Our commitment to quality care
Our hospital is committed to the delivery of high quality care in a safe environment. Quality improvement is a continuous journey, and the Niagara Health System will continue to strive for optimal performance throughout this journey.
Our hospital’s priorities and our action steps for quality improvement are outlined in our annual Quality Improvement Plan. The QIP is just one of the ways that we are keeping our focus on constantly doing better. Through our QIP, our community will be able to very clearly see our targeted areas for improvement and will be able to chart our progress.
What is the QIP?
The Excellent Care for All Act (ECFAA) came into effect in Ontario in June 2010. This new legislation requires all hospitals to create and make public annual Quality Improvement Plans. Our first plan was implemented for April 1, 2011 to March 31, 2012. Our second plan was implemented April 1, 2012 for the period up to March 31, 2013.
The ECFAA sets out a number of other requirements for hospitals including establishing quality committees, implementing patient and care provider satisfaction surveys, developing a declaration of values following public consultation, and establishing a patient relations process to address and improve the patient experience.
While there is more work to do, we’re pleased that Niagara Health System has had all of these quality initiatives in place for some time.
Our NHS 2012/13 Quality Improvement Plan
The Niagara Health System has a renewed commitment to quality as a fundamental business strategy in order to achieve two pivotal goals:
- To deliver a great patient experience
- To engage our staff, physicians and volunteers
Our goal is to have our patients, our staff, our physicians, and our volunteers share their stories of great care, safe and innovative work environments, accountable and transparent practices – all defining the NHS as a high quality hospital system. We will rebuild and retool a robust quality framework based on guidance from leading practice organizations. Our commitment to leadership development is key to our success.
Over the course of the next year, Niagara Health System will focus on improving the overall quality of care and services delivered at all seven hospital sites. By March 31, 2013, the NHS will achieve the following aims and measures.
Safety:
Our aim is to improve the safety of care we provide by reducing the hospital acquired C. difficile infection rate. Our target is a 10% reduction in our hospital acquired C. difficile infection rate.
Our aim is to improve the safety of care by reducing falls in our complex care residents. Our success in achieving this aim will result in a 5% reduction in the number of patient falls.
Effectiveness:
Our aim is to improve the effectiveness of our services by improving our organizational financial health. Our success in achieving this aim will result in continued financial improvement which will see us achieve a balanced budget.
Our aim is to reduce the number of unnecessary deaths in hospital. Our success in achieving this aim will result in a 3% improvement in our Hospital Standardized Mortality Ratio (HSMR).
Access:
Our aim is to improve access to our services by reducing ED wait times for admitted patients. Our target in this area is a reduction of time patients who are admitted to hospital wait in the ED before moving to their inpatient bed, to 35.2 hours.
Patient-Centred:
Our aim is to improve the patient experience, reflected by a 1% improvement, to 87.03% of ER patients and 74.51% of acute care patients surveyed recommending our hospital to friends and family.
Integrated:
Our aim is to reduce the time our patients unnecessarily spend in acute care when they should be receiving care in another setting; we are targeting an 11% reduction in our percentage of Alternate Level of Care (ALC) days.
Our aim is to reduce unnecessary hospital readmissions; our target in this area is a 5% improvement.
Our performance to date
Tracking our progress and performance enables us to build on the areas where we are doing well and identify the areas where there is room to improve. The following two documents outline our progress and performance on our quality improvement priorities for 2011/12 and explain our targets for 2012/13.
Reconciliation for QIP 2011/12 View / Download PDF (67 KB)
QIP Progress for 2011/12 and Plan for 2012/13View / Download PDF (33 KB)
QIP archives
QIP Narrative 2011/12 View / Download PDF (740 KB)
QIP Indicators 2011/12View / Download PDF (70 KB)
For more information:
Niagara Health System: Marilyn Kalmats, at 905-378-4647, ext. 45549; Marilyn.Kalmats@niagarahealth.on.ca
Ministry of Health and Long Term Care: MOHLTC Excellent Care for All webpage