This post is part of a series about how quality standards can be used to support quality improvement together with others who are working on adopting the quality standards. The introductory post can be found here.
Mississauga Halton LHIN in collaboration with their Regional Quality Table and a Regional Quality Improvement Specialist at Health Quality Ontario, have developed a process to prioritize Quality Standards and engage with LHIN programs to implement them.
Our thanks to Dr. Amir Ginzburg, Clinical Quality Lead, Angela Jacobs, Director of Quality and Risk, and Jutta Schafler Argao, Vice President of Quality and People at Mississauga Halton LHIN, as well as Julie Skelding, Regional Quality Improvement Specialist at Health Quality Ontario for sharing their journey.
How did you develop a process for prioritizing and implementing Quality Standards?
We started by using a framework co-developed by the provincial Clinical Quality Leads and Health Quality Ontario’s Quality Improvement Program Delivery team. The Common Approach to the Adoption of Quality Standards Framework details actions that LHIN/HQO Clinical Quality Leads should adopt to advance Quality Standards within their regions.
From left to right, the Framework identifies key steps, such as understanding the data, developing an action plan, and monitoring and sharing successes and opportunities noted during the process.
Figure 1: Common approach to the adoption of Quality Standards for Clinical Leads
We used these key steps in the Framework to develop and answer questions to help guide our decision-making process:
Question #1: Does the Quality Standard provide an opportunity to improve service delivery in the Mississauga Halton LHIN?
This question is explored at our bi-monthly Regional Quality Table (RQT) meeting in consultation with our Decision Support team and the RQT Secretariat (Director Quality & Risk, Vice President Quality and People, Clinical Quality Lead and HQO’s Quality Improvement Specialist). The RQT coordinates evaluation of our LHIN’s local data, reviews the Quality Standard data briefs and Recommendations for Adoption document to determine if there are current gaps is service delivery.
If our region is performing well, then the Quality Standards will be circulated to our stakeholders. If an opportunity to improve is identified in multiple quality statements within the Quality Standard, then we work on answering the next question.
Question #2: Does this Quality Standard align to existing/planned activities in our region or is new regional work needed?
In order to answer this question, we determine whether the improvement opportunity aligns with our Integrated Health Services Plan, Annual Business Plan and/or Integrated Regional Quality Improvement Plan.
If it does, the RQT engages with the Vice President(s) of the appropriate program(s) related to the Quality Standard, which also requires collaboration and validation with the Clinical Leaders Committee; comprised of physician Clinical Leads and chaired by the Vice President, Clinical.
If the Quality Standard tandard does not align with the above or current projects and is flagged as a priority for the LHIN, it is taken to Leadership Council (CEO, Vice Presidents and Directors) for consultation and recommendation. Part of this decision is made by understanding available Quality Standard data and the capacity to implement, sustain and spread our existing inventory of regional quality improvement projects.
Did you develop any tools to support your decision making?
Although the above two questions seem relatively simple to answer, we quickly realized that a more detailed decision-making model was required. We wanted to ensure that we engaged with the LHIN and health service providers to get their support for the adoption of a growing number of Quality Standards.
We decided to create the below decision tree: the Mississauga Halton LHIN Approach to Quality Standards Implementation, which took several months of development and iterations engaging all levels of the LHIN.
Once it was complete, it was brought to the RQT Secretariat, to the LHIN Leadership Council for approval and highlighted for the Board Quality Committee for information.
LHIN leadership engagement was very helpful in agreeing, where appropriate, to leverage already fully deployed teams (e.g., decision support and quality improvement). Leadership engagement also developed a Most Responsible Portfolio / Person (MRP) approach wherein a LHIN executive would be assigned to lead the implementation of improvement areas in a Quality Standard determined by the decision tree to be a priority for our region.
Figure 2: Mississauga Halton LHIN Approach to Quality Standards Implementation
In conjunction with the decision tree, a RACI (Responsible, Accountable, Consulted, Informed) Chart was developed which provides a matrix to guide activities and decision-making authorities. This ensures that complex relationships and dependencies across the region are well supported and promote effective change leadership.
Have you implemented your new process?
Yes. The RQT Secretariat decided to trial our process with the Behavioural Symptoms of Dementia Quality Standard.
During the first run through of our proposed process, updated data from Health Quality Ontario and the Mississauga Halton LHIN decision support teams helped to characterize potential improvement opportunities. Working with staff from the Quality and Risk Department at the LHIN, we prepared a summary and recommendations that were brought forward to the RQT Secretariat and then the RQT for discussion and recommendation.
We engaged with the LHIN department most aligned with the Quality Standard prior to the RQT meeting to better understand existing priorities and projects. Informative discussions occurred regarding the quality improvement resources that may be needed to support the MRP in their planning and implementation activities. Suggested activities included a current state analysis, gap analysis against the Quality Standard, and scheduled reporting back to the RQT on the implementation status of the Standard.
Ultimately the RQT recommended that the Behavioural Symptoms of Dementia Quality Standard aligned with existing work in our LHIN, and the VP Regional Programs was assigned as the MRP.
Did you face any challenges?
The process to achieve a disposition for this Quality Standard took longer than expected and required resourcing. Acquiring updated data to inform decision making, as well as the multiple interfaces between the RQT and its stakeholders were required. The RQT Secretariat concluded that a more nimble triaging tool would be beneficial given the volume of new Quality Standards planned for release in the near future.
Thus, we’ve made a slight change to prioritizing Quality Standards and are currently trialing a heat map approach to supplement the process we trialed. This heat map includes data from each Quality Standard with rankings of performance relative to other LHINs provincially.
If any Quality Standard has relative provincial performance in the bottom tertile, we have agreed that recommendations on disposition/improvement opportunities would then come from analyzing the Standard via the more detailed process we have already established and trialed.
What are your next steps?
For the Behavioural Symptions of Dementia Quality Standard, the MRP will report back on a semi-annual basis to the RQT on implemenation status.
We are excited that the heat map tool has already provided us with insights on our next opportunities within the Quality Standards program. We are also cataloguing the full inventory of current projects in our region that support or aligned to the implementation of already released Quality Standards.
We continue to review provincial priorities and available tools to support our work, including sources for current data to inform our regional improvement opportunities.