for the year at 56%. (Target is 75%) It is interesting to note that C. difficile
infection rates have decreased while hand hygiene rates have remained below
target. This highlights the importance of environmental cleaning and
antimicrobial stewardship in preventing C. difficile infection - it's not just hand
hygiene that prevents C. difficile infection.

Documented Medication Reconciliation (Med Rec) Upon Admission
Q3 Med Rec on Admission rate is 72.8% continuing a rise over the past year but
still below target of 85%. A monthly report for physicians on Med Rec
performance was deployed in Medicine and Pediatrics beginning in December.