The Hospital for Sick Children 1 555 University Avenue, Toronto ON M5G 1X8

Quality Improvement Plan (QIP) Narrative

3/30/2016

The Hospital for Sick Children 2 555 University Avenue, Toronto ON M5G 1X8

Overview Our Vision: Healthier Children. A Better World. SickKids’ strategic plan, Building Connections, Accelerating Impact 2015-2020, launched in April 2015 has a continued focus on “Improving Quality and Safety” as a strategic direction. Our aim to achieve the highest quality patient care, research and education continues to be a priority at SickKids. Our focus on quality improvement has matured over many years and is framed by the six dimensions of quality defined by the Institute of Medicine (2001): care that is safe, timely, effective, efficient, equitable and centred on patient and family needs. Our annual Quality Improvement Plan (QIP) is an opportunity to share with the public our focus on selected quality improvement priorities that contribute to achieving our strategic aims. Each year we develop our QIP in consideration of:

• Provincial and Local Health Integration Network (LHIN) priorities and our Health Service Accountability Agreement;

• Standards and best practices, including those specific to children’s health; • Accreditation Canada standards and required organizational practices; • Patient safety priorities identified from safety reporting, quality of care reviews, critical incidents and

prospective risk analysis; • Improvement opportunities identified by feedback from children, families, community partners and

staff; • Organizational and departmental performance scorecards; • Organizational Daily Continuous Improvement Plan framework; • Service excellence and innovation strategies.

SickKids’ 2016-17 QIP includes selected indicators that demonstrate our commitment to continuously improving the care and service that we provide to children and their families. SickKids provides specialized care to children. Some of the work that we do is unlike any other hospital in Canada. The standards of quality that we aim to achieve and the ways in which care is integrated at a systems level sometimes require us to benchmark and to partner with peers beyond Ontario. As a result, some of our QIP indicators, targets and strategies are relevant to SickKids but different from other Ontario hospitals. This year, we chose to reduce the number of indicators on our QIP to sharpen the focus on six key indicators that reflect strategically important work that we are doing to improve quality at SickKids. This year we will:

1. Continue to reduce wait times for patients admitted from the Emergency Department. Despite increasing numbers of patients using emergency services at SickKids, since 2012, we have achieved greater than 40% improvement and we now rank 11/73 in the province.

2. Improve our methods of identifying and documenting patients who present at the Emergency Department with symptoms of sepsis (the body’s response to infection). Early detection is linked to better outcomes.

3. Efficiency is an important part of effective care. We aim to reduce the length of stay for admitted patients by about 3000 patient days overall. Reducing unnecessary time in hospital is better for patients and families and it improves access to care for others.

The Hospital for Sick Children 3 555 University Avenue, Toronto ON M5G 1X8

4. At SickKids, we believe that child- and family-centred care is achieved through respect, communication, and partnership, whereby children and families are engaged in their care in an authentic and collaborative way. We believe that this approach results in optimal health, patient safety, health equity, and a positive patient and family experience. We are implementing a new measurement tool this year to better understand patient and family experiences.

5. Healthcare associated infections can be harmful to patients. Optimal hand hygiene before and after contact with patients and their environments can reduce the risk of some infections. We will remain focused on improving hand hygiene compliance as a core safety practice.

6. Central venous lines are necessary devices for delivering fluids and medications to patients at SickKids. Infections associated with central lines can cause serious illness in children. Reducing the number of infections will be a primary focus within our Caring Safely program.

QI Achievements From the Past Year SickKids has always been a leader in advancing safe and high-quality care for children, as well as providing a safe working environment for staff. There have been steady improvements in safety at SickKids as a result of various structures and processes that have been put in place, and the great work and commitment of all our staff. Despite these efforts, preventable harm still occurs to patients and staff.

Through the Strategic Plan Building Connections, Accelerating Impact, SickKids has renewed its commitment to safety and quality, with a plan that makes "eliminating preventable harm" one of our key strategic objectives. We are collaborating with nearly 100 children’s hospitals in North America to learn together how to make care safer, by systematically introducing error prevention strategies, leadership methods, and a combination of cultural elements that will evolve over a number of years. More information on the collaborative known as the Solutions for Patient Safety can be found at: http://www.solutionsforpatientsafety.org/ At SickKids, in order to keep our focus on eliminating preventable harm, we have launched an organization-wide initiative called Caring Safely. It will be the driving force behind four key objectives:

1. Reduce the incidence of seven Hospital Acquired Conditions (HACs): Injuries (moderate or greater) from serious Falls Adverse Drug Events (ADE) Ventilator Associated Pneumonia (VAP) Central Line Associated Blood Stream Infections (CLABSI) Catheter Associated Urinary Tract Infections (CAUTI) Pressure Ulcers (PU) Surgical Site Infections (SSI)

2. Reduce the incidence of Serious Safety Events (SSEs)

The Hospital for Sick Children 4 555 University Avenue, Toronto ON M5G 1X8

3. Enhance our Safety Culture by adhering to the principles of High Reliability Organizations (HRO) 4. Improve Staff Safety by reducing lost time injury count, frequency rate and/or severity

The Caring Safely initiative aligns with a number of other organizational objectives and will enable us to strengthen many of the things that we already do well, but aim to do better. To ensure our success, Caring Safely has a formal governance structure, including senior leadership through to front-line staff, and will engage everyone at SickKids.

Integration & Continuity of Care In alignment with SickKids’ strategic direction to Champion the Evolution of the Health System, we continue to lead and collaborate with our system partners at both the local and provincial levels to improve integration and continuity of care for children, youth and families, including:

Developing the concept of an Integrated care system for children, similar to ‘care networks’ developed in other parts of Canada and the world. We are collaborating with others to develop a Kids Health Alliance concept will evolve to encompass collections of providers across sectors and levels of care, including: children’s hospitals, academic and community paediatricians; community hospitals; community nursing and other health care services; children’s mental health organizations; and primary care providers. The Alliance will achieve a more coordinated, consistent, high-quality system of healthcare for children and their families as they receive care across multiple care settings by using standardized, evidence-based approaches to care delivery; and, ultimately, improve the long term outcomes by coordinating a holistic and longitudinal approach to clinical care.

Continuing to work closely with community hospitals in the GTA LHINs to build local capacity to deliver paediatric emergency, neonatal intensive care, and inpatient paediatric care.

Leading two local health system planning initiatives in partnership with the Toronto Central LHIN and other local health system partners, including: An Advisory Table to address challenges faced by transitional aged youth (16 to 24) with mental health and addictions issues as they move from the paediatric to adult health system; and a broader planning Table with the mandate to advise the LHIN on system level change related to child/youth heath.

Continuing to build capacity with our community hospital partners with the expansion of SickKids’ Complex Care Satellite Program, with the goals: to improve access to integrated care closer to home for children with medical complexity (CMC); and support improved collaboration and communications between health care providers. The Satellite Program currently supports approximately 300 CMC from across the GTA and North Simcoe Muskoka regions to receive intensive service coordination and expert care delivery via SickKids’ Complex Care Program and five regional community hospital partners. Expansion of the program aligns, and is supported by, the Provincial Council for Maternal Child Health’s (PCMCH) Complex Care Kids Ontario (CCKO) provincial strategy – to provide high quality standardized care for medically complex, technology dependent children across the province.

Building on our longstanding history of partnership with Holland Bloorview Kids Rehabilitation Hospital (HBKR), we have identified an opportunity to work collaboratively to explore opportunities to enhance transfer of patients requiring complex transitional care as they move from SickKids to HBKR and ultimately to their home communities.

The Hospital for Sick Children 5 555 University Avenue, Toronto ON M5G 1X8

Continuing to implement a standardized clinical pathway for children and youth presenting in the Emergency Department with mental health issues to provide standardized assessments and linkages to community mental health agencies. This partnership has grown over the last year to include two additional community mental health agencies, bringing the total to five.

Engagement of Leadership, Clinicians and Staff

SickKids has a longstanding and comprehensive focus on quality improvement directed towards six dimensions of quality: care that is safe, timely effective, efficient, equitable and patient centred. Using performance and quality scorecards, progress against improvement targets is continuously monitored by care providers, managers, senior leaders and governance committees. All of our QIP indicators are included on the Hospital Quality Scorecard and are reviewed monthly by senior and governance quality committees. Stakeholders for each indicator provide detailed progress reports at scheduled intervals throughout the year. Front-line staff and their managers are engaged in improvement work through the Daily Continuous Improvement Program (Daily CIP). Over the past three years, this program has been fully implemented and it provides standard tools, language and time for staff to actively improve care at SickKids. Daily CIP processes include regular team huddles and structured daily conversations based on Lean Methodology. Each day staff focuses on QIP indicators along with other quality and safety priorities by systematically applying sound improvement methodologies. They are encouraged to think creatively and learn from each other along the way. Unit based scorecards include QIP indicators so that performance is tracked in an ongoing way by front line staff. For more than a year at SickKids between 15-20 hospital leaders connect every day by telephone to engage in what’s known as our Daily Safety Brief. The purpose of the call is to improve situational awareness about issues related to safety and quality by looking backward and forward to identify safety issues in order to be clear about immediate priorities and action plans. For many years, SickKids has been investing in developing expertise in quality improvement. Our in-house experts help us to develop effective improvement strategies and support all of our staff to be involved in quality as it relates to their individual roles. We want everyone working at SickKids to have a shared aim of achieving exceptional quality and to have the knowledge, skills and tools to achieve our aim. To that end, we have begun a training program for all staff that will unfold over the next two years. All staff will learn about safety behaviours and error prevention strategies. Leaders will learn specific methods to reinforce safety behaviours. Unit based safety champions will coach and encourage their peers to get better at using newly learned error prevention strategies. Our ultimate goal is to reduce and eliminate harm to patients and staff, and our success depends on the engagement of all SickKids staff. The development and execution of our annual QIP involves a large number of broadly representational internal and external stakeholders. It is a complex process that brings together diverse perspectives, strategic priorities, innovative ideas and challenging targets to help us achieve the exceptional level of quality our patients, families and staff should expect from SickKids.

The Hospital for Sick Children 6 555 University Avenue, Toronto ON M5G 1X8

Patient/Family Engagement

The Centre for Innovation and Excellence in Child and Family-Centred Care was established in 2011 to build on SickKids' long history of child and family-centred care. The Centre works with children (patients), families, and staff to test innovative approaches and implement best practices for the advancement of child and family-centred care. Through an organizational assessment and an external scan conducted in 2012/13, we identified the key areas of priority for advancing child and family-centred care. These priority practices were identified in collaboration with children, families, staff and physicians. Our shared work is framed by our model of Child and Family-Centred Care, which depicts the child and family at the centre of everything we do:

SickKids invites feedback from patients and families to measure their satisfaction with care and to identify opportunities for improvement through a number of strategies including:

• Validated satisfaction survey tools; • Informal survey tools available on-line and at points of care; • Child and Family Relations processes which invite and document complements and complaints as one

way to support and guide staff, as well as patients and families, to build positive care relationships and experiences based on SickKids’ values and expectations;

• The Child and Family Advisory network; and • Family presence at nursing shift handover.

We continuously evaluate the committee structure that oversees quality improvement at SickKids. The newly formed Patient Experience Advisory Committee explicitly advises on the measurement of patient and family experience along with the priorities for improvement. This committee complements our existing Children’s Council, Family-Centred Care Advisory Committee and Families as Partners in Patient Safety Committee, all of which have a role in informing our QIP from the perspectives of patients, former patients and families of patients.

The Hospital for Sick Children 7 555 University Avenue, Toronto ON M5G 1X8

The engagement of patients and families directly or indirectly influence the improvement priorities contained in SickKids’ QIP. Some specific examples include:

• Patient/family committees, groups, task forces, and panels such as the Family-Centred Care Advisory Council, the Children’s Council, Families as Partners in Patient Safety and many more;

• Multiple feedback mechanisms such as post discharge satisfaction surveys, comment cards, bedside rounds, Child and Family Relations processes, and social media;

• Analyses of serious safety events, safety reports, morbidity and mortality reports, safety & performance data and other information;

• The establishment of a Family Advisory Network consisting of trained Family Advisors who sit on hospital committees and inform various hospital initiatives including projects focusing on quality and patient safety;

• Having a family advisor as an active member of the 2016-17 QIP Steering Group; • The inclusion of family advisors as members of senior hospital committees that provide oversight and

approval of the QIP (Quality Management Council and Board Quality Committee). We aim to communicate in ways that meet patient and family information needs about the QIP. As one example, videos have been developed which are targeted directly to our patients/families about some of the priorities outlined in the SickKids QIP.

We engaged patients to refresh our reminder program of public signage as one of our initiatives to improve hand hygiene. Patients used their creativity and voices to tell us why hand hygiene is important to them. In addition to the signs as visual reminders, a video of one patient’s vision for hand hygiene sent a powerful message to staff, family members and others who are present in the hospital: Clean Hands Prevent Harm: Jake’s Story can be viewed on YouTube: https://www.youtube.com/watch?v=I-HdogjCjH0

The Hospital for Sick Children 8 555 University Avenue, Toronto ON M5G 1X8

Ella Korostil, age 11. “My poster shows that germs are all around us, and I thought using bright colours would help people see the posters. I also made the tap and the soap look friendly.”

Khahish Kaur, age 12. “My Dad helped me come up with the idea for the poster. I decided to draw some soap with germs and bacteria in the background. It was hard because I could only use my left hand to draw the poster, so it took me a while to actually draw it and colour it in.”

Alexia Cantore, age 12. “I’ve always loved to draw since I was a kid. In my drawing I made the bar of soap a superhero because soap is something that saves people. Doing the drawing was a really nice way to pass the time.”

The Hospital for Sick Children 9 555 University Avenue, Toronto ON M5G 1X8

Next year we will engage patients and families even earlier in the QIP development process. We will also focus on sustaining and expanding the Family Advisor role in our quality work across the hospital. Formalized processes to facilitate the participation of Family Advisors on committees and improvement initiatives are being expanded. This year, a Family as Faculty Program will also be implemented and will train Family Advisors on how to tell their story in various forums including education sessions, committees, etc. These stories will focus on patient and family experiences and will inform quality improvement initiatives.

Performance Based Compensation Our Quality Improvement Plan (QIP) is an integral part of our goal to provide high quality, family centred care at SickKids. Senior quality committees of the hospital and Board have oversight of the QIP development and they track progress through targeted interval reports and monthly quality scorecards. Individual departments involved in change initiatives are accountable through departmental scorecards. To drive organizational performance and enhance management's accountability for delivery of our strategic objectives and priorities, our executives are eligible for performance based compensation. In 2015, our Performance Assessment Framework is set with a 40% weighting applied to organizational performance indicators (of which QIP is a major component) for our senior management team. The other components include portfolio objectives, management responsibilities, and hospital values. For 2016, we have quality improvement goals related to five main dimensions of quality, including safety, access, patient‐centred, efficient, and effective care. Our executives play a major leadership role and are accountable for these quality improvements, thus a component of their compensation is directly linked to achieving the following QIP three performance targets. We have chosen to place greater focus on three QIP indicators related to executive compensation this year:

Quality Dimension Indicator 2016‐17 Target Weighting Quality Dimension 2016/17 Proposed Indicator 2016/17 Target Weighting

Effective ED Patients with Documented Sepsis Screening (%) 80% 33.3%

Safety Hand Hygiene Compliance (%) 89% 33.3%

Efficient Average Length of Stay Hospital Wide (days) 6.34 33.3%

TOTAL 100%

Executive Performance Incentive Plan Performance based compensation accounts for an additional 30% of the CEO's annual base salary, 19% for EVP's and 15% for VP/Chiefs. Of these amounts, 40% of the performance based compensation is directly linked to achieving 100% of the QIP targets. If the organization achieves 100% of the QIP targets set out above, the percentages listed below are multiplied by each executive's base salary to determine the value of the performance based compensation tied to the achievement of the QIP.