Quality Improvement Plan

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Our commitment to quality care: Niagara Health is “looking forward”, charting its future to deliver high quality and safe care.  Our hospital’s organizational goals and priorities and our action steps for quality improvement are outlined in our annual Quality Improvement Plan (QIP).

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.

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

Accreditation

I-Equip

Laboratory Accreditation

Quality Framework

Quality Improvement Plan

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 2017/18 Quality Improvement Plan

Niagara Health has realized several significant achievements over the past year, including the focus on improving patient flow through daily huddles and bullet rounds, the introduction of Unit Based Teams, continued training in crucial conversations and accountability as well as the internal campaign for Patient Safety week activities. 

QIP Narrative 2017/18 | QIP Workplan 2017/18 | ECU QIP Workplan 2017/18

There are six (6) 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 to 88%, for a 90% compliance rate.

We will improve the safety of care by reducing the number of patients who fall in complex care from 19.2%to 10% and reducing the number of harmful falls in acute care by 5%.

Effective:

We will reduce the Hospital 30 Day Readmission Rates for patients with a Mental Illness or an Addiction from 11.4% to 10.8% for a 5% improvement.

Patient-Centred:

We will improve patient experience by improving the satisfaction scores from 72.7% to 74.9% for our inpatients and from 49.6% to 51.7% for our ED patients, for a 3% improvement overall.

This will mark the third 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 2017/18 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 form 23.99% to 22.61%

We will improve our resident safety by reducing the number of harmful resident falls to 13.3%. 

We will improve our resident safety by reducing the number of worsening pressure ulcers to meet the Provincial average of 3.3%. 

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

Effective:

We will improve the effectiveness of our services by striving for a 100% compliance rate in the area of hand hygiene in order to reduce the spread of infectious disease.

Patient-Centred:

We will improve the resident experience by improving our scores in the following areas:

  • Increasing the percentage of Residents responding positively to the question “What number would you use to rate how well the staff listen to you?” to 75%
  • Increasing the positive responses to the question “I can express my opinion without fear of consequences” to 82.5%

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.

Niagara Health System