1. Quality Improvement Planning 2014/15 March 17, 2014 1

2. Quality Improvement Plans QIPs are mandatory. 11 indicators are all recommended by Health Quality Ontario / MOHLTC. No additional indicators at this time. QI work should build on and help inform existing initiatives. Data sources include client surveys, MSAA reports, ICES profiles, etc. 2

3. DOMAIN: ACCESS ObjectiveAccess to Primary Care when needed. Indicator% of clients able to see a MD/NP on the same day or next day, when needed. Target43.5%  50% Initiatives1.Track # of unused appts  increase supply 2.Track # late cancellations & no-shows: Admin follow up & Client education 3.Med Sec training on triage & U/C booking 4.Client education re type of appointments 5.Add questions to client survey Same day/next day consultation via phone Offered but rejected same day/next day appt. 3

4. DOMAIN: ACCESS ObjectiveReduce ED use by increasing access to primary care Indicator% of clients who visited the ED for conditions best managed elsewhere (BME). Target7.6 per year  7 per year Initiatives1.Client education 2.Medical Secretary training re triage and scheduling urgent care appts. 3.Monitor and assess electronic data from SJHC when available. 4

5. DOMAIN: INTEGRATED ObjectiveTimely access to primary care appointments post- discharge through coordination with hospital(s). Indicator% of clients who saw their primary care provider within 7 days after discharge from hospital for selected conditions. TargetMaintain at < 5 people per year Initiatives1.Client education 2.Medical Secretary training 3.Monitor and assess electronic data from SJHC when available. 5

6. DOMAIN: INTEGRATED ObjectiveReduce unnecessary hospital readmissions Indicator% of clients who are readmitted to hospital after they have been discharged with a specific condition. Target- InitiativesLess than 5 clients were discharged from hospital during the ICES study time. Until hospital discharge data becomes available, this indicator will not be measured and no quality improvement initiatives will be implemented. 6

7. DOMAIN: PATIENT-CENTRED ObjectiveReceiving and utilizing feedback regarding client experience with the organization. Indicator% of clients who stated that when they see the MD/NP, they or someone else in the office (always/often) involve them as much as they want to be in decisions about their care and treatment. Target 87.5% > 91% Initiatives1.Update survey question. 2.Review survey results with Clinical Team and discuss opportunities for improvement. 7

8. DOMAIN: PATIENT-CENTRED ObjectiveReceiving and utilizing feedback regarding client experience with the organization. Indicator% of clients who stated that when they see the MD/NP, they or someone else in the office (always/often) give them an opportunity to ask questions about recommended treatment?. TargetMaintain current performance of 97.5% Initiatives1.Update survey question. 2.Increase survey frequency and collect baseline for monthly survey response rate. 3.Review survey results with Clinical Team and discuss opportunities for improvement. 8

9. DOMAIN: PATIENT-CENTRED ObjectiveReceiving and utilizing feedback regarding client experience with the organization. Indicator% of clients who stated that when they see the MD/NP, they or someone else in the office (always/often) spend enough time with them? TargetMaintain current performance of 91.1% Initiatives1.Update survey question. 2.Review survey results with Clinical Team and discuss opportunities for improvement. 9

10. DOMAIN: POPULATION HEALTH ObjectiveReduce influenza rates in older adults by increasing access to the influenza vaccine. Indicator% of client population over age 65 that received influenza immunizations. Note: we are expanding this initiative to capture all high-risk clients, including those over the age of 65. Target 36% > 40% Initiatives1.Clinical Team to review 13/14 MSAA data. 2.Clinicians to implement automated recall feature in new EMR. 3.Outreach to identified clients. 10

11. DOMAIN: POPULATION HEALTH ObjectiveReduce the incidence of cancer through regular screening. Indicator% of eligible clients who are up-to-date in screening for breast cancer. Target 62% > 65% Initiatives1.Clinical Team to review 13/14 MSAA data. 2.Clinicians to implement automated recall feature in new EMR. 3.Outreach to identified clients. 11

12. DOMAIN: POPULATION HEALTH ObjectiveReduce the incidence of cancer through regular screening. Indicator% of eligible clients who are up-to-date in screening for colorectal cancer. Target 55% > 58% Initiatives1.Clinical Team to review 13/14 MSAA data. 2.Clinicians to implement automated recall feature in new EMR. 3.Outreach to identified clients, and health promotion / education initiative (eg workshop). 12

13. DOMAIN: POPULATION HEALTH ObjectiveReduce the incidence of cancer through regular screening. Indicator% of eligible clients who are up-to-date in screening for cervical cancer. Target 79% > 90% Initiatives1.Clinical Team to review 13/14 MSAA data. 2.Clinicians to implement automated recall feature in new EMR. 3.Outreach to identified clients. 13