Bill 46: Quality Improvement Plan
St. Joseph’s Healthcare Hamilton is committed to providing quality care which is safe, kind, effective and timely, and is provided in an environment of inquiry and learning. Quality care can be measured in many ways and we believe that keeping you, our community, informed of our performance is important. In June , 2010, the Ontario government passed the Excellent Care for All Act, 2010. This legislation will help support hospitals to improve care through the public reporting of Quality Improvement Plans. This plan outlines exactly how we will improve the quality and safety of care to you and your family.
Quality Improvement Plan
Quality Definition:
Quality care at SJHH is safe, kind, effective and timely, and it is provided in an environment of inquiry and learning.
Participation Philosophy:
Everyone is a member of the quality team.
Quality and Patient Safety Plan Goals:
Four quality and patient safety priorities were identified by the Quality and Patient Safety Committee, and at the 2010 Nursing Retreat. These have been adopted as overarching corporate priorities:
- Reducing Infections*
- Reducing Falls*
- Reducing Medication Errors
- Improving Patient Flow
Quality Plan Infrastructure
How Quality Improvements are Operationalized
Quality and patient safety improvements are operationalized through Program and Department Quality Councils and, where different, through Safer Healthcare Now Teams, and Accreditation Canada Teams, and other project specific teams.
Accountability
At a strategic level quality and patient safety improvements are accountable to the HBC and its Quality and Mission Committee. The Quality and Mission Committee tracks high level clinical outcome and process improvement metrics on a quarterly basis and meets with quality teams in priority areas. Presentations to the Quality and Mission Committee are made via WebEx, and meeting time is reserved for questions and answers. Feedback and expectations are providing in writing by the Committee.
The Senior Leadership Team (SLT)
At a strategic, tactical and operational level, Quality Councils and other improvement teams are accountable to the SLT through the Quality and Patient Safety Steering Committee. This committee sets, monitors and investigates quality and patient safety priorities. The Senior Leadership Team also engages in Patient Safety Walkabouts.
Both and the Hamilton Board Committee and Senior Leadership Team monitor and respond to Critical Incidents as they occur.
Clinical Outcome and Performance Monitoring
Real Time Tracking and Response
Key quality and patient safety indicators are monitored by leaders and teams on a real time basis. For example never events, critical incidents, infections, access to inpatient care, and patient flow are tracked as they are identified.
The Hamilton Board Committee and Senior Leadership Team
The Hamilton Board Committee and Senior Leadership Team track key metrics using a Quarterly Big Dot and Mission Excellence Scorecard that focuses specifically on Patient Outcome Measures in the following Big Dot priority areas:
- Timely Access (Heal Me)
- Incidents (Dont Hurt Me)
- Infections (Dont Hurt Me)
- Mortality (Dont Hurt Me)
- Satisfaction (Be Nice to Me)
The Medical Advisory Committee, Professional Advisory Committee, Quality Councils and other quality and patient safety teams use balanced scorecards and other measurement tools to track performance and set targets.
- 2013/2014 Quality Improvement Plan
- Parts A, C and D
- Part B: Improvement Targets and Initiatives
- Quality Improvement Plans (QIP): Progress Report for 2012/13 QIP - 2012/2013 Quality Improvement Plan
- Parts A, C and D
- Part B: Improvement Targets and Initiatives
- Quality Improvement Plan (QIP) 2012/13: Progress on QIP Year One (2011/2012) - 2011/2012 Quality Improvement Plan
- Parts A, C and D
- Part B: Improvement Targets and Initiatives - Patient Declaration of Values
- Rights and Responsibilities Document
