Osler's 2016/17 Quality Improvement Plan Progress Report

Our Quality Improvement Plan (QIP), plays a part in demonstrating specific things we are focusing on as an organization over the next year to improve the care we provide to our community. To promote accountability, the compensation of Osler's executives is tied to the achievement of the improvement targets outlined in the QIP.

The QIP consists of 4 parts:

  • PART A: Overview of our hospital's Quality Improvement Plan 
  • PART B: Our improvement targets and initiatives 
  • PART C: The link to performance-based compensation of our executives 
  • 2016-17 QIP Accountability Signoff

Click here to download Osler's 2016-17 QIP

Indicator

Goal

Starting Performance

 Are We On Track?

Reduce hospital acquired infection rates
Clostridium difficile infection (CDI) rate per 1000 patient days (number of patients newly diagnosed with hospital-acquired CDI)

0.27 per 1,000 patient days

0.16

 

Increase proportion of patients receiving medication reconciliation upon admission Percentage of Best Possible Medication History (BPMH) completed on admitted patients through the emergency department

77.5%

67.4%


Indicator

Target

Starting Performance

 Are We On Track?

30-day all-cause readmission rate for patients with Congestive Heart Failure

19.18% 

20.19%


Indicator

Target

Starting Performance
 Are We on Track?

Reduce wait times in the ED
90th percentile Emergency Department (ED) length of stay for admitted patients

34.7 hours
(5% improvement over year end)

36.5 hours

The relative proportion of high acuity patients is the highest in the province.  The winter of 16-17 saw the worst influenza season in years nationally, which crippled EDs across the province including at Osler.

Indicator

Target

Starting Performance
 Are We on track?

Improve patient satisfaction - Emergency Department
Would you recommend this hospital to family and friends - top box only (ie, "yes, definitely") for the Emergency Department

75.6%
(5% over current performance)

71.5%

Change plans are in progress, directed towards key areas of improvement related to communication, attitude and sharing of information.
 Improve patient satisfaction - Inpatients
Would you recommend this hospital to family and friends - top box only (ie "yes, definitely") for inpatients
 85.7%  82.3% Change plans are in progress, directed towards key areas of improvement related to communication, attitude and sharing of information.

Indicator

Target

Starting Performance
Are We on Track? 

Reduce unnecessary hospital readmission
Percentage of patients readmitted to any facility for any reason within 30 days for selected inpatient groups (HIG's).

14.49%

15.25%

This broad indicator includes various clinical conditions making it difficult to isolate contributing factors. Osler has made significant gains related to readmissions.

Reduce unnecessary time spent in acute care
Percentage of total inpatient days that are designated as Alternate Level of Care (ALC) days divided by the total number of patient days for open, discharged and discontinued cases in the same period

5%

5%

 Due to increasing patient acuity, discharges are increasingly complex. Osler continues to implement various strategies so patients, families and teams feel supported, while also ensuring patients are in the right care setting at the right time, and that hospital resources are used wisely.
 

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