Quality improvement workplan for Tall Pines

Priority indicators and change ideas identified for the 2024 to 2025 Quality Improvement Plan reporting cycle.

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: 16.84% (Source: CIHI CCRS, CIHI NACRS / October 1st, 2022, to September 30th 2023)
Target: 16.84%
Target justification: Maintain current performance.
External collaborators: Nurse led outreach team, Neurobehavioral Nurse Practitioners, Psychiatry, Geriatrician

Change Idea # 1: PreviewED - 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 PreviewED tool at 0800 and any triggers will be followed up with the nursing staff and for subsequent consultation with NLOT/MD and subsequent transfer if needed.

Process measures:
Percent of residents with completed daily PreviewED tool.

Target for process measures:
100% of residents with completed daily PreviewED 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)
% of staff receiving refresher training

Target for process measures:

Reduce the number of transfers by 1%
Collect baseline data
100% of Registered Nurses trained in PoET

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 1%

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 NP/NLOT/MD prior to sending the resident to the ED in order to be proactive in minimizing an avoidable transfer
SBAR tool to be applied 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)

Process measures:
% of RNs/RPNs trained on SBAR

Target for process measures:
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: Aim is to have all staff complete in-person training on Culture, Inclusion and Well-being in 2024

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: 76% (Source: In house data collection, Resident Experience Survey)
Target: 76%
Target justification: Maintain current performance.

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% staff attend the in-person training on Emotion Based and Relational Care
To ensure 100% 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: 79% (Source: In house data collection, Resident Experience Survey)
Target: 79%
Target justification: Maintain current performance (The home strives to work towards 100% of residents responding positively).

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:

Review of Bill of Rights and Whistleblower Policy at Resident Council meetings and staff meetings
Town Halls for families/residents at a regular frequency
% of residents who responded positively to the statement: "I can express my opinion without fear of consequences".

Target for process measures:

4 reviews per year to assess the effectiveness of the methods
Maintain or increase the agreement percentage

Indicator 5

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

Current performance: 14.13% (Source: CIHI CCRS / July 2023–September 2023)
Target:12.00%
Target justification: The home will continue to strive for continuous improvement and to meet the HQO benchmark.

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

Methods:
Training on Falls Prevention and Management (including 4Ps, SBAR), assigned to all staff in a direct care role (PSW, RN, RPN and Activation teams)

Process measures:

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

Target for process measures:

15% reduction in number of falls
15% reduction in falls with injury
100% staff trained (PSW, RN, RPN and Activation teams) on Falls Prevention and Management

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:

15% reduction in number of falls
15% 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: 8.24% (Source: CIHI CCRS / July 2023–September 2023)
Target: 8.24%%
Target justification: Maintain current strong performance

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 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% 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.