May 30, 2016 CAEH Conference Our Quality Improvement Journeys Presenters: Brian Davis ED, Houselink Community Homes Jaipreet KohliManager, Support Services Brigitte Witkowski ED, Mainstay Housing

2 Outline: Sector Drivers Our Journeys: Houselink – 1.5 year renewal and 6 months into our journey of framing it in QI terms Mainstay – 4 years into our journey Our collaborative work together Sharing: – Tools and Resources – Change management principles – Learnings

3 Five Domains of Quality “ECFAA 2010” Effective Timely / Accessible Tenant Centred Quality Safe Integrated

© 2014 All rights reserved Along with the ECFAA, there are other External drivers…. The work you have undertaken on your governance journey to date will not be sufficient to take you to where you need to be tomorrow - what will your tomorrow look like? ECFAAMSAAAccreditation Public Expectation Funding Reform Research/ Evidence Discussions about Consolidation

5 Quality dimensions defined…(HQO) Safe: People should not be harmed by the care that is intended to help them. Effective: The best science and evidence should be used to make sure the service we give is the best, most appropriate possible. Timely: Reduce waits and sometimes harmful delays for both those who receive and those who give care. Consumer-centred: Provide care that is respectful of and responsive to individual consumer preferences, needs, and values and ensuring that consumer values guide all service decisions. Efficient: Avoid waste, including waste of equipment, supplies, ideas, and energy. Equitable: Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. (Don’t hurt me!) (Support me!) (Don’t make me wait!) (Be nice to me!) (Treat me fairly!) (Provide me with well coordinated care, without any duplication!)

6 Our In-Common Internal Drivers Mission, Vision, Values Staff passion and compassion Our service users desire for quality service Recovery = dignity and control over their lives and the services they need or want “A person who sees quality and feels it while [she]/he works is a person who cares. A person who cares about what [she]/he sees and does, is a person who’s bound to have some characteristics of quality.” R. Persig: Zen and the Art of Motorcycle Maintenance

7 Houselink – The Context & Culture Permanent supportive housing to 486 residents (422 units) 39 year history – High retention of staff – High housing retention Historical “de-professionalism /non-medical or clinical” - work with our residents, not for them Inclusive and supportive employment Participants in decision making at all levels of the organization

8 Co-design/ Co-production Partnership between staff and residents – Co-design solutions based on participatory research – Leadership strengthening – Shift focus on strengths Outcome – 17 Change Ideas Going forward: – Enhanced peer support (maintenance and community development – Informal peer support network for pets – Improved and comprehensive orientation – ‘Skills for Safer Living’ support group – More culturally specific events

9 Co-design/ Co-production Learnings: – Best used to solve concrete problems – Empowered residents – Really great ideas, but we came up with too many – Managing the power differential (contentious issues) – Challenges in staff feeling defensive – Researching the hidden challenges (liability, legislative factors) – The more process – the more time it takes! For more Information

10 Changing our Support Model Key recommendations in 2014 report – Homogeneous roles -> multi-functional teams – Introduce Peer support roles – Use data to inform decisions “is the data actionable?” Acknowledging our Capacity Long term residents with a ‘clubhouse model’ What our data was telling us: [use a chart?]

11 Title: Project TitleSCOPE/BOUNDARIES Determine beginning and end steps and the process being focused on TEAM EXECUTIVE SPONSOR someone who will be accountable at a senior management level to remove barriers and ensure adequate resources are provided TEAM LEAD Person accountable for leadership of the project team and for day-to-day project progress PROCESS OWNER A management position accountable for the process being improved; this person is also the Team Lead IMPROVEMENT ADVISOR Someone who provides and builds QI expertise in the team Not necessarily a content expert May also be a Team Lead instead of process owner TEAM MEMBERS Front line staff who most familiar with the process Service Users who may be impacted by the project inputs or outputs AIM STATEMENT (Project Aim) How much (amount of improvement – eg 30%) By when (a month and year) Target population (eg Tenants dealing with addictions) As measured by (a high level indicator or a description of the indicator(s)) Problem Statement:. What is the problem and what parts of the organization does it impact/touch?. Why is this important to the organization? Is it linked to a strategic priority?. Is there data or other evidence that helps to highlight the problem? Measures: Include a Family of Measures:. Outcome Measures. Process Measures. Balancing Measures ROOT CAUSES OF THE PROBLEM How were they identified? Any available evidence Change Ideas: What are they? What is the hypothesized relationship between the root causes and the change ideas? Is there evidence in the literature or elsewhere for the relationship? Anticipated Barriers and Mitigation Strategies:Anticipated Timeline Over how many months will the project be conducted? If possible, specify start date by month and year, and end date by month and year Key Milestones: Identify key points over the project duration at which time you anticipate key deliverables/results Resources Required: Budget Dedicated Staff Time ( hrs or %) i.e. to determine if you need to back up frontline staff or free up management time. Signatures: Signals that these individuals have read the Charter and are aware of the project focus, and at minimum, commit to and agree with the design, set up, and resource requirements at the early stages. Executive Sponsor: _______________________________ Process Owner: __________________________________

12 Title: Redesign of Service Delivery Model Scope/Boundaries: Phase 1:North and Central Houselink Teams – Assess tenant member needs to align staff resources with member needs Phase 2: Work with the LHIN, Access Point & Toronto Community Housing to redeploy Houselink staff to meet case management needs of clients on the Access Point & Community Housing Wait Lists Team Executive Sponsor: Team Lead/Process Owner: Improvement Advisor: Team Members: Problem Statement: At Houselink, we are not currently distributing our staff resources in an optimal way, resulting in: Offering/provision of support to ALL members – some who no longer need 1:1 support to reach or maintain their recovery goals and do not wish support, while others beyond our housing, have numerous needs that we are currently unable to address Not having developed areas of specialty, known to be a better approach to providing support, and Lacking Peer Recovery Workers, identified in the literature to be a key support for recovery for our population In the broader delivery system, outside of Houselink, there are many individuals with MH & A service needs who are currently unable to access service, such as: 11,000 individuals on the wait list for supportive housing, Over 1200 at Access Point who require case management support Aim Statement: To increase the percentage of tenant members with recovery/housing retention needs who are actively engaged in working on those goals by ___% by _______________(when?). By ___________ (when?), 80% of tenant members receiving case management support will rate the type and level of support being received as “excellent”. To decrease the number of Access Point and/or Toronto Community Housing clients on wait lists for case management services by _____ individuals by __________ (when?). Measures: Outcome: % of Tenant Members with Recovery/Housing Retention Needs Who Are Actively Engaged in Working on Those Goals % of Tenant Members Receiving Case Management Support Who Rate the Type and Level of Support Being Received as Excellent. # of Clients on Access Point/Community Housing Wait Lists Receiving Case Management Services from Houselink Balancing: Employee Satisfaction with Caseloads & Roles Process:

13 The Board’s Role Board Policy Direction: – use evaluation tools to measure the impact and effectiveness of programs and services and to use data in planning and evaluation design. – have procedures in place that address equity in housing, health, service provision and governance. If inequalities in access emerge, the Executive Director will work to remove those barriers. Quality and Accountability Committee – Oversee quality and risk management Revised Executive Director Evaluation – Shifting from ‘management’ (linked to a Balanced Scorecard to ‘quality improvement’

14 Dedicated Day to Capacity Building and Workplaning To develop a shared understanding of the Board’s role in oversight of an organizational Quality Agenda; To explore the key drivers for effective governance of a Quality Agenda; To reflect on where Houselink Community Homes is on the quality journey relative to leading governance and leadership practices, and agree on a roadmap for addressing identified priority gaps;

15 Roles and Responsibilities for Developing the Quality Plan The BoardSenior Management Agree on issues/areas for quality agenda priorities Approve the Short & Long Forms with a focus on: Short Form Outcome measures for focus Targets on outcome measures Regularly monitor progress – ask key strategic questions! Articulate SMART Aims to reflect the areas for priority Populate the Short and Long forms for Board approval Identify measures, baseline data and aspirational targets Engage staff in developing an action plan with process measures and appropriate targets to achieve outcomes Assign Management Leads, regularly monitor progress, problem solve and coach Approve the articulation of the quality priorities and the Plan

16 Board High Level Aims on Their Strategic Priority: Support Services Renewal By __________ to increase the # of people that HL is able to provide housing and support services to within its health funding envelope by _____. Within the support services renewal, a survey is piloted to rate the effectiveness and experience of participants using HL housing and support services. The survey tool will be piloted by December 31, 2016

17 Change Management Strategies Culture and Communicat ion – Reinforcing the rationale for change in many ways – Labour partner and divided loyalties Infrastructure – Raising the profile of our data analyst – Changing Ourselves First: Modeling data oversight – Linking roles to data monitoring Using Focussed Conversations with Staff – Informal discussions – “The Art of the Focussed Discussion”

18 Mainstay Housing’s Quality Journey  Our Culture  Building Blocks for Mainstay’s Quality Agenda  Strategic Plan  Board & Leadership Roles  Building Capacity Among All Staff  Developing a Quality Improvement Plan  ED Performance Objectives  Lessons Learned

19 Quality Journey at Mainstay Housing Culture: Tenant-member centered services With stable housing as a foundation, everyone has a bridge to a better life

20 Building Blocks for Mainstay’s Quality Agenda Strategic Plan – “Enhance relevance and quality of our services” Board & Leadership Roles: High Quality Aims, Indicators & Dashboard Building QI Capability Among all Staff – Training – Hiring to build internal infrastructure for data & for QI Support Developing A Quality Plan – and Implementing It! – Quality Improvement Plan Narrative – Annual Quality Plan Executive Director’s Performance Objectives - Quality

21 Building Blocks: Board & Leadership 3 High Level Quality Aims Achieve a reduction in unscheduled Emergency Department visits using the TCLHIN target of 50% by March By March 2018 we will contribute to an improvement in the well-being of our tenant members by supporting them in achieving their personal goals with an emphasis on housing stability and community and belonging. By March 2018 through improved property management, we will increase the number of tenant members who rate their housing experience as excellent by 20%.

22 Building Blocks: Indicators Align with ECFAA Dimensions and Quality Aims Dimension s SafeEffectiveAccessTenant-CentredIntegrated Indicators -Critical Incidents -Tenants at Risk of Hoarding -Tenants attendance in internal programs -Eviction Prevention -Average cleanliness scores -Complex and At Risk tenants on track to meet service goals - % Acceptance -Average business days from referral to lease signing -% clients who refuse an offer -% tenants who have a positive overall experience -% offers declined by Mainstay -% calls for serious issues that case managers respond to within 24 hours -# ED visits for tenants at high risk -% of Complex and At Risk tenants linked to primary care

23 Quality Journey at Mainstay-Dashboard Format Dimens ion Indicator Safe Effective# New Level 1 & 2 WRAP certifications 2727 % Evicted of Those Served a Notice 5 Average Cleanliness Score (%) Page Dashboard INTEGRATED Definition afdagdgagdgdgagdfgasdg Ever since meeting with the agencies to discuss these data, monthly data points demonstrate fairly consistent month over month improvement, with six data points above the median demonstrating significant improvement since June This positive shift was negatively impacted over the past quarter. Run Chart, Definition and Interpretation for Each Indicator Quarterly Review Demonstrating results to those that matter

24 Dimensi on Indicator Baseli ne 2014/ 15 Targe t 2015 / / /2016 Q1Q2Q3Q4Q1Q2Q3Q4Annu al Safe # Critical Incidents % Tenants at Risk for Hoarding (score 4+) of Those Scored (all identified units) 44%40%39%33%71%44%85%30%29%24%34% Effective # New Level 1 WRAP certifications # Tenant Attendances in Internal Programs 12,183 13,10 4 3,3693,2882,8652,661 3,85 1 3,82 5 3,638 3, ,60 4 # Tenants Participating in External Programs % Evictions Prevented as a Percentage of Notices 98%96%98% 95%99%97%88%96% 100 % 96% Average Cleanliness Score % 87%85%79%81%85%87% % Complex and At-Risk Tenants on Track to Meet Service Goals 89%90%84% 91%94%92%93%91%89%91% % Tenants in General Population on Track to Meet Service Goals % Tenants in General Population Who Have Achieved Their Service Goals Level of Tenant Engagement Quality Committee Scorecard – Part 1: A 2-Page Quality Dashboard

25 Dimensio n Indicator Baselin e 2014/ 15 Targe t 2015 / / /2016 Q1Q2Q3Q4Q1Q2Q3Q4Annu al Access % Acceptances 48%N/A30%54%77%53%50%46%68%64%55% Average Business Days from Referral to Lease Signed 27N/A Tenant- Centred % Clients who Refuse an Offer 41%N/A55%38%23% 35% 43%46%24% 23% 32% % Tenants Who Have a Positive Overall Experience % Tenants Who Feel Involved in Decision- making % Tenants Who Feel Respected by Staff % Tenants Who Feel They Have a Voice Integrate d % Offers Declined by Mainstay 8%N/A15%8%0% 3%8% 14%11% % Calls for Serious Issues that Case Managers Respond to Within 24 Hours 92%100%91%93% 91%94%92%97% 100 % 96% # ED Visits for Complex and At-Risk Tenants 38TBD % of Complex and At-Risk Tenants Linked to Primary Care 92%95%90%92%95%92%96%95% 94%95% Quality Committee Scorecard – Part 1: A 2-Page Quality Dashboard

26 EFFECTIVE The intent is to assign a unique identifier to each resident in order to include a better indicator - tenant members involved in one or more internal programs. These will include Mainstay organized programs and tenant- initiated programs. The current data include multiple attendances at different programs for the same individuals, so the number of unique tenants involved in the programs is not known. The current data will continue to be displayed in parallel with collecting data for a new, better indicator. Tenant participation increased slightly in October to 1,277. However, it reduced in November to 961, for the first time since April 2015, which is below the target of 1,092. There were fewer tenants attending food programs and other tenant –led initiatives. Participation surged to its highest level in December to 1,400 as a result of increased attendance at building- based seasonal celebrations and community events. EFFECTIVE Percent of tenants who are evicted of those who are served a notice of eviction for a variety of reasons. The number of tenants evicted reduced to two in Q3, compared to five in the previous quarter. Reason for the first eviction was:N4 (non- payment of rent) and for the second one was N4 and N8 (no longer qualified for RGI). This performance indicator for Q3 met the target. Good New Reportin g Tool Started Staffing Shortage Began Good

27 Evolution to A Scorecard Summary for the Full Board

28 Quality Journey at Mainstay: The Model for Improvement Specify and set the aim Establish measures Change concepts & change ideas PDSA Cycle Langley, Nolan, Nolan, Norman, Provost; The Improvement Guide, 1996.

29 Organizational Quality Plan

30 Organizational Quality Plan AIMMEASURECHANGE Quality dimensionObjective Measure/ Indicator Planned improvement initiatives (Change Ideas) Process Measures Target (2015/16) EffectivenessSupport all tenants in achieving their personal goals for successful tenancy % Tenants achieving at least 80% of their Service Goals by Target Date % of Goals Achieved by Target Date Set a minimum amount of time for Supportive Housing Workers' (SHW) to spend establishing and working with tenants on goals % SHW’s Allocating Standard Minimum Time in Calendar to 1:1 Tenant Sessions 90% For tenants identified with a high number of unmet needs, accurate completion of a checklist and goal achievement tracking form % of Checklists Completed Accurately % of Tenants who Qualify for One- on-One Coaching and Are Tracked Accurately on Goal Achievement Tracking Form 90%

31 Quality Journey at Mainstay Our biggest challenges ….. – Time – Resources ● Hiring a Manager Quality Improvement and Performance Management and our biggest rewards in doing this work…. – Direct service staff engaged differently - they surface the barriers to success (root cause analysis) and develop the change ideas to ensure better outcomes for tenant members (ideas and expertise tangibly valued) – Time to study, learn, improve, gain new skills – Tenant Members as membership excited and have ideas – Tenant Members who receive change idea services see outcomes

32 Training Resources in Quality Improvement Quality Thru Improvement: Paula Blackstein-Hirsch G. Ross Baker Institute of Health Policy, Management and Evaluation University of Toronto Excellence through Quality Improvement Program (E-QIP) AMHO & CMHA Ontario & OCASI website: IDEAS Ontario:Ideas Ontario Ontario U of T: formation/ Health Quality Ontario: improvement/quality-improvement-frameworkhttp:// improvement/quality-improvement-framework

33 Wrap Up What excites you about what you’ve heard? What challenges you? What questions does it raise?