VP Quarterly Report on Strategies Q3 – 2015/16

1. Vision: Healthy people, families and communities. VP Quarterly Report on Strategies Q3 – 2015/16 VP: Marlene Smadu - Quality and Transformation Multi-year Plans: - Patient and Family Centered Care Multi-year Plan - Patient Safety/ Stop the Line Multi-year Plan

2. Portfolio Overview • Regional Infection Prevention and Control • Patient Safety Office—Risk, Privacy and Access to Information • Transfusion Safety • Patient Advocate Services • Kaizen Promotion Office • Clinical Quality and Professional Practice • Advanced Care Planning

3. Multi Year Strategic PlanVP leading on: Patient and Family Centred Care RQHR Outcome By March 31, 2017 RQHR will have created a culture of Patient and Family Centered Care that leads to zero defects, no waits and waste from the perspective of patients and families, and that incorporates the core concepts of Patient and Family Centred Care (dignity and respect, information sharing, participation and collaboration).

6. 2015-16 Multi-year Plan • Transforming the system • Supporting family presence through implementation of the provincial Open Family Presence policy • Multi Disciplinary Rounds and shift to shift report at the bedside • 100% use of whiteboards • Intentional rounding/purposeful interaction • Appropriate patient centred signage

7. 2015-16 Multi-year Plan • Transforming the system – Cont’d • ID badges • Patient Experience Survey in RGH / PH / Rural • Patient and family advisory groups • Coordinating with provincial partners • Staff and physician education on PFCC • Policy on patients/families on interview panels • Patients and families engaged in improvement / lean work • Professional Image Policy

8. Patient and Family Centered Care Multi-year Plan • Successes/What is working • Focusing on key drivers from driver diagram • Patient and family advisors engaged in: educating public on HH, region orientation, board meetings, flow visioning, patient experience survey/whiteboard presentations to staff, administrative quality and safety, committee, leading gemba walks, focus groups • Implemented initiatives such as multidisciplinary rounds at the bedside, white boards, safety huddles, manager rounding, purposeful interaction, Accountable Care Unit • Improved informed consent for transfusions • Implemented family friendly and evidence based PPE protocols for visitors and families of colonized isolated patients. • Beginning implementation of “real-time concern handling” • Implemented “Standards of Care” related to what patients/residents/clients can expect in care • Implemented Champions group for Advanced Care Planning, and improvement opportunities identified

9. Patient and Family Centered Care Multi-year Plan • Challenges/Gaps/Risks/ • Much work to spread and replicate practices redesigned by patients and frontline staff and physicians. • Lack of EHR and difficulty getting RQHR forms on physicians’ EMR, e.g. Accuro • Have not yet implemented many best practices, e.g. family presence policy, signage • Huge requirement for education/training in all areas and don’t have a region-wide integrated learning system, including monitoring • What isn’t working/What can be improved • Timely disclosure to patients/families and resolution of client concerns in real time • Patient information needs to travel with the patient—advanced directives, blood consent, etc. • “Concern handling is not a department – it is everyone’s responsibility” – processes need to continue to evolve

10. Patient and Family Centered Care Multi-year Plan • Next Steps: • Region-wide spread and replication of best practices in patient and family centred care • Emphasis on hand hygiene continues—aim 100% • Increased communication/education of staff, physicians, public, patients, residents, clients, families—Planning for integrated learning system • Patient Experience Survey analysis to direct improvements • Family presence policy implementation • Professional Image policy implementation

11. Patient Safety/ Stop the LineMulti-year Plan 2015-16 Provincial Outcome & Improvement Targets • To achieve a culture of safety, by March 31, 2020 there will be no harm to patients or staff. • By March 2018, fully implement a provincial Safety Alert / Stop the Line (SA/STL) process throughout Saskatchewan. • By March 31, 2018, all regions and the Cancer Agency will implement the six elements of the Safety Management System. (SMS) • By March 31, 2019, all regions and the Cancer Agency receive a 75% evaluation score on the implementation of the elements of the Safety Management System • By March 2019 there will be zero shoulder and back injuries.

12. Getting to Green: SA/STL Model Implementation RQHR SA/ STL Roll Out Plan: • SA/ STL educational material & video – complete by Jan. 31, 2016 • Communication/education re: SA/ STL with key stakeholders January-March 31, 2016 • SA/ STL region wide roll out April 01, 2016

13. Patient Safety/ Stop the LineMulti-year Plan • Successes/What is working • STL Algorithm & Roles/Responsibilities document have been developed and are being used by other RHAs • RQHR SAFER model has been chosen for provincial use • STL working group has patient representatives engaged • RQHR STL is moving forward as planned with anticipated roll out date of April 01, 2016 • Confidential Occurrence Reporting Database is being kept current—trending occurring in real time • STL PDSA Trials of an electronic reporting form are complete and facility roll out will proceed in two facilities in March 2016

14. Patient Safety/ Stop the LineMulti-year Plan • Challenges/Gaps/Risks/What isn’t working/What can be improved • The current database and adverse event reporting system continue to present challenges. The province is looking at a potential four year process for roll out of a provincial adverse event management system • Feedback: need for clearer communication of what constitutes a Stop the Line event

15. Patient Safety/ Stop the LineMulti-year Plan Next Steps • Work towards implementation of the regional roll out plan • Heighten awareness of STL as a priority within RQHR & continue to work on culture change • Continue to provide leadership on multiyear plans for the two highest COR concerns—medication errors and falls