Health Planning Group November 2015

Planning Framework Strategic Plan HFHT QIP Plan Practices QIP Plans Patient Experience Practices QIP Plans Stakeholders MoH/HQO QIP Plan

Board Quality Committee Many boards have found a board quality committee to be an effective venue for: Providing in-depth oversight of quality improvement projects, Supporting the Board of Directors in fulfilling its governance responsibilities with the MOHLTC, Linking organizational strategic directions with quality improvement plans. Fulfilling the requirements of the Excellent Care for All Act.

Integrated Planning Approach Board of Directors Board Quality Committee Health Planning Group Operational Management Strategic Plan Quality Improvement Plan Operational Plan

Board Strategic Plan (emerging) A Comprehensive Primary Care System for Hamilton Outstanding Quality Patient Experience Capacity and Resources to Achieve Our Goals Team-based Culture and Organization THEMES Quality Improvement Plan (2015/16) Integration Patient Centeredness Population Health Access THEMES Operational Plan Program Priorities QIP Implementation Capacity Building Resource Allocation

Quality Improvement Plan (2015/16) Integration Patient Centeredness Population Health Access THEMES All parts of the health system should be organized, connected and work with one another to fill in gaps and eliminate duplication in care. Engage patients in the design and improvement of services Identify populations and monitor progress. Timely access to care when needed DEFINITION Identify patients discharged from hospitals Support development of process for 7 day follow-up post discharge Increase the # of patients experience surveys completed Focus on: cancer screening and collection of clinical data Increase # of practices offering Same Day/ Next Day/ Day of Choice CHANGE IDEA Cancer Care Ontario Data to Decisions Minimum Data Set Review results and develop a plan for improvement Practice Facilitators analyze and support change Promote Clinical Connect – admission and discharge data PLAN

Quality Improvement Plan (2015/16) Integration Patient Centeredness Population Health Access THEMES All parts of the health system should be organized, connected and work with one another to fill in gaps and eliminate duplication in care. Engage patients in the design and improvement of services Identify populations and monitor progress. Timely access to care when needed DEFINITION ER Diversion Tool Ocean Tablet Project Cancer Screening Initiative Clinical Connect Survey INITIATIVES Pain Management Data to Decisions Palliative Care Minimum Data Set Physiotherapy Hospital/ FHT Collaboration

Integration Survey HQO’s priority indicator for integration is percentage of patients with selected conditions who have primary care physician follow-up within 7 days of hospital discharge In order to improve the rate of follow-up, it is important to understand What information HFHT practices currently receive from hospitals about their patients who have been hospitalized and/or visited the ED How and when the information is communicated, e.g., use of tools such as ClinicalConnect How practices track patients who have been discharged from hospital Challenges practices have encountered with the current process A brief online survey was developed and distributed to HFHT practice managers via e-mail at the end of October with a 3-week response timeline.  Survey results will help inform the development of strategies to improve the follow-up rate as well as help determine what needs to be in place to support new tools such as Hospital Report Manager (HRM)

Data to Decisions (D2D) Board Quality Committee decision to move forward with D2D AFTHO membership-wide annual report on performance in primary care Interactive reports & peer comparison Measures include: Patient experience Preventative Care (Cancer Screening) Integrative Care (Post discharge follow up) Population Health (Diabetic patient management) Data Quality (EMR vs. SAR) Many of the measures align with QIP HFHT participating for D2D 3.0 (opens Dec. 2015) Partial data submission (Oceans and ED level HQO PCPR)

Cancer Screening Initiative Improve cancer screening rates through focused intervention based on toolkit resources Facilitate physician access to the Screening Activity Report (SAR), including EMR reconciliation Using SAR data, learn from high screeners and improve rates of low screeners Develop a sustainable written cancer screening protocol Identify office cancer screening champion Development and refinement of cancer screening toolkit resources Ultimately, increase screening rates and reduce impact of cancer

Ocean Tablet Pilot Project Streamline collection of clinical information through an EMR-integrated tablet platform Aid in administrative workflow by automating certain data entry processes such as demographic information Administer patient experience surveys and collect data based on responses Chronic disease management 38 Physicians, 2 NPs currently involved in pilot project