In 2017, Health Quality Ontario developed tools to support people interested in quality improvement to develop a Quality Improvement Plan (QIP) for any program they are involved in. The tools to support the development of these “programmatic QIPs” are available here.
We spoke with Kelly Hubbard and Tonya Claughton at Hospice Simcoe. Their team used these tools to develop a QIP to improve the palliative care they provide at their hospice.
This project was led by the Quality, Safety and Risk Committee at Hospice Simcoe.
What was the problem you were trying to solve that prompted you to use the programmatic tools?
Our Board of Directors questioned how our Quality Improvement Plan would align with our strategic plan.
Who was involved?
This project was led by the Quality, Safety and Risk Committee at Hospice Simcoe
How did you get set up?
We drafted a project plan to develop a QIP, and to identify potential outcomes of the work. We then struck a committee, created terms of reference, and developed the inaugural draft QIP, ensuring that the QIP aligned with our strategic plan and included key quality dimensions.
We received Lean training (yellow belts). Our Quality, Safety and Risk Committee was very helpful and guided us to improve the accuracy and precision of our draft QIP.
Tell us about how you decided what problems to address.
We looked at the dimensions of care in the QIP. We were interested in a distribution of measures that looked at aspects of effectiveness, patient experience, and safety. We decided to focus on these dimensions of quality then identified quality gaps within them.
For indicators, we explored the QIP indicators for the home and community care as well as long-term care sectors. Neither gave us what we thought was truly relevant to a residential hospice setting, so we embarked on creating our own.
Could you tell us about what you wanted to improve and how you would measure progress?
Occupancy
When we looked at our occupancy rate, we were guided by a target to keep the rate at 80% or better. Our average length of stay is nine days.
We did root cause analyses and identified a problem that was important to address: that admissions to our hospice were limited to mostly daytime hours and patients waiting for admission remained in hospital longer than necessary.
While we could not measure change occurring in hospitals, we could improve what was within our control by accepting residents after hours.
As we began to outline our change ideas, we realized that staff and healthcare providers working in the evenings and on weekends were not admitting as many new residents as they could be, and this prompted us to add training as an important change idea.
Working in partnership (with Royal Victoria Regional Health Centre, North Simcoe Muskoka Local Health Integration Network) we are exploring an opportunity to reduce the amount of time patients remain in hospital that may benefit from hospice care. One cause of delayed admission to hospice is a lack of understanding (by hospital staff) of the scope of care that hospice staff could manage, including aspects of advanced nursing care.
We are exploring training and other ways of effectively sharing this information with our hospital colleagues and building partnerships to facilitate faster admission to our hospice.
Below are some other lessons learned:
- Focusing on key subpopulations: we see benefit in focusing on the community hospice patients and learning about gaps in patient experience from this group.
- Target: Our goal is 90% (or better) of respondents saying they are very satisfied with hospice care.
- Pull on experts; don’t be afraid to ask for help.
- Health Quality Ontario helped get us started (thanks, Sue!).
- Tap into board members who have the expertise - ours were very supportive and helpful.
- Continue to execute the improvement plan.
- Create a scorecard for performance.
- Define and measure current indicators created.
- Decide on next year’s improvement targets.
- Connect to strategic plan.
- Communicate the QIP, improvement process and the outcomes to staff.
Patient experience
While our client/resident experience surveys demonstrate a high rate of patient satisfaction, we wanted to try additional measures and approaches, beyond surveys, to learn more about what we can do to capture resident-reported gaps in key areas of end-of-life care.
We use the Voices survey (for palliative care) however our results weren’t as meaningful because of the low resident response rate. We have set a goal to obtain a 30% response rate.
Medication errors
Internal audits revealed discrepancies and errors in the use of two drugs with similar names and packaging.
Target: Reduce medication errors due to improper dispensing of these medications by 50%.
Change idea: Separate these drugs in two different drawers so that there is a decreased risk of being improperly dispensed.
Outcome: The discrepancies are now much reduced.
Falls
Although performing well, we wondered if we could further reduce falls in the palliative population?
Our understanding of the problem did not reveal any obvious opportunities for improvement. We counted and found we had had 12 falls for 230 residents in the past year.
Change idea: We want to trial the use of a falls risk assessment to focus on a group of residents at high risk of falls and see if some process changes can help. We hope to reduce this by 50% in the coming year.
What were some lessons learned? How did the tools help and what were the barriers?
The framework and structure of the QIP template was helpful. Initially we were a bit confused about using process measures and targets for process measures but have been fortunate to have the support of a regional specialist from Health Quality Ontario, as well as the Quality, Safety and Risk Committee at Hospice Simcoe who helped us work through the process.
What would you tell others who might want to try this?
- Rely on experts - don't be afraid to ask for help.
- Health Quality Ontario helped us get started.
- Tap into board members who have the expertise - ours were very supportive and helpful.
Where are you in your plan now? For instance, are you testing and refining your measurement plan, looking for better or new measures?
We are in the final stages of testing measures and reviewing data to identify best practices for next year’s QIP measures.
What are your next steps?
- Continue to execute the improvement plan.
- Create a scorecard for performance.
- Define and measure current indicators created.
- Decide on next year’s improvement targets.
- Connect to strategic plan.
- Communicate the QIP, improvement process and the outcomes to staff.
You may also be interested in:
Quorum’s Indicators & Change Ideas page. Find more information about QIP indicators and related change ideas.