STEGH 2014/2015 Annual Report

QUALITY

Read about our Quality Improvement Plan

Our Quality Improvement Plan (QIP) for 2014/2015 highlighted seven priority objectives for improvement. Measures of improvement are at the core of the system monitored daily at staff huddles, and drive the selection of strategic /operational improvement projects. Two have already been addressed in the “Safety” section of this report, namely hand hygiene and medication reconciliation.

The other objectives were:

  • Reduce wait times in ED, specifically, reduce the 90th percentile Physician Initial Assessment time for CTAS 3 patients to two hours. We have a very nimble system to address CTAS 1 and 2 patients (life and limb and the most urgent) and an accelerated system to address less acute CTAS 4 and 5 patients through our rapid assessment zone.
  • At the end of this fiscal year, we were on the brink of consistently meeting this two hour target for CTAS 3 patients with an overall 90th percentile of 2.23 hours.
  • Reduction of unnecessary time spent in hospital by continuing to reduce our Alternate Level of Care (ALC) rate for all patients by December 2014 to 16%. This new target included Complex Continuing Care beds and Rehabilitation beds where previously it only measured acute care beds where the indicator had been measuring less than 6%. At the end of this fiscal year, our ALC rate was 5.2% days.
  • Patient Satisfaction had two objectives for 2014/2015. We desired to see an increase in the percentage of patients responding “Yes, Definitely” to “Willingness of patients to recommend this hospital to friends and family” in response to our in house survey.STEGH also started a new process of implementing Post Discharge calls. The target was to have post discharge calls to 80% of all discharged patients by December 2014. We met both of these targets by the end of the fiscal year.
  • Finally, STEGH aimed to reduce the incidence of new pressure ulcers (stage two or greater) across the entire patient population at our hospital by December 2014. This has been a focus for the past few years and last year’s goal of 1.2 per 1000 patient days for the Complex Continuing Care unit was exceeded. This new target of a 50% reduction was a significant stretch goal and included all patient care areas. This metric is reviewed on every floor every week and there is a consistent organization wide approach to wound care including standardization. The average for this past fiscal year 2014/15 = 0.1 per 1000 patient days.
Nurses pushing the Critical Intensive Care Unit Crash Cart