Quality Improvement Plan

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Niagara Health is committed to providing all of our patients, their families, staff, physician, students, learners and volunteers Extraordinary experiences.  Our hospital’s Quality Improvement Plan (QIP) outlines our organizational goals, priorities and action steps for quality improvement.

The QIP is just one of the many ways that we are keeping our focus on constantly doing better. 

Click on the links below to learn more about our Quality Initiatives

Accreditation

I-Equip

Laboratory Accreditation

Quality Framework

Contact Information

Email Marilyn Kalmats
905-378-4647 ext. 45549

Visit the MOHLTC Excellent Care for All webpage

What is the QIP?

The Excellent Care for All Act (ECFAA) came into effect in Ontario in June 2010. This legislation requires all hospitals to create and make public annual Quality Improvement Plans. Many significant improvements have been made since our first plan was developed in April 2011.

ECFAA sets out a number of requirements for hospitals including:

  • establishing quality committees;
  • implementing patient and care provider satisfaction surveys;
  • developing a declaration of values with public consultation;
  • establishing a patient relations process to address and improve the patient experience; and
  • involving patients and families in the development of QIPs.

Our 2018/19 Quality Improvement Plan

Niagara Health has realized several significant achievements over the past year, including the continued focus on improving patient flow through daily huddles and bullet rounds, the introduction of Extraordinary U, the ongoing evaluation and enhancement of the Emergency Management Program and improving identification and treatment of malnutrition with the More 2 Eat Study.

QIP Narrative 2018/19 | NH QIP Workplan 2018/19 | ECU QIP Workplan 2018/19

There are seven (7) key areas of improvement focus in our 2017/18 Hospital QIP across the safe, effective and patient-centred dimensions of quality, as outlined below.

Safe:

We will improve the safety of care we provide by increasing the proportion of patients who have their medications reconciled on admission and discharge to 90% in all units implemented.

We will establish a baseline for Workplace Violence Incidents.

Effective:

We will reduce the Hospital 30 Day Readmission Rates for patients with a Mental Illness or an Addiction from 12.3% to 9.8%.

We will reduce the number of new stage 2 or higher Pressure Ulcers for our complex care patients by 5%.

Patient-Centred:

We will improve patient experience by improving the satisfaction scores from 81.5% to 83.9% for our inpatients and maintaining our target of 51.7% for our ED patients.

 

This will mark the fourth year that Long-Term Care and Extended Care Units (ECU) are required to submit and publicly post a QIP. 

There are seven (7) key areas of improvement focus in our 2018/19 ECU QIP across the safe, effective and patient-centred dimensions of quality, as outlined below.

Safe:

We will improve our resident safety by reducing the percentage of residents who were given antipsychotic medications without psychosis in the 7 days preceding their resident assessment from20.68% to 18.48%

We will improve our resident safety by reducing the number of harmful resident falls to 15.63%.

We will continue our goal of 100% compliance rate in the area of hand hygiene in order to reduce the spread of infectious disease.

We will improve our resident safety by reducing the number of residents requiring the use of restraints to 10.4%.

Effective:

We will reduce the number of new and worsened pressure ulcers to 7.25%

Patient-Centred:

We will increase the percentage of Residents responding positively to the question “What number would you use to rate how well the staff listen to you?” to 93.7%

We will increase the positive responses to the question “I can express my opinion without fear of consequences” to 91.1%

QIP Archives

QIP Narrative 2017/2018

QIP Workplan 2017/2018

ECU Workplan 2017/2018

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.  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.

QIP Progress Report 2017/18

Niagara Health System