Read about our Quality Improvement Plan
STEGH’s commitment to quality care is a key driver and a strategic priority. Each year, STEGH submits a Quality Improvement (QIP) to the Ministry of Health and Long Term Care. The QIP is developed with active input from hospital leaders, board members, staff and physicians. In its 2015/16 QIP, STEGH highlighted six priority objectives for improvement, all of which align with our vision to deliver an excellent patient care experience. A number of metrics are tracked to measure success and sustainment of quality improvement efforts.
STEGH relies on a short internal patient feedback survey administered at discharge to measure patient satisfaction. Responses, including all written comments, are processed in a seven-day cycle with results posted visibly on huddle boards across the hospital. The questions were revised this past year to better align with the National Research Council of Canada survey process and to allow for increased understanding of patient experience. STEGH is driving patient experience and patient centered concepts into care processes and is supported by the hospitals patient experience council.
The QIP included tracking the question, “Overall, how would you rate the care you received?” and set a target of 92% answering excellent or very good across all inpatient units. We are pleased to report that we exceeded our target this year with an average of 94%.
A second metric in the QIP relates to access in the Emergency Department. STEGH set an aggressive target of two hours for physician initial assessment (PIA) for CTAS 3 patients. CTAS is the Canadian Triage Acuity Score – a five level scale used to assess priority of patients. CTAS 1 is the highest severity (resuscitation) and CTAS 5 is the lowest (non urgent).
The PIA time for CTAS 3 patients continues to be a challenge due to the increasing ED volumes and longer time to address medical needs of less urgent patients in the ED. At the end of this past fiscal year, our average PIA CTAS 3 wait time was 2.6 hours.
STEGH staff and physicians are proud of the continued ranking of STEGH as the #1 ER wait times hospital in Ontario in 2012, 2013, 2014 and 2015. STEGH carefully monitors levels of quality/safety while continuing to drive wait times lower.
Best Possible Medication History (BPMH)
STEGH committed to a target of 85% completion of Best Possible Medication History (BPMH) within 24 hours for all admitted patients to Intensive Care, Medical and Surgical Units. A BPMH is a history created using a systematic process of interviewing the patient/family and a review of at least one other reliable source of information to obtain and verify all of a patient’s medication use (prescribed and non-prescribed). The BPMH is a ‘snapshot’ of the patient’s actual medication use, which may be different from what is contained in their records. This is why the patient involvement is vital. BPMH is easily measured on our computer order entry system and this is the basis for an effective medication reconciliation process on both admission and discharge.
STEGH committed to implementing all 11 Canadian Patient Safety Institute “Safety Bundles” into at least one area by end of 2015. This was a stretch goal, but one in which STEGH leaders were committed to given the reliable nature and the practicality of the tools for improving quality and patient safety. For more information on Safety Bundles, click here.
Discharge Summaries and Follow Up Appointments
STEGH was experiencing higher than expected readmission rates and implemented two key strategies to address this situation. These included increasing the proportion of acute medical patients discharged from STEGH seeing primary care provider within seven days of discharge and to increase the proportion of discharge summaries sent within 48 hours from hospital to primary care or community provider for acute medical patients. The QIP target was to have 85% of discharge summaries completed within 48 hours for all discharged inpatients – a target which we met! The completion of discharge summaries is highly dependent on the medical staff and STEGH leadership worked collectively and collaboratively with the Medical Advisory Committee, department chiefs, and entire medical staff to achieve this target. The target for booking follow up appointments with primary care providers at the time of discharge from medical units was 90% and we are pleased to report that we exceeded that target.
Chemotherapy nurse, Janice Purcell, attends to a patient in STEGH’s Chemotherapy Clinic.