Quality Improvement Plan
PURPOSE
The mission of Community Care is to be a leader in the collaborative design and delivery of integrated, responsive health and community support services that respect individual choice, dignity and independence. We strive to create a safe, healthy environment where physicians, staff and volunteers work together to provide quality client care and services.
Our organization defines Quality as the provision of care and services that are:
Safe – avoiding injuries to clients from the care that is intended to help them
Effective – providing the right service at the right time to the right people
Client Centred – providing care that is respectful of, and responsive to, individual client preferences, needs and values
Accessible – reducing waits and potentially harmful delays
Efficient – avoiding waste, including waste of equipment, supplies, ideas and energy
Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status
Responsive – to need and to expectation (Satisfaction)
This Quality Improvement Plan (QIP) demonstrates our organization’s commitment to improve the quality of client care services that we deliver. The QIP:
– allows for a systematic, co-ordinated and continuous approach to improving performance by focusing on the processes and mechanisms that address these values.
– outlines the goals and strategies for ensuring client safety, delivering optimal care, and achieving high client satisfaction.
– focuses our quality improvement efforts on direct client care delivery processes and support processes that promote optimal client outcomes and effective business practices.
QIP IMPROVEMENT PLAN OBJECTIVES
– To objectively and systematically monitor and evaluate the quality and appropriateness of the services performed by Community Care
– To address any areas where the services may be improved
– To demonstrate efforts toward resolution of identified problems
– To work toward the goal of increased desirable outcomes
– Assure appropriate, accurate and complete documentation of the client care process
– Provide for established criteria that allow for setting of priorities for improvement activities. Such priorities will be based upon assessment of opportunities for improvement, and/or on the need to reduce or eliminate undesirable change in performance
– Assure that effort is made to provide care that is sufficient to assure client co-operation and satisfaction
– Assure compliance with the requirements of all federal, provincial and accrediting agencies in regard to quality assessment and performance improvement activities
This is accomplished through quality management committee initiatives, accreditation process, survey analysis, outcomes review, performance appraisals, and other appropriate quality improvement techniques. To achieve this goal, all employees of Community Care will participate in ongoing quality improvement efforts.
QUALITY IMPROVEMENT PROCESSES AND METHODOLOGY
The QIP is a framework for the organized, ongoing and systematic measurement, assessment and performance of improvement activities. The components of this plan may include:
– A quick-fix process that will be used for problems that do not need a comprehensive approach to problem solving and solution implementation;
– Quality assessment activities, such as client and staff satisfaction surveys, infection control surveillance, utilization management, and medical record review. These activities help assure that standards are met and maintained, and identify areas for review by quality improvement teams;
– Quality improvement teams, which may be inter or intradepartmental, and which look at particular issues to identify opportunities to improve processes and outcomes;
– Dashboard report, which provides summary data about selected indicators, prepared for the Board, Quality Management Committee, and staff;
– Outside sources/comparative databases that may be available, as well as professional practice standards, will be used to compare our outcomes and processes with others, identifying areas to focus quality improvement efforts.
Our QIP includes the following activities:
– all direct and indirect client care services affecting client health and safety
– client/staff/physician/volunteer satisfaction surveys
– safety and risk management activities
– accreditation
Performance Indicators
The assumptions that were used for the development of performance indicators included:
– data is available and timely
– indicator is feasible
– indicator is valid and reliable
– indicator is actionable
– impact on high volume, high cost and high risk
Priority and focus was on capturing the vital few, rather than many, to ensure meaningful and actionable responses to improve quality of care. Indicators were also selected to ensure alignment with our strategic directions.
In order to ensure our ability to monitor and track the performance trends and results, all measures and targets selected must be SMART:
Specific Measurable Achievable Realistic Time sensitive
Monitoring Effectiveness and Evaluation of the Quality Plan
The Community Care Board of Directors is ultimately responsible for assuring that high quality care is provided to clients. The Board delegates the responsibility for implementing this plan to the clinical and program staff, through its senior management team, and the Quality Management Committee. The Chief Executive Officer (CEO) executes and monitors the effectiveness of the QIP on behalf of the Board. The CEO reports on the Plan to the Board quarterly. These reports include performance measures where appropriate and, in the absence of data, expert opinion is provided. Information in these reports enables the Board to assess the progress being made in implementing the action plans and the results being achieved for each objective. Board reports will include Quality Plan goals, broad indicators of success (a “rolled up” scoreboard of key indicators), as well as an interpretation and action plan section. Progress and goals of the Quality Plan will be monitored and managed by the Quality Management Committee.
Quality Management Committee
The Committee consists of the following individuals: The CEO, the Director of Community Support Services, the Director of Hospice Servies, the Clinical Program Manager, a Nurse Practitioner, the Data Management Co-ordinator, and two Board members. Consistent with the Mission, the main goal of the Quality Management Committee is to analyze data from various sources and change the patterns of care in targeted areas. The targeted areas are identified based on their public health importance and on the feasibility of measuring and improving quality.
Members of the Quality Management Committee are responsible for:
– co-ordinating the QIP, and will assemble criteria, standards, professional literature, statistics from reference data banks, and whatever information is necessary to enable the Committee to evaluate their performance, to plan improvements in client care, and to implement such improvements
– assuring that the review functions outlined in this plan are completed
– prioritizing issues referred to the Quality Management Committee for review
– assuring that the review functions outlined in the plan are completed
– prioritizing issues referred to the Quality Management Committee for review
– assuring that the data obtained through Quality Management activities are analyzed, recommendations made, and appropriate follow-up of problem resolution is conducted
– identifying other sources for incorporation into the organization’s overall quality improvement efforts
– reporting on ongoing findings, studies, recommendations and trends to the Board quarterly and annually; and reporting to staff as appropriate
– identifying educational needs and assuring that appropriate staff education for quality improvement takes place
– appointing sub-committees or teams to work on specific issues, as necessary
– assuring that the necessary resources are available
– co-ordinating activities with the Accreditation Committee
Methods
– all evaluations shall be problem-focused, monitoring only those areas which are known or suspected to have problems
– problems shall be prioritized according to their potential impact on patient care and outcome, their impact on efficacy of care, their frequency of occurrence, and their impact on cost-effectiveness
– problem assessment shall be accomplished by whatever method best yields the desired results. These may include formal audit with the pre-established criteria, process reviews and evaluations
– the Committee shall be responsible for the identification and analysis of problems
– outcome assessments and action implementation shall be referred to the appropriate staff, committee or department
– periodic evaluation of the results of corrective actions shall be the responsibility of the Committee
Comparative Databases, Benchmarks and Professional Standards & Practices
Community Care will use comparative databases that may be available, to incorporate a process for continuous assessment with similar organizations, standards and best practices. This assessment then leads to action for improvement as necessary.
Communication
The Quality Management Committee provides oversight and functions as the central clearing house for quality improvement data and information collected throughout the organization. The Committee tracks, trends and aggregates data from various sources to document and disseminate results, including preparing reports for the Board and staff.
Education
All staff are given responsibility and authority to participate in Community Care’s QIP. To fully accomplish this, all staff will be provided education regarding the QIP during their initial orientation, and on an annual basis thereafter. This education will include a description of the QIP and how they fit into the plan, based on their particular job responsibilities.
The Quality Management Committee shall regularly review and evaluate staff needs. Educational topics shall be co-ordinated with the findings of the formal evaluations, attempting to focus the educational efforts. All educational offerings shall be multidisciplinary.
Annual Evaluation
Our QIP will be evaluated by the Committee on an annual basis for effectiveness in achieving the goal of assuring that the most appropriate quality of care and associated services were provided to clients. A summary of activities, improvements made, care delivery processes modified, projects in progress, and recommendations for changes to the QIP will be compiled and forwarded to the Board for action.
Areas that will be evaluated:
– indicators for monitoring were appropriate to identify the high-risk, high volume and problem-prone areas of patient care
– effectiveness of process for providing information to the community regarding issues of availability of care, and access to care
– statistical information relating increase in desirable client outcomes, and effectiveness of the roles of committee members to direct the quality management and improvement of the organization
Program Staff Responsibility
Every program area within our organization is responsible for implementing quality improvement activities. All quality improvement initiatives are conducted as a part of the organization-wide Quality Management Committee activities. Each Program Manager is responsible for assisting with the identification of quality indicators, collecting and submitting data, developing and implementing changes to improve service delivery, and monitoring to assure that improvement is made and sustained. The ultimate goal is to improve the quality of care that is routinely provided to Community Care clients.
The Three-Year Quality Process
As outlined earlier, regular monitoring, quarterly reporting and annual evaluations of the QIP will continue to be part of the quality improvement journey. With institution of a multi-year process, planning will now be done with a three-year horizon in mind. This may include the further development for existing goals or may involve the addition of a new corporate goal based on priorities and/or an emerging issue that involves Community Care.
