Quality improvement workplan for Malton Village

Each year, long term care homes review their current performance by using selected optional indicators identified by Health Quality Ontario. Improvement action plans are then developed based on our performance in these indicators.

Indicator 1

Rate of ED visits for modified list of ambulatory care–sensitive conditions* per 100 long-term care residents.

• Current Performance: 20.51% (Source: CIHI CCRS, CIHI NACRS / October 1st, 2022 to September 30th, 2023)
• Target: 19.48%
• Target justification: Target will be to improve by 5% to get back to previous level of performance over time.

External collaborators: Nurse led outreach team, Neurobehavioral Nurse Practitioners, Psychiatry, Geriatrician

Change Idea # 1: Preview ED - Continue utilization of the Preview ED tool in POC/PCC to identify early signs of illnesses such as UTIs, dehydration, etc., to prevent ED transfers.

Methods: The Day PSW staff will complete the Preview ED tool at 0800 and any triggers will be followed up with by the nursing staff for subsequent consultation with NLOT/MD and subsequent transfer if needed.

Process measures:

• Percent of residents with completed daily Preview ED tool.

Target for process measures:

• 100% of residents with completed daily Preview ED tool.

Change Idea # 2: Refresh of Prevention of Error-based Transfer (PoET) Project.

Methods:

• Participate in POET project to reduce unnecessary transfers to hospital.
• Advance Care planning and /or Individualized Summary discussions will be held on admission and at care conferences (admission, annual and situational).
• PoET refresher training & Certification.

Process measures:

• # of unplanned transfers (monthly).
• % of unplanned transfers that were not seen/consulted by the NP/NLOT/MD prior to transfer (monthly).

Target for process measures: 

• Reduce the number of transfers by 5%.
• Collect baseline data.

Change Idea # 3: PDSA Initiative: Decrease ED Transfer Rate through analysis of transfer data and adaptation of strategies as required.

Methods:

• PDSA project by CQI Specialist on the ED transfer data, and review of the results on a quarterly basis.
• Conduct root cause analysis of ED Transfers, identify any systemic issues, gaps in care and implement strategies to reduce transfers. Continuously monitor the impact of interventions on the rate of ED visits over time. Adjust strategies as needed and evaluate the effectiveness of interventions in achieving desired outcomes.
• Collaborate with RAI coordinator and NP for reviewing the results on a quarterly basis.

Process measures:

• Rate of ED visits for modified list of ambulatory care–sensitive conditions* per 100 long-term care residents.

Target for process measures:

• Reduce the number of transfers by 5%.

Change Idea # 4: Enhance proactive measures by consulting prior to emergency room transfers and improve communication protocols to minimize avoidable transfers

Methods:

• Registered staff to consult with Physician/NP/NLOT prior to sending the resident to the ED to be proactive in minimizing an avoidable transfer.
• SBAR tool to be utilized when communicating any emergency transfers.
• Train the registered staff on SBAR tool as part of 8-hour Clinical Nursing Skills (SBAR will be incorporated in multiple modules as a tool to work through scenarios).
• Family/Caregiver education re: resident experience of being transferred to hospital and re: services that can be offered in-house within the Centre.

Process measures:

• # of educational sessions offered to families/caregivers during Family Town Halls.
• % of RNs/RPNs trained on SBAR.

Target for process measures:

• 2 educational sessions to be offered to families/caregivers during Family Town Halls over the course of 2024.
• 100% RNs/RPNs to be trained on SBAR tool.

Indicator 2

Percentage of staff who have completed relevant equity, diversity, inclusion, and anti-racism education.

• Current Performance: Collecting Baseline (Source: In house data collection)
• Target: 100%
• Target justification: Plan is to ensure all staff trained on Culture, Inclusion and Well-being.

Change Idea: Provide DEI training to all staff members, Employee Ambassador program and Leadership Education Huddle Tools.

Methods:

• Collaborative working with other teams on diversity, equity and inclusion (DEI) initiatives in the home.
• In person training on “Culture, Inclusion and Well Being” at Mandatories (Sept-Nov).
• The Employee Ambassador (EA) Program provides an opportunity to have many diverse voices championing strategic priorities to enhance employee engagement and enablement.
• Leadership Education Huddle Tools: Celebrate Each Other (DEI themed). Purpose of Huddle Tools is for Leaders to connect with their employees by conducting regular conversations related to psychological health and safety in the workplace. This tool provides evidence based key messages, conversation starters, and team building activities. A variety of options are provided so Leaders can choose a question or activity that suits their style and comfort level to hold space for these conversations.

Process measures:

• % of all staff who have completed in-person training on Culture, Inclusion and Well-being (This training is conducted as part of the full-day mandatories for all staff members).

Target for process measures:

• The target for this process measure is to have 100% of staff complete the training in the workplace by Dec 31, 2024.

Indicator 3

Percentage of residents responding positively to: "What number would you use to rate how well the staff listen to you?"

• Current Performance: 79% (Source: In house data collection, Resident Experience Survey)
• Target: 83%
• Target justification: The target will be to improve by 5% to gradually get back to previous performance levels of 92%.

Change Idea: Provide education to staff on effective communication techniques. 
Methods:

• Training sessions focusing on Emotion Based and Relational Care (This training is conducted as part of the full-day mandatories for all staff members).
• Training sessions focusing on Customer Service and Handling Complaints (This training is conducted as part of the full-day mandatories for all staff members).
• Incorporate this topic as a regular agenda item during Resident council meetings, allowing residents to provide feedback and insights during the sessions.

Process measures:

• % of staff trained on emotion-based and Relational Care.
• % of staff trained on Customer Service and Handling Complaints.
• % of residents who responded positively to the statement in the survey: "Staff listen to me."

Target for process measures:

• To ensure 100% of staff attend the in-person training on Emotion-Based and Relational Care.
• To ensure 100% of staff attend the in-person training on Customer Service and Handling Complaints.
• Maintain/increase the agreement percentage.

Indicator 4

Percentage of residents who responded positively to the statement: "I can express my opinion without fear of consequences".

• Current Performance: 74% (Source: In house data collection, Resident Experience Survey)
• Target: 77%
• Target justification: The target will be to improve by 5% to gradually get back to performance level in 2022-23 of 86%.

Change Idea: Raise awareness of the Resident Bill of Rights and invite residents to contribute suggestions for potential areas of enhancement.

Methods:

• Review of Bill of Rights and Whistleblower Policy at Resident Council meetings and staff meetings.
• Town Halls for families/residents at a regular frequency.
• Review the minutes of Resident Council meetings to determine any opportunities for improvements.

Process measures:

• # of Town Halls for families/residents.
• % of residents who responded positively to the statement: "I can express my opinion without fear of consequences".

Target for process measures:

• Minimum of 1 Townhall held/quarter.
• Increase the agreement % by 5%.

Indicator 5

Percentage of LTC home residents who fell in the 30 days leading up to their assessment.

• Current Performance: 12.81% (Source: CIHI CCRS / July 2023–September 2023)
• Target:12.49%
• Target justification: Target would be to improve by 5% as part of continuous quality improvement efforts as performance has slowly been declining over the last 5 quarters.

Change Idea #1: Sustain Preventing Falls and Reducing injuries from Falls BPG.

Methods:

• Training on Falls Prevention and Management (4Ps/Purposeful Rounding/RNAO BP Guidelines).
• Discuss high risk residents at shift change reports to alert PSWs to monitor residents.
• Friendly competition between nursing home areas with respect to having the lowest number of falls sustained over 2 months with a prize awarded every 2 months.
• Falls huddles to be completed by interdisciplinary team after each fall to review, implement, and evaluate strategies to decrease falls.

Process measures:

• # of falls per month.
• % of falls with injuries.
• % of staff trained in Falls Prevention and Management (Online Learning).

Target for process measures:

• 5% reduction in number of falls.
• 5% reduction in falls with injury.
• 100% staff trained on falls program.

Change Idea # 2: PDSA Initiative: Decrease the percentage of falls through analysis of falls data and adjustment of strategies as necessary.

Methods:

• Conduct root cause analysis of falls occurring in home to determine strategy to decrease incidence, risk and severity of falls by CQI Specialist.
• Review all residents who are at high risk for falls during Falls Committee Meeting.

Process measures:

• # of falls per month.
• # of falls committee meetings per year.

Target for process measures:

• 5% reduction in number of falls.
• 5% reduction in falls with injury.

Indicator 6

Percentage of LTC residents without psychosis who were given antipsychotic medication in the 7 days preceding their resident assessment.

• Current Performance: 9.05% (Source: CIHI CCRS / July 2023–September 2023)
• Target: 9.00%
• Target justification: The target would be to maintain performance at this level or improve by 0.5% as performance has been showing steady improvement for the last 7 quarters for Malton Village.

Change Idea #1: Implement evidence-based interventions, monitor medication practices, and provide targeted education to interdisciplinary teams. 
Methods:

• Continue to review residents receiving antipsychotic medication at monthly BSO bi-monthly meetings/medication review meetings to ensure that medication is warranted, and diagnosis is documented (where applicable).

Process measures:

• # residents on antipsychotics without a diagnosis of psychosis.
• # case reviews completed monthly.

Target for process measures:

• 100% of residents on antipsychotics without a diagnosis will be reviewed.

Change Idea # 2: Implement an antipsychotic review pathway for new admissions.

Methods:

• BSON to engage with care planning for all new residents who move into the Home with anti-psychotic medications and to assist in identification of non-pharmacological approaches.

Process measures:

• % of new residents on antipsychotics reviewed within six weeks of admission.

Target for process measures:

• 100% of new residents on antipsychotic medications will be reviewed by BSO within 6 weeks.