Quality Improvement Interim Report

Quality Improvement Interim Report

Designated Lead: Linda M. Tracey, CEO

Quality Priorities for 2022/2023

The 2019-2024 Strategic Plan has been approved by the Board of Directors and is used to guide the Quality Improvement activities of the organization.

The strategic priorities set out in the plan are:

Marianhill Services: Provide quality, ethical, person-centred services across the continuum of care in the Catholic tradition.

Marianhill Culture: Cultivate and guide an environment that celebrates Marianhill’s caring community in the Catholic tradition.

Marianhill Facilities: Provide vital and innovative LTC facilities close to family, friends and community in the Catholic tradition.

In 2019 this plan was developed with the anticipation of redevelopment construction starting in 2020 and becoming the focus. With the ongoing impact of the COVID-19 pandemic the Board of Directors confirmed that these priorities remained relevant for the organization in June 2022.

Quality Objectives 2022/2023


A) Priority Indicator: Number of emergency department visits for modified list of ambulatory care sensitive conditions:

Planned Improvement Initiative (change idea): Discussion and support for residents and families for selected ambulatory sensitive condition assessments and treatment in house is included in Marianhill model of care.

Recognize and discuss with residents and their SDM/family members that admissions to LTC have at least one major chronic disease and often co-morbidities. This also relates to the early identification conversation for end of life discussions and planning of palliative care into the future care planning.

Continued enhancement to palliative care services.

Continue to focus on scope of professional designations/practice model for our inter-professional team members and to position intra-professional care as part of our culture change.

Review best practice guidelines for PSWs in recognizing changes in condition (acute).

Registered staff to prioritize rounds based on change in status of residents e.g. return from hospital, other change in conditions etc. have been implemented and will be monitored. Purposeful rounds are part of PCC.

Current Performance: 28.0 (Q3 2020/2021-Q2 2020/2021)

Target: ≤16.0 (Q3 2020/2021-Q2 2020/2021)

Target Justification: Marianhill to remain below the provincial average.

Consideration re selecting work plan methods, initiatives/targets/measurement:

This is based on hospital NACRS (National Ambulatory Care Reporting System) data and the diagnosis assigned by hospital and is the # of emergency department visits for modified list of ambulatory care sensitive conditions (unadjusted)
(Examples of these conditions include: angina, asthma, gad mal seizure disorders, hypertension, hypoglycemia, injuries resulting from a fall, pneumonia, septicemia and severe ear, nose and throat disorders)

To discourage or avoid sending residents to the emergency department for conditions as listed above is not congruent with the mission and values of Marianhill. To discourage or avoid sending residents to the emergency department for conditions as listed above is not congruent with the mission and values of Marianhill.

Marianhill advocates for reasonable access to healthcare for all residents.

Marianhill monitors the CCRS (Continuing Care Reporting System) emergency department visits and considers that data in setting targets (5.1%)

Issues unique to rural/county medical and health resources challenge residents ability to avoid being transferred to ED (e.g. MD practices that cover ED shifts and MD of resident ask resident to be sent to ED to be seen there by them or by a consultant, lack of onsite diagnostic testing such as radiology/laboratory diagnostics.)

Practitioner and sometimes family choice influences where residents are seen and they cannot be discouraged from accessing the emergency department.

Methods: Continue to educate and work with staff and families to use the palliative care approach to provide end of life care for all residents. Care conferences at admission, include end of life planning and occur within 6 weeks and sooner if end of life care is foreseeable.

PSWs will utilize education related to palliative care model within their scope of practice.

Process Measure: Emergency Department visits will aim to remain below provincial average.

Goal for Change Idea: Care and treatment planning will aim for provision of care to continue at Marianhill as end of life needs approach. The full implementation of purposeful rounds and addressing residents’ needs in a proactive manner will assist with early assessment of changes in the subtle signs of potential decline e.g. offering water decreases potential dehydration and its accompanying issues.


B) Priority Indicator: Percentage of residents responding positively to: “I can express my opinion without fear of consequences.”

Current Performance: Current overall score is 77.21

Target: 2020 NRC Score = 84.6%

Target Justification: NRC Average

Consideration to consider in selecting work plan (methods) initiatives/targets/ measurements:

Previously this indicator was identifed through Health Quality Ontario. As per the Fixing Long-Term Care Act, 2022 resident engagement is required and this will show evidence of resident engagement.

Methods: Re-introduce family and resident information nights bi-annually. Meet with Resident and Family Councils as required and ensure proposed changes are discussed as appropriate (e.g. various leaders are guest presenters at the meetings, policy changes effecting residents/families are shared).

Process Measure: % of resident who respond positively.

Goal for Change Idea: That the score will be in line with average LTC Surveyed by QoL Survey


C) Priority Indicator: Early identification:

Documented Assessment of the needs for palliative care residents (the proportion of residents who were identified at risk of dying and in need of palliative care in the last 6 months and had documented assessment of their palliative care needs).

Planned Improvement Initiative: This is a new indicator with no previous data for analysis. This year the team will test various models that can be used to evaluate resident assessments.

Unit of Measure: proposed % expressed as a proportion i.e. # of residents who have documented assessment of their palliative care needs in their medication record/# residents identified in need of palliative care over the last 6 months (high risk of dying).

Current Performance: Baseline data to be established.

Target: Baseline data for a fixed 6 month period (Q3 and Q4 2022-2023)

Target Justification: Initial collection of this data and use of the indicator and will be evaluated.

Consideration re consider in selecting work plan (methods) initiatives/targets/ measurements: Notes to consider in using this indicator:

  • Applies to LTC residents
  • Identification of LTC residents who are at high risk of dying over the last 6 months (denominator) needs some discussion.

Limitations of this measure include that the needs change over time; patients may have more than one hospitalization; and needs may have been assessed in other settings as well. The quality of the assessments will not be captured, only completions. It is difficult to assess the timeliness and comprehensiveness of needs assessment.

Methods: Education regarding palliative care and early identification and conversation for care planning.

Process Measure: Documentation of early identification and care planning for palliative/end of life/ MDS code identifying palliative care status.

Goal: Collection of baseline data and renewed focus on assessments to ensure appropriate plan of care.


Quality Improvement Program

Marianhill’s Quality Improvement Program is based on the Resident First Initiative previously set out by the Ministry of Health and Long-Term Care which has as its foundation the Institute for Healthcare Improvement’s work. While work on the priority indicators will proceed in 2022/2023 a the Continuous Quality Improvement Program will be reviewed and updated to align with the Fixing Long-Term Care Act, 2022 and O. Regulation 246 during this year as well.

Policies and Procedures

The program is comprised of the following policies/procedures used to identify the priority areas and communicate the outcomes of the quality improvement initiatives:

  • Continuous Improvement Program
  • Continuous Quality Improvement Performance Indicators
  • Continuous Quality Improvement Process
  • Terms of Reference Governance Quality Improvement and Risk Management Committee (under review)
  • RACI Matrix Template
  • QI Project Charter Worksheet
  • Resident Family Care Concern CQI Report Form
  • Quality of Care Information Protection Act Process and Procedures

Process for Monitoring and Measuring Progress

The next meeting of the Quality Committee will be in the fall of 2022 and will the Committee will review the data available on each of the process measures set out above. The Committee will provide to Resident Council, Family Council, the Management Team (responsible for communicating updates to staff) and Board of Directors information on the progress in attaining identified targets as well as opportunities for re-evaluating both process measures and targets.

Updates will be shared through a variety of communication strategies which are tailored to the specific improvement initiative. These include, but are not limited to:

  • Posting on unit quality boards, in common areas
  • Publishing stories and results on the website or via a newsletter
  • Direct email to staff and families and other stakeholders
  • Handouts and one:one communication with residents
  • Presentations at staff meetings, townhalls, Resident Councils, Family Council
  • Huddles at change of shift
  • Use of Champions to communicate directly with peers
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