Tall Pines action plan
The annual Resident Experience survey took place in August, 2023 and Family/Caregiver Experience survey took place in October, 2023. Resident surveys were administered in-house with the assistance of volunteers, while family surveys were distributed both by mail as paper copies and via email with a SurveyMonkey link for online completion. Paper surveys were later entered into SurveyMonkey, and the results were compiled.
The analysis of our 2023 Resident Experience Survey results indicated overall satisfaction with the accommodation, care, services, programs, and goods provided to our residents. Additionally, it highlighted specific areas where targeted improvement efforts are needed to further enhance the resident experience.
Nursing Care Team
Focus of improvement
The nursing care team take time to talk and listen to me.
Key action
Providing training sessions focused on Emotion Based and Relational Care.
Outcomes of action
- Implemented November 2024.
- Completed: 100% front-line staff trained.
Key action
Providing training sessions focused on Emotion Based and Relational Care.
Outcomes of action
- Implemented November 2024.
- Completed: 100% of staff trained during in-person mandatory training.
Problem solving and communication
Focus of improvement
My problem was resolved to my satisfaction.
Key action
Provide refresher education in emotion based and person-centered care and 4 Ps.
Outcomes of action
- Implemented July 2024.
- Completed: refresher emotion-based training provided to all and 4Ps refresher training provided to registered staff.
Focus of improvement
Improved staff communication techniques.
Key action
Provide education to staff on effective communication techniques (Customer Service training in-person).
Outcomes of action
- Implemented November 2024
- Completed Mandatory training for all staff.
Services
Focus of improvement
Describe how you feel about the foot care services (podiatry/foot care nurse).
Key action
Ensure that information regarding foot care services is available to residents and families through brochure or welcome package.
Outcomes of action
- Implemented May 2024.
- Completed: acquired footcare brochure from vendor and added to the admission package.
Menu and dining
Focus of improvement
There are a variety of menu choices to choose from.
Key action
- Supply more loaves for days and evenings.
- Present more savoury options for nights.
Outcomes of action
- Implemented July 2024.
- Completed: new menu implemented according to feedback received.
Focus of improvement
The menu offers cultural and ethnic food options that I like.
Key action
Distribute spice caddies in each dining room to enable resident to flavour food according to preference.
Outcomes of action
- Implemented June 2024.
- Completed: spice caddies with sauces and spices implemented in all dining rooms.
Activation
Focus of improvement
Gardening program.
Key action
Host a gardening day to plant seedlings with resident and families for the upcoming season.
Outcomes of action
- Implemented May 2024.
- Completed: residents and their families planted together. Event was a success.
Key action
Launch a farmers’ market with vegetables from garden.
Outcomes of action
- Implemented December 2024.
- Completed: vegetable from the garden was used for residents’ lunch as well as a farmers’ market for staff, residents, and families.
These are the priority areas identified for the year 2024/25. Tall Pines’ Quality Improvement Initiatives align with annual submissions of Quality Improvement Plans.
Focus of improvement 1
Reduction in the number of resident falls in the 30 days leading up to their assessment.
Key action
Initiate a Falls PDSA project.
Outcomes of action
- Implemented December 2024.
- In progress: practice areas identified through analysis. Action plan initiated.
Key action
Maintain utilization of the Falls BPG.
Outcomes of action
- Implemented December 2024.
- Completed: all staff aware of the Falls BPG and expectations.
Focus of improvement 2
To reduce the percentage of residents given an antipsychotic medication with a diagnosis in the 7 days preceding their assessment.
Key action
Implement an antipsychotic review pathway for new admissions.
Outcomes of action
- Implemented December 2024.
- Completed: all residents reviewed every 2 months.
Key action
Implement evidence-based interventions, monitor medication practices, and provide targeted education to interdisciplinary teams.
Outcomes of action
- Implemented December 2024.
- Ongoing: this practice is ongoing and effective.
Focus of improvement 3
Reduce rate of emergency department (ED) visits
Key action
Utilization of the PreviewED tool at 0900.
Outcomes of action
- Implemented December 2024.
- In progress: analysis of the effectiveness of the tool to reduce ED transfers in process.
Key action
Arrange refresher training on the PoET project tool.
Outcomes of action
- Implemented December 2024.
- Completed: all staff trained on the PoET project.
Key action
Initiate a PDSA project.
Outcomes of action
- Implemented December 2024.
- In progress: action items identified and in process.
Key action
Improve communication and consultation prior to ED transfer.
Outcomes of action
- Implemented December 2024.
- Completed: evidence of consultation and improved communication prior to ED transfer.
Key action
Utilize diagnostic tool to prevent ED transfers.
Outcomes of action
- Implemented December 2024.
- In progress: this initiative is new and will need more data to review efficacy.
Focus of improvement 4
Increase percentage of staff who have completed DEI and anti-racism training.
Key action
Provide DEI and anti-racism training.
Outcomes of action
- Implemented December 2024.
- Completed: 100% of staff completed the DEI training.
Key action
Continue of the Employee Ambassador training.
Outcomes of action
- Implemented December 2024.
- In progress: involvement with the Wellness team and site level committee to implement staff ideas.
Focus of improvement 5
Percentage of residents who feel positively about expressing themselves without the fear of consequences.
Key action
Raise awareness of the Resident Bill of Rights and the Whistleblower policy.
Outcomes of action
- Implemented December 2024.
- In progress: will review efficacy after the 2024 Resident Satisfaction Survey.
The Resident Council holds monthly meetings where members can ask questions, share their expectations, and discuss their preferences for care and treatment. Quality Improvement plans are discussed regularly at Resident Council and Family Council meetings. Regular updates on the status of action plans are provided, and feedback from both councils is collected and documented in meeting minutes. Additionally, ongoing updates about the plan's implementation are posted on the information board.
Quarterly Continuous Quality Improvement (CQI) meetings are held to provide progress updates and identify areas needing further attention. Discussion on Quality improvement initiatives is a standing agenda item at CQI committee meetings. The CQI Committee aids in implementing the action plan by offering recommendations and continuously assessing the effectiveness and sustainability of the actions taken.
Including outcomes based off RES, FCES, and Home’s Priority Areas
Residents: Information was shared to Residents through the Resident Council meeting minutes. The action plan was discussed in the Resident Council meeting on March 20, 2024, and the outcomes were communicated on September 9, 2024.
Families: Details were provided to families through the Family Council meeting minutes. The action plan was discussed during the Family Council meeting on Feb 21, 2024, with outcomes shared on May 16, 2024.
Both Residents and Families were informed about the action plans through postings on the Resident and Family Council boards on August 19, 2024.
Staff: Updates were shared via CLT and CQI meetings, where action plans were discussed regularly. The outcomes were presented during the CQI meeting on August 23, 2024. Ongoing updates regarding plan implementation were posted on the quality board.