sunnybrook health sciences centre€¦ · urgent care access to same-day care for urgent issues,...

Sunnybrook Health Science Centre 1 2075 Bayview Ave., Toronto ON M4N 3M5

Quality Improvement Plan (QIP) Narrative

Sunnybrook Health Sciences

Centre

3/27/2020


Overview Sunnybrook Health Sciences Centre (SHSC) is pleased to share its tenth annual Quality Improvement Plan (QIP). This narrative provides a brief introduction to our hospital and describes our key priorities for quality improvement. SHSC is a large academic health sciences centre that is fully affiliated with the University of Toronto. Sunnybrook has three campuses, nine clinical programs and is Canada’s largest trauma centre. The Hospital provides a broad range of tertiary regional programs and services including (but not limited to) specialties in cancer, cardiovascular disease, neurological disorders (including mental health), high-risk obstetrics and gynaecology, orthopaedic and arthritic conditions, trauma and critical care, rehabilitation, and community care. In addition, Sunnybrook is Canada’s largest facility caring for the country’s war veterans. Sunnybrook is further advancing specialized care in geriatrics and brain sciences through new developments such as the Peter Cipriano Centre for Seniors Health and the Garry Hurvitz Brain Sciences Centre. The hospital has 11,000 staff and physicians and 1,000 volunteers who support our vision ‘To invent the future of healthcare’. Each year we:

• Care for 1.3 million patients (about 70% are from outside of Toronto) • Teach 5000 students (from 95 countries around the world) • Conduct in excess of $100 million in research

Sunnybrook also has a dedicated group of approximately 140 Patient Partners, working with teams across clinical disciplines to support Patient & Family Advisory Committees (PFACs), working groups and other operational committees to guide decision-making, resource allocation and quality improvement activities from a patient centred lens. Sunnybrook’s four strategic directions, which guided the selection of the QIP priorities, aim at achieving excellence in the following areas:

1. Personalized and precise treatments - Sunnybrook understands that every patient is unique. This Strategic Direction is about tailoring treatments to meet the specific needs of patients

2. Integrated and sustainable models of care - Sunnybrook understands that a visit or stay in the hospital may only be a small part of the patient’s journey through the health care system. Regardless of where a patient’s pathway through the system may lead, this Strategic Direction aims to ensure people find their way and have consistent care throughout their experience.

3. Quality and creating a better care experience - Achieving the best possible outcome for patients while exceeding their expectations for care and service is Sunnybrook’s primary concern. Through this Strategic Direction, Sunnybrook is building on its comprehensive strategy to continually improve the quality of care, and engaging patients and families to improve their experience

4. High performing teams- Sunnybrook is committed to building and strengthening high performing teams that invent the future of health care. To deliver high quality care requires teamwork – not only from within the walls of Sunnybrook, but also in collaboration with partners in the system. In this Strategic Direction, the emphasis is on building high performing teams that centre around the needs of the patient both at the hospital and in the community.


The other key framework that informed our QIP is the hospital’s multi-year Quality Strategic Plan, with its six dimensions of quality (safe, effective, efficient, compassion, partnerships, quality culture). To learn more, please visit our website Sunnybrook.ca In determining our annual QIP priorities we apply a selection criteria model which ensures each initiative aligns with the corporate strategic priorities of the hospital, of Health Quality Ontario and/or other external or regulatory requirements such as our service accountability agreements and opportunities identified in our Accreditation Report. Quality Improvement Plans are then further evaluated based on their potential impact as well as strength of the data and proposed change ideas. Each plan must engage patients in the development or implementation. In addition, we seek to focus on work that is in collaboration with our system partners. Describe your organization's greatest QI achievement from the past year We are very proud of the progress we have made on all of our 12 QIPs from 2019/2020. While there have been several Quality Improvement successes we have highlighted both internally and externally, we would like to showcase one specific initiative aimed at reducing our cancer surgery wait times by reducing hospital occupancy through improved access to urgent / off-hours care for our vulnerable cancer patients. Change Idea: The Oncology Urgent Care (ONUC) – Medical Oncology Pilot aimed to divert emergency department (ED) visits and admissions for medical oncology patients by helping them gain urgent access to high-quality care for urgent issues related to cancer or cancer treatment. Background: To address a gap in cancer patient care that had been identified namely that there was no urgent care access to same-day care for urgent issues, other than going to the ED or clinic add-ons. This gap often led to unnecessary admissions to the hospital, increasing the hospital occupancy and potentially creating a domino effect leading to cancelled surgeries due to no bed. In review of our system partner practices, Sunnybrook found itself as an outlier in this approach to service provision. The pilot is operational on weekdays from 9:00am – 5:00pm out of the Complex Malignant Hematology outpatient clinic, and select patients can also be seen through the ED. Potential medical oncology patients are identified from the oncology nursing ‘live voice answer’ call line and clinics, and are screened for eligibility according to specific clinical criteria by a Physician Assistant (PA) in collaboration with Medical Oncologist. This close collaboration between roles to triage, consult on and treat patients, provides them with timely access to specialized care. Outcome: With the vision of helping improve quality of care, patient-centred care in oncology, while improving the appropriate use of hospital resources, this new model demonstrated value for our patients in its first few weeks of opening.

• Eight patients received the urgent care they needed and were sent home without having to stay in the ED or hospital within the first two weeks of launching.

• For one patient in particular, the ONUC enabled her to receive expedited treatment as a result of timely assessment. Through the ONUC, this patient was able to be diverted from both the ED and MRP clinic and was able to receive assessment, work up and imaging all in one day. As a result, she received a paracentesis that same day and expedited a systemic treatment change given the progression seen in the imaging results.

https://sunnybrook.ca/content/?page=strategic-plan-2018-21


• These patients have expressed their gratitude and appreciation for the new service including those who were physically seen in ED; they were happy to have expedited access to oncology specific care, thus by-passing the typical ED process.

• Additionally, this service is helping provide better and safer care for patients. A patient shared, “I had initially been advised to go to the ED by my medical team and I chose not to go because I wanted to avoid the wait times. Now with the ONUC as another option, I’m more willing to come into the hospital for assessment.” “It was a long time coming,” another patient shared.

“This is an important avenue of care for select patients. For these patients, access to an urgent care model allows them to have the care they need without going to the ED, or being added on to already busy clinics, where acute issues cannot always be managed. The intent is that this will be a safe and efficient way to address the needs of these patients, and improve the efficiency of the health care system at large” says Dr. Gandhi, the pilot’s Medical Director and the Sunnybrook Division of Medical Oncology Quality Lead. Cancer Surgery Wait Times QIP will continue into 2020/2021 and will include an expanded iteration of this change idea building off learnings from the pilot, looking at a dedicated, permanent space to serve the needs of this population and provide greater access to urgent care for medical oncology patients. Collaboration and integration Sunnybrook continues to collaborate with its community partners to ensure our patients receive high-quality, accessible and coordinated care. Through our 2019/20 QIP:

• The Michael Garron (MGH) partnership for Gynaecological Oncology surgery continued. Each month at MGH, we completed four to six cases which positively impacted Sunnybrook’s cancer surgery wait lists.

• The North Toronto Sub Region (NTSR) Palliative Care Journey Committee was established and is

comprised of provincial, LHIN, community and hospital provider stakeholders. Committee members participated in a quality improvement planning exercise to identify priority areas for improvement that would inform a three-year Palliative Care Action Plan.

• Sunnybrook adopted the Patient Oriented Discharge Summary (PODS). PODS standardize the information patients and their caregivers receive when they leave the hospital, and serves as a tool for a structured conversation with patients, ensuring they receive crucial information in a simple format to help them manage their health after leaving the hospital. Together with Michael Garron Hospital, we developed and implemented simulation based PODS education tools and resources for immersive learning, with reflection and practice debrief to enhance health care professional communication skills.

• Sunnybrook co-founded a Patient Safety Collaborative with 11 partner hospitals across the GTA and beyond to share learning from patient safety incident cases and develop common approaches to understanding and preventing adverse events.

Sunnybrook is a partner organization with the North Toronto Ontario Health Team (OHT). OHT partner organizations include:


• Baycrest Hospital • Client, patient, family, caregiver and community representation • Home and Community Care • LOFT Community Services (LOFT) • Primary care partners • SE Health (member of the SE family of companies) • SPRINT Senior Care (SPRINT) • Sunnybrook Health Sciences Centre (Sunnybrook) • Unison Health and Community Services (Unison) • VHA Home HealthCare (VHA) • Vibrant Healthcare Alliance (Vibrant Health)

Together, we are designing an integrated care delivery model that is focused on ensuring seamless navigation and coordinated care for frail seniors Specifically, our vision is to become one connected system of health care for people living and seeking care in our North Toronto OHT. This means working together to provide an integrated continuum of care that meets the needs of our population. In the eyes of our community, care will be simple to access, it will be coordinated, and providers will communicate and collaborate as One Team to provide comprehensive, integrated care. An Executive Leadership Team has been established to jointly establish accountabilities and identify key interventions and performance metrics for the NTOHT. Year 1 priorities of the NTOHT will focus on:

1. Co-designing new models with Primary Care that build on existing services (e.g. Vibrant and Unison) and successes such as the Interprofessional Primary Care Model developed by Baycrest Hospital; used in Toronto Community Housing Corporation buildings and Pine Villa.

2. Demonstrating Home Care Re-Design, such as the Neighbourhood Care models, to ensure patients have access to a strong interprofessional team that includes primary, home and community care.

3. Enabling Digital Care to support information sharing, patient access, and identification/tracking of patients.

4. Build a governance framework that will be inclusive, nimble, and has the appropriate authority to enable system change.

5. Engage Community, Families, Patients and Caregivers to develop a strategic plan for our OHT. Proposed quality metrics are currently being established, and will form the basis of future shared Quality Improvement Plans across participating organizations in the OHT partnership. Potential performance metrics include: Seniors with High Risk Needs

• High Patient feedback scores • Increase # of seniors actively attached to care coordinators • Increase # of seniors attached to homebound primary care


Seniors with Rising Risk Needs • Reduced CTAS III – V visits to the Emergency Department by seniors • Increased physician attachment to SCOPE/TIP/SPIN • Increased % of seniors that have access to interprofessional primary care teams

Seniors with Low Risk Needs • Increase % of seniors with a virtual health care encounter in the last 12 months • Increase % of seniors with access to digital health records

Patient/client/resident partnering and relations Sunnybrook actively creates a culture of patient, resident and family engagement to support the delivery of safe, quality and person-centred care. We partner with our Patient and Family Advisors to offer them a forum for sharing their unique thoughts and perspectives and to help ensure that the voice of patients, families, and caregivers are heard, considered, and included in programs and plans. Our aim is to ensure a Patient and Family’s voice is consistently included at the table in the majority of decision making around new and ongoing initiatives. In the planning for our 2020/21 QIPs, all of Sunnybrook’s 13 Patient and Family Advisory Committees (PFACs) were invited to take part in a digital consultation via an online survey asking them to comment on a selection of QIP proposals and to provide specific commentary on the focus of goals and share insights to inform change ideas. What we heard as a result was the importance of receiving clear and comprehensive communication especially at times of transition and discharge. This information will be shared with the Sunnybrook Connects team; an innovative model that was designed in collaboration with patients, families and system partners to improve the coordination, continuity and integration of care both within the hospital and community setting, through two streams of care including the Emergency Department (ED) One Team and My Healthcare Navigators. Sunnybrook Connects – Connected Care and Navigation is one of our eight (8) QIPs for 2020/21. During the QIP solicitation and vetting process, data gathered from Patient Experience surveys and Conversations with Patients were considered in the development of new quality improvement plans. In addition to the above, each of the eight (8) QIPs chosen as areas of focus for 2020/21 will engage patients and families in the implementation and/or evaluation of the change initiatives. As a component of each quality improvement plan, teams have outlined how they will engage patients and families in their quality improvement work in 2020/21. Examples include:

• Creating a formal role for patient engagement in hand hygiene improvement activities by identifying, and engaging a patient who has been affected by a hospital-acquired infection; providing them with hand hygiene education so that they can attend and participate in unit quality conversations and Hand Hygiene-IMPACT network teleconferences on a quarterly basis.

• Patient and families will receive education about pressure injuries, including their personalized risks, an overview of Pressure Injuries and the importance of strategies to reduce risk (e.g. mobilization) which will be created in collaboration with the Communications team, and volunteer patient and family partners

• Partner with the Office of the Patient Experience to identify patient and family complaints related to Emergency Department admission wait times to use as means to identify further opportunities for improvement.


Additionally, patient partners have reviewed this narrative document to ensure appropriate language and a person centred lens. Workplace Violence Prevention Violence in the workplace presents a risk to the well-being of Sunnybrook staff, physicians, volunteers, students, patients and visitors. We recognize that the majority of violent acts are preventable within the workplace and we strive to create a culture that supports this philosophy; to create a positive environment with mutual respect and open communication. At Sunnybrook we begin with an approach to workplace violence that is guided by the principle that patients exhibiting behaviors often stem from medical conditions and can be a response to what is happening internally to a patient or externally in their environment. As such our strategy focuses on analyzing and addressing the root cause of the behavior, and preparing staff to use approaches to care that prevent violent occurrences and manage high risk behaviours. Workplace violence prevention at SHSC is guided by:

• A Harrassment, Discrimination and Violence Policy, which requires a full root cause analysis, review of processes and follow up to mitigate future incidents

• A Respect Policy, Diversity Statement and Principles, which includes respectful methods for communicating with patients, families and staff

• Harrassment and Discrimination and Code White training SHSC has a comprehensive approach to violence prevention for staff and patients, which consists of:

• Continued focus on Non-violent Crisis Intervention education for staff for areas identified as high risk of violent incidents, including key de-escalation and prevention techniques, and verbal / non-verbal skills for communicating with at-risk patients or families.

• Adherence to a “Framework for Responding to Reported Violent Incidents” which follows the standard process including 1) debriefing, 2) creation of a patient safety care plan with family input regarding triggers following serious incidents, 3) root cause analysis for serious incidents and 4) implementation of recommendations.

• Initiation of an observed Behavioral Assessment to be completed in the patient's health record in the Emergency Department, identifying patients who have a history of, or have demonstrated behaviour that puts others at risk and outlining care strategies that can be used to address the behavior.

• Employee incidents, events or occurrences that could or does result in employee injury or illness are also tracked by Occupational Health & Safety to identify and mitigate potential risks to patients/families and staff.

The development of flagging protocol and criteria to identify patients at high risk for violent behavior will also be an area of focus as this initiative will better support continuity of safety for these patients and their care teams. The flagging protocol and criteria will be developed within a sub-committee of the Workplace Violence Committee. This committee will include physicians and patients and will consult and collaborate with community and family partners. Understanding why these events occur is key to preventing future events. Encouraging reporting and situational awareness are two factors that are critical in the development of effective preventative measures. In partnership, the Quality and Patient Safety department, the Workplace Violence Committee


and Emergency Preparedness Committee will undertake a systematic review of aggressive and abusive patient incident reports to identify actionable themes. These will help inform Non-violent Crisis Intervention education training. Virtual care Virtual care, a term that broadly encompasses all the ways healthcare providers remotely interact with their patients such as telemedicine, eVisits, and online scheduling. Virtual care helps ensure health care delivery in Ontario is efficient and equitable and is key to enhancing access and modernizing health care delivery. Integrated & sustainable care; it is through this strategic direction that Sunnybrook will continue to build and leverage digital health solutions to create virtual connections to provide care that best meet our patient’s needs. While Telemedicine’s roots in Ontario can be traced back to Sunnybrook, one of the four sites where telemedicine was launched in the province in April 1998, Virtual Care, a newer approach to providing patient care is making headway at Sunnybrook. Through the eVisit solution, patients and providers can complete virtual care visits using an online platform on their computer or smartphone. As timely access to primary care providers continues to be a challenge for patients, which may lead to unnecessary emergency department visits, eVisits allow our Physicians to connect with patients to help widen the distribution and delivery of their care – improving access, quality and patient outcomes. At Sunnybrook, the Department of Medicine is leveraging digital health solutions and are yielding substantial gains. Within the Infectious Diseases (ID) division for instance, all physicians have registered for Ontario Telemedicine Network (OTN) and have integrated eVisits (using the OTN Direct-to-Patient Video Visit platform) into their outpatient practice. Patients deemed appropriate for an eVisit are identified in clinic and given the option to attend subsequent follow-up visits virtually from their own home. These patients are carefully chosen based on their clinical needs, and the ability to utilize the technology. The ID division averages approximately 20-25 virtual care visits per month - which means 20-25 saved trips to Sunnybrook and time off work for these patients. The ability to provide timely virtual ID care extends beyond the Bayview Campus. Using the same platform, eVisits are being carried out for inpatients with orthopedic infections at the Holland Campus using a shared iPad tablet device that is brought to the patient's bedside. This allows the ID consultant (situated at the Bayview campus) to assess patients at the Holland campus without the need for travel. This successful internal collaboration has positively impacted patient care by improving the timeliness of assessments, and reducing patient transportation between the two hospital sites. Moreover, the Division of Endocrinology has also adopted virtual care solutions, like eConsult and Video Visits. Dr. Ilana Halperin, staff physician at Sunnybrook Health Sciences Centre and Quality Lead for the division of endocrinology at the University of Toronto shares her experience with virtual visits:


“About 15% of my outpatient visits are virtual, but it could be more! I usually do about 10 virtual visits a week. My patients love it. Connecting with patients through virtual visits is so efficient, especially for those that require high frequency but low touch interactions. The beauty of home video visits means they can be anywhere: at home, at work, in their car, in their backyards.” Dr. Halperin also supports her patients through email, she often helps patients with type 1 diabetes manage their high and low blood sugar levels after hours, avoiding unnecessary trips to the emergency department. “This is an easy win for everyone, responding from my smartphone takes just a few minutes and I know it provides my patients with a sense of security.”

She also is part of the OTN eConsult program, a secure website for primary care physicians to ask focused clinical questions of specialists. “eConsult is best for asymptomatic laboratory and imaging findings, I can answer the questions about what additional work up is needed and provide some education. I often attach guidelines and reviews to my response and this saves the patients from having to attend a consult in person.”

Sunnybrook continues to support exploration for opportunities to work with additional Divisions to find models that suit their sub-specialty and patient population. Executive Compensation For many years, Sunnybrook has had a performance-based component to its executive compensation for the CEO and the Senior Leadership Team. A percentage of the executive’s compensation (21-30%) is based on the achievement of annual goals and objectives that are aligned to the organization’s strategic goals and to the individual’s portfolio. Sunnybrook’s Executive Performance Management Program is well established, comprehensive and governed by the Performance and Compensation Committee of the Board of Directors. The Program includes both a 360° performance evaluation (built on the foundation of leadership competencies) and specific performance goals that are used to drive quality and organizational improvement. For April 1, 2020 – March 31, 2021, QIP performance is tied to five per cent at risk payment and performance is equally divided among four indicators (newly selected for executive compensation for 2020/21) as displayed below.

Plans Indicator Definition Weight

Workplace Violence Prevention % of active staff assigned on a regular basis in high risk areas that attend a non-violent crisis intervention education session (every other year). 25%

% of COPD, CHF, CAP, Oncology, Nephrology, and select Trauma patient inpatient encounters with either of the following:

Advance Care Planning and of Care

Goals • A new or updated Advance Care Planning (ACP)/Goals of Care (GOC) note documented in SunnyCare during the inpatient encounter in the reporting period

25%

• An existing Advance Care Planning (ACP)/Goals of Care (GOC) note documented in SunnyCare within the last year of the inpatient encounter.

Conversations with Patients (CWP)

# of Conversations with Patients conducted across all Sunnybrook campuses. 25%

Connected Care and Navigation # of patients who are seen by and/or Sunnybrook Connects Team

have their care coordinated by the 25%


Sign-off It is recommended that the following individuals review and sign-off on your organization’s Quality Improvement Plan (where applicable): I have reviewed and approved our organization’s Quality Improvement Plan

Board Chair (signature)

Board Quality Committee Chair (signature)

Chief Executive Officer (signature) Contact Information Darren Gerson Vice President of Quality & Performance Sunnybrook Health Sciences Centre 2075 Bayview Avenue, Toronto, Ontario Toronto, ON M4N 3M5

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