1. Health Planning Group
November 2015

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

3. 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.

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

5. 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

6. 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

7. 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

8. 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 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)

9. 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)

10. 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

11. 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