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Indicators & Change Ideas

Are you looking to improve the issues facing today’s health care system?

 

Explore the quality indicators being tracked by health care organizations in Ontario through Quality Improvement Plans (QIPs) and change ideas to help improve them. Connect with others to share your experiences and ideas of your own.

Looking for more help with your QIP? Review our guidance materials on the QIP Guidance page, or check out the QIP Support and Training page to access webinars, help sessions, videos, and more.

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Unplanned emergency department visits within 30 days of hospital discharge

Reducing or even attempting to eliminate unplanned, less-urgent emergency department (ED) visit within the first 30 days of discharge from hospital will help patients to manage their care at home and reduce overcrowding in the ED.

Click here to visit Health Quality Ontario’s Indicator Library and learn how to measure this indicator.

Key resources

Change Ideas

Assess post-discharge risk and activate the appropriate follow-up

  • Use an evidence-based risk assessment tool to assess risk for rehospitalization
    Process measure: Percent of patients who have a risk assessment done prior to discharge
    LACE online risk assessment tool by the Health System Performance Research Network
  • Consider referring patients with multiple chronic conditions and complex needs to Health Links
    Process measure: Percent of patients with multiple chronic conditions and complex needs referred to Health Links
    Health Links Resources by Health Quality Ontario
  • Provide a warm handoff from hospital to home care (e.g., by having home care coordinators in place in hospital and holding care conferences before discharge that involve the care coordinator and the community interdisciplinary team)
    Process measure: Percent of patients identified to be at risk for rehospitalization who were offered a pre-discharge care conference with interdisciplinary team, including the home care coordinator

Provide patient education and encourage self-management


Use specialized teams of practitioners and technology to enable care at home

  • Use technology such as the Ontario Telemedicine Network or e-notifications about patient discharge
    Process measure: Percentage of eligible patients who receive care via the Ontario Telemedicine Network

Unplanned emergency department visits within 30 days of hospital discharge

Reducing or even attempting to eliminate unplanned, less-urgent emergency department (ED) visit within the first 30 days of discharge from hospital will help patients to manage their care at home and reduce overcrowding in the ED.

Click here to visit Health Quality Ontario’s Indicator Library and learn how to measure this indicator.

Key resources

Change Ideas

Assess post-discharge risk and activate the appropriate follow-up

  • Use an evidence-based risk assessment tool to assess risk for rehospitalization
    Process measure: Percent of patients who have a risk assessment done prior to discharge
    LACE online risk assessment tool by the Health System Performance Research Network
  • Consider referring patients with multiple chronic conditions and complex needs to Health Links
    Process measure: Percent of patients with multiple chronic conditions and complex needs referred to Health Links
    Health Links Resources by Health Quality Ontario
  • Provide a warm handoff from hospital to home care (e.g., by having home care coordinators in place in hospital and holding care conferences before discharge that involve the care coordinator and the community interdisciplinary team)
    Process measure: Percent of patients identified to be at risk for rehospitalization who were offered a pre-discharge care conference with interdisciplinary team, including the home care coordinator

Provide patient education and encourage self-management


Use specialized teams of practitioners and technology to enable care at home

  • Use technology such as the Ontario Telemedicine Network or e-notifications about patient discharge
    Process measure: Percentage of eligible patients who receive care via the Ontario Telemedicine Network