Completing Yo r Q alit Completing Your Quality Improvement Plan

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Setting Performance Goals and Targets• Consider best practice in Ontario or worldwide• VAP, CLI rate 0 (Ontario, international examples)• C diff. rates of ~ .15 (some hospitals in Ontario)• % definitely recommend at 80‐90% among leaders inUSA; 70% average in Ontario• Surgical waits: 100% within target for all surgeries forall priority levels (North <strong>Yo</strong>rk General)• Consider decreasing gap from current to best by half• Consider pace of improvement seen elsewhere• E.g. decrease in HSMR of 5‐10 points / yr
Performance Goals, Targets• ED length of stay: official provincial target is 8 hours• most small & medium volume hospitals within the provincial target, butcould still improve• current provincial average 11.6 hrs; some large hospitals > 20 hrs• Hospitals with the best results include:– Pediatric hospitals, CHEO (7.5 hours)– Teaching hospitals, Thunder Bay Regional (10.7), Mt Sinai (11.3 hours)– Very‐high h volume community hospitals, Oakville‐Trafalgar l (6.5 hours),Orillia –Soldiers memorial (6.6), Windsor‐Grace (8.9), Queensway‐Carleton (9.7), Windsor‐Metropolitan (9.8), St. Joseph’s–Toronto (10).– Mdi Medium volume community hospitals, Hldi Haldimand dWar Memorial l(3.2),Carleton Place (4.5), Perth and Smith Falls District (5.1)– High volume community hospitals, Georgetown (4.9), Orangeville(6.1), Owen Sound d(6.4)37
Page 1: Completing Your QualityImprovement
Page 4 and 5: What are Required Indicators?• Fo
Page 6 and 7: Statistical Variation in Measures
Page 8 and 9: Rare EventsIf you had a bad eventTh
Page 10 and 11: Patient Experience SurveyThis comin
Page 12 and 13: Seasonal Variation• Some indicato
Page 14 and 15: Rare EventsIf you had a bad eventTh
Page 16 and 17: Ideas for Improvement:Change Sectio
Page 18 and 19: Example• Our plan: improving the
Page 20 and 21: Template: Line‐by‐Line StyleImp
Page 22 and 23: “Improvement Initiative”• Opt
Page 24 and 25: Falls• Hospitals tracking falls i
Page 26 and 27: VAP, CLI- Follow BundlesVAP:• Hea
Page 28 and 29: • Special considerations:C Diffic
Page 30 and 31: ALC, ED waits, Readmissions• Thre
Page 32 and 33: HSMR• Possible goals: reduction 5
Page 34 and 35: Patient Experience ‐ Data• Curr
Page 38 and 39: Part A- Overview• Provide plain l
Page 40 and 41: Part A ‐What the organization wil
Page 42 and 43: Part A ‐ Ideas for ImprovementFro
Page 44 and 45: How the plan aligns with the other

Completing Yo r Q alit Completing Your Quality Improvement Plan

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