Body: RULAC Type: Document Meeting: Regular Date: Date unknown Collection: Documents Municipality: Frontenac County
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Document Text
QUALITY IMPROVEMENT PROGRAM
Last Edited January 28, 2011
TABLE OF CONTENTS
General Statement Goals of Quality Improvement Program Mission, Vision, Values & Organizational Goals Organized/Required Programs Quality Improvement Role of Teams How to Bring Forward Quality Improvement Ideas Role of Quality Assessment & Assurance Committee (QAAC) Submission of Quality Improvement Ideas to the QAAC Communication & Documentation Program Evaluation Quality Improvement Plan - 2011
Last Edited January 28, 2011
GENERAL STATEMENT
Fairmount Home is committed to the continuous improvement of our services to our residents, staff, volunteers and the greater Fairmount community. We have developed a structured quality improvement program to allow the organization and management of quality initiatives as follows:
Fairmount Strategic Plan
Mission, Vision, Values & Organizational Goals
Departmental Team Goals
Residents, Volunteers, Family, Council and Community Members
Other Teams’ Goals
Identified QI Initiative
Quality Assessment & Assurance Committee Reviews & Responds Departmental Team
Other Teams
Carry Out QI Initiative
Carry Out QI Initiative
Regular & Final Reporting
Regular & Final Reporting
Communication to Fairmount Community
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GOALS OF THE QUALITY IMPROVEMENT PROGRAM
- To provide a culture of continuously improving systems, methods and processes to improve the Home’s services to its residents, staff, volunteers and the greater Fairmount community.
- To ensure the quality improvement program is interdisciplinary.
- To ensure a process is in place for the identification of quality initiatives.
- To ensure the coordination and monitoring of quality initiatives.
- To ensure communication of quality initiatives.
- To ensure adequate documentation is kept of all quality initiatives.
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Mission, Vision, Values & Organizational Goals Mission Statement Fairmount is an accredited long-term care home for 128 residents, dedicated to providing the best quality of life to those who live and work here. The Fairmount community fosters a creative and responsive environment in which all members – staff, families, volunteers, students, community partners and the residents themselves – respect and promote the strengths and abilities of each other, especially those for whom this is home. A full range of high quality programs are provided with the caring expertise of a dedicated, multi-disciplinary, team, responding to the unique needs and wishes of our residents. All members of our Community are advocates for all those who live and work here. Fairmount Vision Statement In response to changing needs of residents and the community, we will continue to develop and implement innovative “best practices” and programs. We will continue to foster and grow an environment of mutual respect for residents and all members of our caring community. We will promote the principles and practices of Continuous Quality Improvement for all aspects of Fairmount’s caring community, and we will maintain the ethical balance between innovation and resident choice, safety and risk management. Building on the foundation of strong relationships, Fairmount will seek to increase the involvement of the wider community by bringing our citizens into Fairmount through the sharing of our expertise, our location, and our excellent programming. Fairmount will also reach out into the wider community as a leader and participant, sharing its knowledge and resources to plan and implement activities that will improve the lives of the elderly throughout the entire area. Fairmount Values CRE– A– T– I– V– E–
Caring and Compassionate Responsive and Respectful Expertise, Enabling Acceptance, Advocacy, Appreciation Team Work Independent and Innovative Vibrant, Visionary Ethical
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C– O– M– M– U– N– I– T– Y–
Community-Oriented Opportunity and Openess Meaningful and Mindful Motivated Unique Neighbourly Inclusive Togetherness YOU – our focus
Fairmount’s Goals
- To ensure all members of the Fairmount Community are knowledgeable and accepting of our Mission, Vision and Values, and put them into practice all day, every day.
- To ensure a holistic life style will be maintained for all residents, including responding to their unique needs and wishes, related to learning and desired experiences, to satisfy their physical, social, emotional, spiritual and mental needs.
- To be a positive learning environment for all staff, volunteers, residents and their families based on best practices and mutual respect, creativity and innovation.
- To continue the development of a “best practices” standard for all aspects of Fairmount’s caring community.
- To be an innovative environment fostering the development and application of new ideas that will enhance the living and working environment.
- To develop and implement a strategy for recruitment, training, retention and succession planning to ensure an exceptional group of staff and volunteers.
- To take a leadership role in the planning and development of the Local Health Integration Network, and in working with other local, area and provincial organizations and people, to ensure the highest quality of care and programming for the long term care sector.
- To enhance the knowledge of our citizens throughout the area about Fairmount and the activities and services it provides.
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Organized/Required Programs There are a variety of organized or required programs that the Home must provide under different pieces of legislation. These include, but are not limited to:
- Nursing & Personal Support Services
- Restorative Care
- Recreational & Social Activities
- Dietary Services & Hydration
- Medical Services
- Information & Referral Assistance
- Religious & Spiritual Practices
- Accommodation Services
- Volunteer Program
- Falls Prevention & Management
- Skin & Wound Care
- Continence Care & Bowel Management
- Pain Management
- Health & Safety
- Medication Management
- Infection Prevention & Control
- Training & Orientation
Departmental and other teams are in place to support quality improvement activities in all organized and required programs.
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QUALITY IMPROVEMENT ROLE OF TEAMS There are a variety of teams in place to support quality improvement at Fairmount. The quality improvement activities of each team are vital to the overall success of the quality improvement program at Fairmount. Each team is required to: a) Establish its purpose and review on an annual basis b) Establish measureable goals which must align with its purpose and the goals of the organization and review on an annual basis c) Establish measures to track its progress in meeting its goals d) Review opportunities for quality improvement and identify quality improvement initiatives to be brought forward for review to the Quality Assessment and Assurance Committee (QAAC). e) Carry out quality improvement initiatives once approved by the QAAC. The Interdisciplinary Program Evaluation form will be used to help each team keep track of all of its goals, measures and quality improvement initiatives.
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HOW DO I BRING FORWARD AN IDEA FOR QUALITY IMPROVEMENT? Ideas for quality improvement can come from a variety of sources which can include, but is not limited to: a) b) c) d) e) f) g) h) i) j) k)
Audit results Inspection results Complaints Survey results Incident reports Risk identification forms Observation Staff meetings Resident and/or Family Committees County Council Publications
Everyone at Fairmount is encouraged to look for and bring forward improvement opportunities. If you see an area where improvement is needed and you have some ideas about how to do so you can bring it forward verbally or in writing to one of the following: a) b) c) d) e) f) g)
The Administrator The Director of Resident Care The Assistant Director of Care The Manager of Environmental Services The Manager of Food Services Residents’ Council County Council
Whoever receives your idea will ensure it is forwarded to the appropriate team for discussion. Quality improvement initiatives identified by team members should be taken forward to the team for discussion and then forwarded to the Quality Assessment and Assurance Committee in the required format (see section entitled Submission of Quality Initiatives to the QAAC).
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ROLE OF THE QUALITY ASSESSMENT & ASSURANCE COMMITTEE (QAAC)
The purpose of the interdisciplinary Quality Assessment and Assurance Committee (QAAC) is to: a) b) c) d)
Prioritize, coordinate and evaluate quality initiatives at Fairmount. Provide a forum for discussion and dialogue on matters of quality and risk at Fairmount. Receive reports from and provide feedback to teams. Communicate quality initiatives and their outcomes to stakeholders, including but not limited to staff, volunteers, Residents’ Council, Family Council and County Council, e) Act as a resource in relation to continuous quality improvement. Membership includes the following individuals: a) b) c) d) e) f) g)
Administrator Director of Resident Care Assistant Director of Care Manager of Environmental Services Manager of Food Services Volunteer & Special Events Coordinator Nurse Practitioner
All quality initiative project proposals must be reviewed and approved by the QAAC.
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HOW TO SUBMIT QUALITY IMPROVEMENT INITIATIVES TO THE QAAC Teams considering quality initiatives will primarily use the Model for Improvement strategy which is built on the following three questions: What are we trying to accomplish? How will we know if a change is an improvement? What changes can we make that will result in an improvement? Once the three questions have been answered the teams will develop, test and implement the change strategies through a serious of small PDSA (Plan, Do, Study, Act) cycles. The Long-Term Care Improvement Guide from the Ontario Health Quality Council will be used to guide quality teams through each step of the quality initiative as follows: a) b) c) d) e)
Defining the quality problem Establishing the AIM Statement Defining the changes Identifying the measures Plan-Do-Study-Act Cycles
Each team will use a Project Charter Worksheet which sets out the purpose, scope, measures and targets for success. It also identifies the key members of the team and specifies the time and resources to be invested as well as the anticipated benefits. The Project Charter Worksheet must be submitted to the Quality Assessment & Assurance Committee for review prior to implementation of the initiative. Upon approval from the Quality Council the team will carry out the quality initiative and report back to the Quality Council using the PDSA Worksheet.
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COMMUNICATION & DOCUMENTATION Formal communication to stakeholders about the quality initiatives undertaken at Fairmount may be conducted by the Quality Assessment & Assurance Committee (QAAC) through a variety of methods including, but not limited to: a) b) c) d) e) f) g) h)
Grapevine Gazette Staff Intranet Fairmount Website Quality Improvement Board Lobby Displays Reports to Residents’ Council Reports to Family Council Reports to County Council
Detailed documentation must be maintained throughout the quality initiative process and the final documentation package must include: a) Minutes of all team meetings including the date, time, location and names of those in attendance b) The Project Charter Worksheet c) All PDSA Worksheets All documentation must be forwarded to the QAAC. The QAAC will ensure documentation regarding communication of the initiatives is kept with the final documentation package.
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PROGRAM EVALUATION Program:
Policy/Regulation reference Screening Protocols Used (if applicable) Assessment/Reassessment Instruments Used (if applicable) Program goals
Measures
Methods used to promote achievement of goals Methods used to monitor outcomes Referral process for specialized resources (if applicable) Location of documentation regarding resident-specific action taken Quality initiatives approved by Quality Assessment & Assurance Committee Annual evaluation of the program
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Quality Improvement
Date of annual evaluation Persons participating in the annual evaluation Summary of changes made to the program as a result of the evaluation To whom and how were changes communicated?
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QUALITY IMPROVEMENT PLAN – 2011 Goal #1 A comprehensive list of current quality improvement activities and measures will be prepared by the Management Team for submission to the appropriate teams by February 15, 2011. Measure – List of QI measures completed Responsible: Administrator Goal #2 Fairmount will have 100% of its departmental goals and measurements completed by May 31, 2011. Measurement = # departments with goals & measurements completed/# of departments Responsible: Department Heads Goal #3 100% of the teams (non-departmental) will have their goals and measurements completed by June 30, 2011 Measurement = # teams with goals & measurements completed/# of teams Responsible: Team Chairs Goal #4 100% of all teams will receive Model for Improvement strategy training by October 31, 2011 Measurement = # of teams that received training/# of teams Responsible: QAAC Goal #5 80% of teams will have a Project Charter Worksheet for at least one quality initiative for submission to the QAAC by December 31, 2011 Measurement = # teams with Project Charter Worksheet/# of teams Responsible: Team Chairs
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For the purposes of this plan the departments are identified as: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Nursing & Personal Support Services Restorative Care Recreational & Social Activities Dietary Services & Hydration Medical Services Information & Referral Assistance Religious & Spiritual Practices Accommodation Services Volunteer Program
For the purposes of this plan the Non-departmental Teams are identified as:
- Falls Team
- Wound Care Team
- Intestinal Health/Continence Care Team
- Pain Management Team
- Health & Safety Committee
- Professional Advisory Committee
- Education Committee
- Labour-Management Team
- Management Team
- Pleasurable Dining Committee
- Psychogeriatric Team
- Environment Team
- Information Management Team
- Restorative Care Team
- Palliative Care Team
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PLAN-DO-STUDY-ACT FORM Objective for this PDSA Cycle
Date:
Is this cycle used to: Develop or
test or
implement a change?
What question(s) do we want to answer on this PDSA cycle?
PLAN: Plan to answer questions: Who, What, When, Where?
Plan for collection of data: Who, What, When, Where?
Predictions (for questions above based on plan):
DO: Carry out the change or test, collect data and begin analysis.
STUDY: Complete analysis of data.
Compare data to predictions and summarize what was learned. ACT: Are we ready to make a change?
Adopt
Adapt
Abandon
Plan for the next cycle.
PDSA Reference # _____________ Last Edited January 28, 2011
