Accreditation 2009 The Qmentum Journey CCHSE February 26, 2009

1. Accreditation 2009 The Qmentum Journey CCHSE February 26, 2009

2. St. John’s Rehab Hospital 160 beds in north Toronto (Central LHIN) Founded in 1937 by the Sisterhood of St. John the Divine 2,600+ inpatients per year (Average length of stay from 1 week to 3 months) Almost 50,000 outpatient visits per year Future $35-million, 49,000 sq-ft John C. & Sally Horsfall Eaton Centre for Ambulatory Care to house all outpatient services ~ 450 full, part-time and casual staff

3. Our role in Ontario’sHealthcare System The only hospital in Ontario dedicated to specialized rehabilitation Serve patients from throughout GTA and the province “High-performing hospital” OHA/MOHLTC/CIHI Hospital Report, 2007 and 2008 Individually customized rehab to meet physical, emotional, psychological, work, social and spiritual needs Rebuild lives so people can thrive in the community and be less dependent on health care Alleviate acute care pressures and wait times

4. Our Programs We provide specialized rehab care for adults recovering from: amputations burn injuries (unique in Ontario) Cancer (unique in Ontario) cardiovascular surgery organ transplants (unique in Canada) orthopaedic conditions strokes and neurological conditions traumatic injuries complex medical conditions/procedures

5. Our Rehabilitation Team a Hospitalist a Physiatrist Registered Nurses and Registered Practical Nurses a Physiotherapist and Physiotherapy Assistant an Occupational Therapist and Occupational Therapy Assistant a Speech Language Pathologist a Pharmacist a Social Worker a Dietitian a Pastoral Care Visitor Clinical Nurse Educator Patient Service Aides Program Assistant It takes 13 highly trained professionals to rehabilitate 1 person We should add “Auxiliary” to the list, because, I know -- whether it’s a coffee delivered on the cart or an encouraging smile -- you are part of the rehab team.It takes 13 highly trained professionals to rehabilitate 1 person We should add “Auxiliary” to the list, because, I know -- whether it’s a coffee delivered on the cart or an encouraging smile -- you are part of the rehab team.

6. Partnerships Burn, oncology and trauma care Partner with Sunnybrook on a smooth continuum-of-care, education and research Organ transplant rehabilitation Continuum-of-care developed in partnership with Toronto General Hospital North York General Hospital Integrated inpatient rehab to improve access and reduce ER wait times Shared Information Management Systems (SIMS) Shared technology service to improve care, efficiency and develop e-health records together with 12 other health care organizations We are a part of an already large and growing network We are a part of an already large and growing network

7. Qmentum Timeline & Strategy May – Sep. 2008: Process Preparation & Education Blitz Sep. 29 – Oct. 3, 2008: Qmentum / Patient Safety Expo Oct. 6 – Nov. 14, 2008: Self-Assessment Questionnaires/Instruments/Indicators Nov. 17, 2008: Quality Performance Roadmap & Flags Begin to Develop Action Plans Nov. 2008 – Oct. 2009: Develop/Implement/Monitor/Refine Action Plans June 2009: Submit Evidence of Actions Taken Oct 18-21, 2009: On-Site Qmentum Accreditation Survey We are a part of an already large and growing network We are a part of an already large and growing network

8. Starting the Journey Dedicated Qmentum Project Coordinator Staff competition for Qmentum theme “Quality & Beyond” Banner and newsletter Steering Committee (all team leads) Qmentum link on hospital intranet Contains all educational/promotional materials Education plan Learning Needs Assessment Qmentum Toolkit Presentations, Fact Sheets and Q-Tips Computer Lab Training (used student volunteers) We are a part of an already large and growing network We are a part of an already large and growing network

9. Preparing for theSelf-Assessment Personalized memo to every staff member with links and passwords. Students were available to support people who needed assistance in the computer lab. Sign-up sheets in computer lab with times of student availability highlighted. Option to complete questionnaires manually. Option to complete questionnaires at home (especially useful for Board members and front-line staff with limited access to computers). We are a part of an already large and growing network We are a part of an already large and growing network

10. Conducting theSelf-Assessment Incentives, Incentives, Incentives Beverage coupons for cafeteria Lunch ‘n’ Click / Sup ‘n’ Click sessions Early bird prizes Interdepartmental competition Pizza lunch Weekly tracking by department/area Grand prize We are a part of an already large and growing network We are a part of an already large and growing network

11. Targets and Results Overall Response Rate : 73% Governance : 100% 100% Governance Function: 100% 100% Effective Organization: 100% 89% Managing Medications: 55% 83% Worklife Pulse: 75% 74% Infection Prev. & Control:55% 73% Patient Safety Culture: 75% 71% Rehabilitation Services: 55% 61% We are a part of an already large and growing network We are a part of an already large and growing network

12. Continuing the Journey Quality Performance Roadmap shared with Steering Committee and with broader staff population at Lunch ‘n’ Learn session Teams currently organizing activities and developing action plans based on flags and priorities Submitting evidence along the way. Steering Committee meeting monthly or biweekly as required to maintain momentum Ramping up education on survey process (tracers, etc.) June – October 2009

13. Key Success Factors Dedicated Qmentum project coordinator Qmentum toolkit on intranet Fact sheets and Q-Tips Access to computer lab and readily available assistance from students and project coordinator Incentives, Incentives, Incentives Existing teams (e.g., IPC, P&T, Rehab Teams, Quality of Worklife)