Submitted by: Michele Jordan, Vice-President, Quality Improvement and Transformation, Rouge Valley Health System

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1 Submitted by: Michele Jordan, Vice-President, Quality Improvement and Transformation, Rouge Valley Health System Project Name: Implementing Our QIP Coaching Circle #:QIP-3 1. Aim Statement: At Rouge Valley, our mission is to provide the best healthcare experience to our patients and families and our vision is to be the best at what we do. We do this by having a relentless focus on quality. The Excellent Care for All Act requires hospitals to pay even more attention to quality. Quality improvement is our priority for 2011/12: We will continue the journey of operational and cultural transformation that we began in 2008 to live up to these aspirations. We will use Lean as our management philosophy and our framework for continuous improvement. We will launch our new strategic plan. We will continue to use Personal Business Commitments (PBCs) and a corporate balanced scorecard to articulate clear goals and accountabilities for our leaders 2. Study Population: All staff and physicians but with a particular focus on leadership.. 3. Initial Project Design: QIP fits into our established accountability process using Personal Business Commitments (PBC's) and is one component of our corporate accountability model Integrated with existing RVHS accountability frameworks (PBCs) Aligned with other external accountabilities, e.g. HSAA QIP by itself does not go as far as the PBC approach we have used for the past three years ( this is our 4th year) we are tracking 36 indicators that are form the basis of our executive compensation model We have taken the view that targets should be realistic - some might be considered stretch We have picked 4 major metrics on which to focus Why and how were the big 4 chosen? Current State: Multiple competing priorities contributing to confusion about priorities, fragmentation of improvement efforts and burn-out; large number of indicators to report on and expectation that they will all be improved Desired State: Greater focus and alignment throughout the organization to drive improvement at the hospital-wide level; recognition that we cannot be successful at improving everything at the same time Criteria for selecting the big 4: One from each dimension Data exists Familiar to the organization; buy-in from stakeholders Aligned with our mission, vision, strategic directions and transformation themes There is lots of room for improvement Connect to other processes (multifaceted) Improvement requires hospital-wide, team-based collaboration Outcome driven (not a process indicator)

2 We have designed our executive compensation program with the future in mind The design is comprehensive and forms the basis for 'training all managers All managers will be included in future years if legislation allows Positioning will be incentive not punitive 4. Measures: Our QIP includes 36 indicators that constitute the CEO s annual Personal Business Commitments (PBCs for VPs may vary only slightly from the CEO s PBCs and individual indicators may be weighted differently) Performance Indicators QIP (e.g. pressure ulcers) HSAA (e.g. unplanned mental health ED visits) Publicly Reported (e.g. hand hygiene) Balanced Scorecard (e.g. sick time, Lean deployment) Strategic Directions (e.g. time to send discharge summaries to GPs) Personal Business Commitments 2011/12 At Rouge Valley we have identified 4 themes that define quality performance for our hospital: access to care, service excellence, team engagement and fiscal responsibility. These 4 themes encompass the Triple Aim areas of patient experience, population health and value for money. This year we have also identified 4 key indicators, one for each theme, that will be our top priority focus for improvement in The big four priorities are : Reduce HSMR Reduce ED wait times for admitted patients Improve staff satisfaction Achieve budgeted total margin 5. Coalition Building: We are utilizing our quality committees to drive implementation of the QIP. These committees were established in December in anticipation of the QIP. RVHS Quality Structure Governance Senior Leadership Medical Advisory Chaired by COS Board of Directors Quality & Risk Senior Management Team Chaired by CEO Joint Medical/Hospital Quality Steering Co-chaired by COS and CEO Mgmt, Physicians and Staff Access to Care Service Excellence Quality Healthcare Workplace & Engagement

3 6. Tests of Change and Lessons Learned: 7. Results, Current Status and Next Steps: We have integrated the QIP into our Personal Business Commitments and the work of our quality committees. We have revised our Corporate Balanced Scorecard to align with our QIP. We have developed a framework to educate management and staff about how Lean can be used to drive improvement in each of our big 4 priorities. For example: 6S and the Big 4 6S 6S is a 6 step method for achieving improved organization in the workplace and in life! John Touissant, CEO of ThedaCare Health System (Wisconsin), estimated that 5S improvements had helped reduce the amount of wasted time in an average nurse s 8 hour shift from 3.5 hours a day to just under 1 hour per day. ( Lean Hospitals by Mark Graban, page 100) (1) SORT When in doubt, move it out. (2) SET-IN-ORDER A place for everything, and everything in its place. (4) SHINE (5) STANDARDIZE To be Lean, What you don t know, you must be clean. you can t improve. (3) SAFETY Safety First. (6) SUSTAIN Maintain the gain; forget the blame. HSMR Creates an environment that supports staff in providing proper care and in making the right decisions quickly Frees up more time for staff and physicians to spend with patients because time is not wasted searching for things Supports better infection control ED Admitted Patient Wait Time Creates an environment that supports staff in providing proper care and in making the right decisions quickly Frees up more time for staff and physicians to spend with patients because time is not wasted searching for things Reduces discharge room turnaround time Staff Satisfaction Improves workplace morale, efficiency, and staff safety Staff and physicians feel respected because their time is not wasted by looking for things (e.g. charts, equipment, forms, linen, supplies, etc) Builds a clear understanding of how work should be done. Any abnormalities are detected at a glance Total Margin Makes better use of physical space often reducing the need for costly renovations or expansions Reduced sick time due to higher staff satisfaction and less stressful work environments Reduced cost of Inventory/expired items

4 8. Team Members: A leadership team has been identified for each of our big 4 priorities. The roles of the players on the leadership team are described below. Quality and Risk of the Board Monitor and report to the Board on quality issues and on the overall quality of services provided in the hospital, with reference to appropriate data. Consider and make recommendations to the Board regarding quality improvement initiatives and policies. Ensure that best practices and evidence-based practices are in use Oversee the preparation of the annual Quality Improvement Plan and approve the final plan Chief of Staff Provide corporate oversight and guidance from a medical perspective for all Big 4 indicators Identify physician champions and facilitate physician engagement in quality initiatives Provide leadership for changes in medical practice/ policies that support quality improvement Ensure that the MAC and MSS are kept informed of quality improvement progress CEO Provide corporate oversight and guidance for all Big 4 indicators Provide direction on the allocation of resources to facilitate achievement of quality improvement targets Ensure that the board of directors is kept informed of quality improvement progress VP Quality Improvement & Transformation Provide advice on strategies required to achieve, monitor and report on metrics Provide leadership for the corporate quality improvement infrastructure and resources Oversee the development of the Quality Improvement Plan Executive Lead Provide corporate oversight for a specific Big 4 indicator Ensure that the required level of coordination, collaboration and monitoring are taking place Ensure that Lean tools and evidence-based approaches are used to make improvement Ensure that improvement initiatives are aligned with strategic directions Ensure that improvement initiatives are resourced responsibly to achieve desired outcomes Collaborate with other executives to remove barriers to improvement or measurement and put enablers in place Keep senior management team, Quality s and the Quality & Risk informed of progress Executive Co- Support the co-lead in the roles identified above Lead Physician Champion Share information about quality improvement and engage the broader physician population in improvement initiatives Encourage compliance with required changes Role model desired changes in practice or behaviour Participate in planning and monitoring activities as required

5 Transformation Management Office (TMO) Liaison Coach leaders and frontline staff/physicians in the identification and use of Lean tools that will improve performance in the Big Four indicators Facilitate or co-facilitate large, corporate kaizen events related to the Big Four Identify and organize additional training and support needs Data Lead Provide technical information/data support related to the "Big 4" indicator assigned Support will include monthly performance reporting including drill down and correlation analysis specific to the assigned indicator May provide advice and support for supplementary data collection however this will be limited to consultation and template development Quality s (Access to Care, Service Excellence, QHCWE) Coordinate multiple improvement initiatives within the committee s scope Monitor progress Identify opportunities for further improvement Develop action plans to address barriers Keep the Joint Medical/Hospital Quality Steering informed of progress Also see terms of reference for each quality committee Sample: HSMR Definition: HSMR (Hospital Standardized Mortality Ratio) is a tool used by hospitals in many countries throughout the world to assess and analyze mortality and identify areas for improvement. It compares a hospitals mortality with the overall average rate. A score of 100 means the number of actual deaths and expected deaths is the same as the national average. A number greater than 100 suggests a higher mortality rate and a lower than 100 suggests a lower rate. At RVHS our target is 90. PBC Indicator: in-hospital deaths expected in-hospital deaths X 100 This indicator is calculated quarterly using coded health records. Performance Baseline: 92 Target: 90 Leadership: Executive Lead - Dr. Naresh Mohan; Executive Co-Lead - Michele Jordan; Physician Champions Dr. Yassa, Dr. Pushpapalan; TMO Liaison Vivian Chan; Data Lead Natalie Forde Quality Service Excellence : Improvement Initiatives: Link to Strategic Directions: Accreditation ROP Linkages: Use of IHI Trigger Tool to review all mortality charts and an improved morbidity and mortality review process Implementation of Safer Healthcare Now interventions Implementation of medication reconciliation and strategies to reduce VTE Continued development and increased utilization of order sets and care pathways Roll-out of kamishibai to drive quality improvement at the frontline Always provide friendly, caring, quality service to all our patients and their care supporters Consistently deliver and measure care at each campus to ensure high quality Safety plan; Critical Incident Reporting System; Medication Reconciliation; Prospective Safety Analysis Reporting Balanced scorecard; OHQC (QIP)

6 For more information please contact: Coaching Circle Facilitator Name(s): _Michele Jordan Organization Name(s): Rouge Valley Health System