Page 359 - CEO Orientation

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

This feedback report will support further improvement on Med Rec on
Admission.

Workplace Violence
SJHC experienced a significant number of lost time incidents in Q1, having
exceeded the full 2017/18 target in that quarter. Of the four lost time incidents,
three involved injuries to staff and one to a physician. There were no incidents
involving lost time in Q2 and in Q3.

Reducing Incidence of Hospital Acquired Pressure Injuries
Pressure Injury Prevalence remains above target at 12.2% in Q3 and 10.26% YTD.
Hospital Acquired Pressure Injury “Never Events” rate is decreasing from 2.97%
in April to 1.76% in Q3. The goal for Never Events is zero.

St. Michael’s Hospital
St. Michael’s QIP is focused on:
 Improving hand hygiene compliance prior to patient contact;
 Reducing unnecessary daily blood tests;
 Improving the discharge experience of our patients;
 Reducing the emergency department (ED) length of stay (LOS) for low
acuity non-admitted patients; and
 Preventing staff injury during patient mobilization.

Hand Hygiene & Daily Blood Tests
Despite a small decrease in the overall Moment 1 Hand Hygiene performance
(direct observations) in Q3 to 74%, St. Michael’s remains on track to meet its
17/18 target of 66%. Progress continues with reducing unnecessary routine
blood work in the General Internal Medicine unit. Opportunities to spread this
strategy into the Medical Surgical Intensive Care unit have been identified and
an action plan for implementation is under development.

Discharge Satisfaction
There has been a slight decrease in performance related to patient satisfaction
with the information received on discharge (63.3%). However, we remain
encouraged by the positive responses we continue to receive through our
discharge experience phone calls which provide more real time data and
feedback.

EDLOS for Low Acuity Non-Admitted Patients
St. Michael’s is not on track to meet its overall target of 4.5 hours for Low Acuity
Emergency Length of Stay. A focus on the assignment of appropriate CTAS scores
continues along with identifying strategies to mitigate the impact of upcoming
moves related to construction on the length of stay for all patients.

Staff Injury During Patient Mobilization